Pregnancy in the rheumatic diseases by drdoc on-line

There is no doubt that many physiological changes are associated with the events of pregnancy and lactation. The physical and psychological disabilities of the arthritis sufferer, make such a pregnancy potentially more complicated, but no less satisfying regarding the longer term joy of childbirth.

Several questions regarding the process arise.

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Will I have problems falling pregnant? Am I less fertile?
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Will the pregnancy make the arthritis more severe?
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Will my arthritis make the pregnancy more difficult?
     
What medications can I take during the pregnancy?
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Will my baby develop the Arthritis?
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Will my baby be healthy?
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Will childbirth be normal or will I need a caesarean section?
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Will I be able to cope with the baby?

All these questions go through the minds of my patients, and I answer them all and together we plan the pregnancy from beginning to after, together with the spouse, general practitioner and gynecologist.

Regarding fertility.

For the majority of patients there should be no problem regarding falling pregnant in the first place.

Only in certain rheumatic conditions, the connective tissue disorders (CTDs), where there is an immune attack against the patient’s own tissues, is there reduced fertility. These diseases are rare and include Systemic lupus erythematosus (SLE), and Scleroderma. They vary in severity from mild to life threatening, and require specialist care. They are considered high-risk pregnancies and require close care and follow up. In the case of SLE, a higher incidence of miscarriage, especially in the second third of pregnancy, may be seen, largely association with a blood antibody called the Antiphospholipid antibody. In fact about 20% of pregnancies in SLE, terminate spontaneously. In addition, the hormonal factors of pregnancy also aggravate the course of SLE, with a tendency for flares of the disease and increased complications in the pregnancy.

It must also be remembered that certain medications taken for the arthritis, may require review as they can influence fertility. This applies to both spouses. Sulphasalazine, a disease-controlling drug used frequently in arthritis, may reversibly reduce sperm counts. Therefore if the male has arthritis and is on this drug, it may need to be temporarily discontinued if there are fertility problems related to low sperm counts. This is rare and not usually a problem. Routine stopping of the drug by the male partner is not required.

Other drugs known as cytotoxic drugs, for life threatening aspects of CTD's, may have influence on fertility. These include Cyclophosphamide and Chlorambucil. Both are rarely utilized, but may render the patient infertile.

The effect of the pregnancy on arthritis.

In general several physical changes occur in pregnancy. These are clearly hormonally influenced, but have a huge impact on the immune state and the musculoskeletal system. In general we find a laxity of the ligaments, especially in the last third or trimester of the pregnancy. This is the body’s mechanism to relax the ligaments of the pelvis, to help allow the baby to fit through the birth canal and the pelvis at childbirth. The lax ligaments of the spine result in an increased curvature of the spine. This is called a lordosis, and allows the female to adjust her center of gravity to accommodate the fetus in the abdomen and maintain her posture. As a result low back pain is common in pregnancy, and this does not mean that the patient is developing arthritis. The problem is usually a dull ache that may get worse through the day, and may be throbbing at night. It usually is managed by postural exercises and relation techniques taught at antenatal classes and may require simple analgesia, such as paracetamol. The nature of this pain is benign and is termed “soft tissue rheumatism”, because it originates from the soft tissue – i.e. ligaments, tendons and muscles. It resolves after the end of the pregnancy within weeks in the majority.

There are however certain Rheumatic diseases that are affected positively by pregnancy. Interestingly, in the most severe and commonest type of arthritis affecting women of childbearing age, Rheumatoid arthritis (RA), there is a tendency for pregnancy to induce a remission of the disease for the duration of the pregnancy. This will happen in about 80% of patients with RA who become pregnant, and will likely start to improve within 12 weeks and then progressively improve through the duration of the pregnancy. The only problem is that after the pregnancy, the arthritis comes back, and frequently with a vengeance. 33% will redevelop the arthritis by 1 month, and 98% by 4 months. There are in fact a significant percentage of people who develop RA for the first time in the months after a pregnancy. The reason for these phenomenon are not clear. The answer is not simply estrogen or hormonal changes, but more likely changes in the immune system induced by the pregnant state.

Interestingly, if there is a remission of arthritis in a pregnancy, then it is likely that there will be a similar pattern for subsequent pregnancies.

Effects of the arthritis on the delivery

There are undoubted problems that can occur in women with mechanical problems, but these are entirely individualized problems. The problems of joint limitation may require caesarean section, and the need for this can be predetermined by simple examination and assessment of the patient concerned.

The mechanical problems with arthritis and the almost inevitable risk of a flare in RA patients, makes the task of motherhood extremely challenging but not impossible. People with arthritis, have the same maternal urge, as any other, and the joy of childbirth and the bonding process is as strong. Occupational and physiotherapy specialists may be very helpful here for the provision of assistant devices which make bathing, clothing and feeding of the infant easier.

The effect of the arthritis on the baby

For the patient with RA, there is no fear that the health of the baby will be adversely affected. There are few grounds for fears that the baby will develop arthritis either, and the mother can be reassured. Long-term risks of developing arthritis depend on genetic factors independent of pregnancy related concerns and depend on the individual patient’s diagnosis.

Drug safety in pregnancy

The age of medications – both prescription and over the counter medicines, make it crucial for the patients out there, to know all about the drugs they are prescribed and what they mean regarding both benefit and side effect potential. A simple principle is to avoid drugs unless absolutely necessary, and even then to consult your doctor regarding safety of that drug in pregnancy.

The commonest drugs for rheumatic diseases are the analgesics and the anti-inflammatory agents. Analgesics such as paracetamol are felt to be largely safe in pregnancy and no additional precautions are required. Addition of codeine to the preparations however changes the safety profile. Generally codeine is to be avoided. Anti-inflammatory drugs are not dangerous in early phase of pregnancy, to the fetus. Therefore they can be continued until the pregnancy is confirmed, then we generally discontinue them. In later stages of pregnancy – especially in the last third (trimester) of the pregnancy, they are definitely not advised as they can cause a problem with the fetal vessel anatomy – and also result in a bleeding tendency resulting in greater blood loss at delivery, and risk of fetal hemorrhage. In lactation we generally allow the drugs that are short acting and avoid the long acting drugs. The safety of the COXIB drugs, are not tested in pregnancy. No fetal abnormalities have been described but since they are very new, further information will be required before general advice on their use in pregnancy can be given. Until that time, they should be avoided in pregnancy. Females trying to become pregnant should also probably avoid them, as temporary and short-term effects on ovulation and implantation of the ovum (egg) into the uterus may occur in theory, although not documented in practice. Pregnancy developing whilst taking these medications requires simply to stop the drug, and no additional interventions are required.

Disease modifying drugs are more complicated. The use of these medications, keep arthritis in remission, and withdrawal under normal circumstances results in a flare of disease, usually about three weeks after withdrawal. Pregnancy however itself fortunately maintains remission, and therefore withdrawal of the drugs is not practically a problem. The problem however, is that some drugs have to be withdrawn in anticipation of a pregnancy developing. Methotrexate is a typical example of this. The drug should be withdrawn three months prior to a planning pregnancy. The same applies to immune suppressing drugs such as Cyclophosphamide and Chlorambucil. In addition the Methotrexate as used by the male partner, should also be withdrawn three months before trying to plan a pregnancy. These drugs should be discontinued until after lactation has stopped.

The use of Sulphasalazine has never been associated with fetal abnormality, and a lot of experience is known of the drug during pregnancy and lactation. However we still advice discontinuing the drug in a pregnancy and only using it if absolutely necessary.

Antimalarial therapy such as chloroquine, has not been shown to be unsafe in pregnancy or lactation, but again we recommend only using it if absolutely necessary.

Gold therapy by injection is generally not advised. (There are no reports of fetal malformation, however). Withdrawal at least one month in advance is suggested.

Penicillamine, is not advised in pregnancy, and it is recommended that the drug is withdrawn one month prior to planning pregnancy.

Corticosteroids in pregnancy and lactation, are generally considered safe in low dose. Animal studies showing risk of cleft palate are not shown in humans. They offer the therapy of choice in those pregnant patients who are flaring and cannot take the disease modifying drugs or anti-inflammatory drugs.

Cortisone injections can also be used in pregnancy without problems.

After the pregnancy

After pregnancy, a short period of lactation is advised in rheumatoid arthritis, due to the high risk of disease recurrence, and the need to initiate therapy on that basis. Cleary, every patient is different, but in general we advise patients with severe disease to restart therapy as soon as possible.

The final interesting scenario is the patient who develops pain in the joints after pregnancy is complete. The coexistence of stiffness must make the doctor aware on onset of an inflammatory arthritis, such as rheumatoid arthritis, which is known to frequently, first start, after a pregnancy.

However, pain doesn’t mean such a diagnosis is invariable, as common musculoskeletal problems of tendonitis, especially with back pain are not infrequent. The clinical examination remains the test of choice in this circumstance, and referral to a rheumatologist will often relieve anxiety for the patient with appropriate reassurance given, where possible, but also early therapy, where required.

Conclusion

Pregnancy may indeed be as satisfying to the patient with arthritis as any other person.
Careful planning with the rheumatologist and gynecologist, regarding timing and also proper antenatal and postnatal care, make it even easier, so that practical interventions can be made during the process, to ensure it is pain-free and that nursing is a joy and not a burden.


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Dr David Gotlieb
drdoc on-line
Constantia Arthritis Clinic
Cape Town
August 2000