Rheumatoid Arthritis in Pregnancy

Question

A 30-year-old patient with juvenile rheumatoid arthritis (RA) had a positive result on antinuclear antibody (ANA) test and on anti-extractable nuclear antigen (anti-ENA) and anti-Sjögren's syndrome A (anti-SSA) tests. She is now pregnant for the first time (6 weeks gestation). Do you recommend any special line of treatment or further tests on this patient?

Arild Kloster-Jensen

Response From Expert

Karen L. Koscica, DO
Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York

RA is the most common rheumatic disease that complicates pregnancies -- cases occur in about 1/1000 pregnancies to 1/2000 pregnancies. It is characterized by selective inflammation of the synovial joints in which there is lymphocytic and monocytic infiltration of the synovia.^[1] Symmetrical joint involvement is typical. Extra-articular involvement includes vasculitis, lung disease, pericarditis, neuropathy, and subcutaneous nodules.^[2]

The onset of this disease occurs with pain and swelling in 1 or more joints in the upper extremity. The progression of the disease then settles on the joints symmetrically, with the lower extremities becoming involved. Involvement of the distal finger joints is rare, and the spine is almost never involved. The hip joint may be affected, but this is usually a late manifestation of the disease.^[1]

The course of RA during pregnancy is usually benign. In about three fourths of pregnancies, the symptoms of the disease lessen. In these cases, most women experience relief in the first trimester that continues throughout the pregnancy. RA does not adversely affect pregnancy outcome. With occasional exception, RA returns after the third to fourth month postpartum.^[2]

Juvenile chronic arthritis by definition starts before the age of 16. It not only affects the joints but can also have extra-articular manifestations. Patients suffering from this disease may have difficulties in pregnancy. Growth inhibition of the pelvis or hip may interfere with a vaginal delivery. The temporomandibular joint and larynx can be involved in young patients and should be considered in case of difficulty with intubation, if needed. However, in the only reported case series, by Nelson and Ostensen,^[2] patients with juvenile-onset RA seem to experience improvement during pregnancy. There was no increased risk of poor pregnancy outcomes.^[1,2]

The diagnosis is made on the basis of clinical evaluation and with the supporting laboratory data, namely the presence of rheumatoid factor. This should be positive within 1 year of onset of the disease. Generally, titers of 1:160 or greater confirm the diagnosis. Unfortunately, other etiologies can result in positive titers, such as other rheumatic diseases, chronic inflammatory processes (such as tuberculosis), and subacute bacterial endocarditis.^[1]

Treatment of RA in pregnancy mostly entails drug therapy. Clinicians must determine which agent is safe and effective for a given patient. Acetaminophen should be the first line, and, if not adequate, other nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin should be considered depending on the gestational age of the fetus (NSAIDs used in the third trimester can result in premature closure of the fetal ductus arteriosus). If these agents do not provide relief, corticosteroids are the next line of treatment. Sulfasalazine and penicillamine treatment also seem to be safe for use during pregnancy. Antimalarial drugs such as chloroquine should be avoided, as they may cause chorioretinitis in the fetus. Gold causes blood dyscrasias, drug rashes, and nephropathy and is therefore of theoretical risk to the fetus.^[1]

Medscape Ob/Gyn. 2003;8(1) © 2003  Medscape

Cite this: Peter S Bernstein, Karen L Koscica. Rheumatoid Arthritis in Pregnancy - Medscape - Feb 05, 2003.