Pregnancy and Rheumatic Disease
- Each woman’s rheumatic disease should be well under control for a period of at least 3–6 months before attempting pregnancy.
- Women with a low-risk profile can be managed with usual visits to the rheumatologist as a precaution. Those with a high-risk profile should be managed by both the rheumatologist and obstetric team with experience in high-risk pregnancies
- Up to 50% to 75% of patients with rheumatoid arthritis (RA) improve during pregnancy.
- Patients with systemic lupus erythematosus (SLE) who have anti-Ro (SS-A) and anti-La (SS-B) antibodies are at increased risk for having infants who develop neonatal lupus syndrome.
- Patients with SLE should attempt to become pregnant only when their disease is controlled for over 6 months.
- Hydroxychloroquine offers more benefit than risk when used in a pregnant patient with SLE.
- Azathioprine is the safest nonbiologic disease-modifying agent to use in a patient who requires additional immunosuppressive therapy.
Pregnancy-related conditions may mimic a rheumatic disease exacerbation: facial flushing (mimics SLE malar rash), preeclampsia and eclampsia (mimics lupus nephritis, scleroderma renal crisis), HELLP syndrome (mimics SLE flare), low back pain (mimics ankylosing spondylitis [AS] exacerbation), gastroesophageal reflux (mimics worsening scleroderma), arthralgia and carpal tunnel syndrome (mimics arthritis exacerbation).
Fertility is not affected by the spondyloarthropathies. Fetal outcomes are similar to the general population. The course of ankylosing spondylitis varies during pregnancy (33% improve, 33% worsen) and up to 60% worsen postpartum (mostly low back pain). Notably, up to 50% of patients with psoriatic arthritis improve. Patients with severe back and/or hip disease should be assessed for their capability to deliver vaginally.
Infertility is not increased in patients with well-controlled RA, and there is no significant increase in fetal or maternal complications except for risks associated with its therapy. Patients with active disease during the third trimester are more likely to have preterm births and/or small for gestational age babies. In patients with long-standing RA, joint involvement should be assessed before delivery. If the cervical spine is involved, care should be taken to not hyperextend the neck, and vaginal delivery may be precluded by significant hip involvement.
was once considered to be associated with reduced fertility, but more recent data contradict this. Some (7% to 20%) women experience a worsening of their disease during pregnancy. The most feared complication, scleroderma renal crisis, does not appear to be increased (2% to 3%) during pregnancy. During pregnancy, Raynaud’s symptoms often improve and gastrointestinal reflux and arthralgias often worsen. Fetal complications, such as miscarriage (15%), prematurity (25% to 40%), and intrauterine growth restriction (IUGR) can occur. Patients with pulmonary hypertension have a high rate of adverse maternal and fetal outcomes and should not get pregnant.