Management of Rheumatologic Diseases in Pregnancy

Oier Ateka-Barrutia; Catherine Nelson-Piercy

Disclosures

Int J Clin Rheumatol. 2012;7(5):541-558. 

In This Article

Pregnancy Management Plan

Pre-pregnancy counseling, risk assessment and stratification, multidisciplinary approach, tailored antenatal and postnatal management plan, an experienced high level neonatal unit and early recognition of flares and complications (either medical and/or obstetric), are essential cornerstones to optimize the chance of both maternal and fetal successful outcomes.

The preconception visit should include a detailed summary of previous obstetric history and chronic organ damage, and recent serological profile (RF, anti-CCP, aPL, anti-Ro/La, anti-dsDNA and complement). It is important to ascertain current disease activity and last flare date, additional medical history and risk factors of interest (e.g., diabetes, hypertension, cardiac and cardiovascular problems, nephropathy, smoking and alcohol history, and their complications), and baseline BP, urine analysis and renal function. Harmful or unsafe medications should be stopped or changed to safer ones prior to pregnancy, and discussion of planned scans and visits undertaken. All women should ideally take folic acid (0.4 mg/day) 12 weeks before and after conception in order to reduce the risk of fetal neural tube defects, and should be encouraged to stop smoking and to reduce/cease their alcohol intake. Concomitant prophylactic calcium and vitamin D supplements should be prescribed to women on corticosteroids, heparin and/or at high risk for osteoporosis or vitamin D deficiency. Hemoglobinopathy profile assessment may be indicated in certain circumstances and immunity to rubella should be confirmed.[132]

Presence of aPL/APS and/or anti-Ro/La, poor previous obstetric history, independent risk factors for preeclampsia, severe irreversible organ damage, other medical comorbidities and active disease are associated with obstetric and medical complications. Accordingly, the main risks for the mother and the baby should be discussed. Women with active disease should postpone conception until stable disease remission is achieved, particularly those with internal organ involvement and damage. Pregnancy should be discouraged in patients with severe flare or stroke over the last 6 months, pulmonary hypertension, moderate–severe heart failure, severe restrictive lung disease (FVC<1L), CKD stage 4–5 (eGFR<30 ml/min), uncontrolled hypertension and previous severe early onset (<28 weeks) preeclampsia despite therapy with aspirin plus heparin.

Women considered at high risk should be managed in a multidisciplinary medical/rheumatological/obstetric clinic throughout pregnancy, continuing with adequate joint postpartum care. Women with mild disease and/or considered to be at low risk of complications could be managed by their obstetricians and midwives with medical visits as needed.

The frequency of antenatal visits will depend on the past history and the progress of the current pregnancy. As a guide, from 16 weeks to 28 weeks of gestation women should be reviewed every 4 weeks, fortnightly from 28 to 34 weeks of gestation, and weekly from 34 weeks onwards. Every visit should include urine analysis and maternal assessment, with special attention to hypertension and other features of preeclampsia. Women with previous renal and/or hypertensive diseases should have more frequent BP checks, and those on steroids should be screened for gestational diabetes. Confirmation and quantification of proteinuria by protein-creatinine ratio is mandatory if urine dipstick is positive for protein. Regular blood tests including full blood count, liver function tests, renal profile and activity markers such as C-reactive protein, anti-dsDNA and complement every 4–8 weeks are recommended in those with severe or active disease.

Anomaly scan and uterine artery Doppler is recommended at approximately 20 weeks of gestation, and the latter should be repeated at approximately the 24th week if abnormal. Abnormal waveforms predict preeclampsia/IUGR, and the negative predictive value of normal results for good obstetric outcomes is high.[133]

Ultrasound scans (including biophysical profile, amniotic fluid volume assessment and umbilical artery Doppler) are recommended in patients with active inflammatory disease or may be indicated depending on previous obstetric history and the progress of current pregnancy. In women with anti-Ro/La, regular fetal echocardiography between 18–28 weeks of gestation is offered to identify CHB.[94]

In patients with spinal involvement, scleroderma and reduced respiratory function, and in those receiving therapeutic LMWH, anesthetic review should be arranged. Elective cesarean section is usually only required for obstetric indications.

As discussed above, patients with SLE, RA, UCTD and/or aPL have a higher risk of developing preeclampsia compared with the general population. LDA started early in pregnancy significantly reduces the risk of preeclampsia and its complications in women at higher risk.[134] Dypiridamole probably has similar effects.[201] In addition, all women with aPL should take LDA to decrease their risk of miscarriage.[91]

A recent meta-analysis of 13 randomized trials comparing the intake of at least 1 g of calcium daily versus placebo during pregnancy showed a >50% reduction in the risk of preeclampsia and a 25% reduction in the risk of preterm delivery.[135] Calcium supplementation is therefore appropriate in some of these patients.

All women should be carefully assessed regarding risk factors for venous thromboembolism prior to conception and periodically throughout pregnancy, and should receive appropriate thromboprophylaxis if indicated.[202]

Women receiving high-prophylactic or therapeutic doses of LMWH should discontinue it or swap to prophylactic doses (enoxaparin 0.6 mg/kg once daily; e.g., 40 mg if weight 50–90 kg) 24 h prior to the planned delivery. Those on prophylactic doses of LMWH should discontinue LMWH once labor is established. Re-establishment of LMWH should be postponed until the placenta is delivered. Epidural anesthesia can be safely used 12 or 24 h after the last dose of LMWH on prophylactic or high-prophylactic/therapeutic doses, respectively. LMWH can be restarted 2 h after the epidural catheter has been removed.[136]

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