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

Postpartum

Because of a high risk of disease flare and thrombosis, close surveillance for 2–3 months after delivery is important. A medical visit should be arranged in the first 4–6 weeks postpartum, which should consist of thorough history review, physical examination, urine analysis, BP check and blood tests including full blood count, liver function tests, renal profile and activity markers such as erythrocyte sedimentation rate, C-reactive protein, anti-dsDNA and complement.

All women with aPL should receive prophylactic LMWH for at least 7 days after delivery.[91,202] Some experts recommend extending this treatment for 4–8 weeks postpartum.[90] Those who received prophylactic doses of LMWH during pregnancy or those with high venous thromboembolic risk should continue this treatment for 6 weeks postpartum.[202] Women with previous thrombosis often require long-term anticoagulation. In that case, LMWH should be switched to warfarin or coumadin when the risk of hemorrhage is reduced (usually 5–7 days postpartum).[202] After delivery, therapeutic LMWH can be safely used as a single dose daily (e.g., enoxaparin 1.5 mg/kg once daily).

Counseling on contraception is of great importance in rheumatologic diseases as planned pregnancy is associated with less complications and higher pregnancy success rates.

Barrier methods, including condom and diaphragm, represent an effective form of contraception (83–97% success) and the only protective method against sexually transmitted infections.[137]

Hormonal methods include oral contraceptives (OC; combined or progesterone-only) and subcutaneous devices (i.e., implants, injectables, skin patches and vaginal rings). Despite the classic advice against the use of estrogen-containing OC in women with lupus, current evidence supports the safety of combined OC in well-defined SLE patients with stable and/or low-active disease.[138] However, because of the increased risk of thrombosis, combined OC are contraindicated in patients with aPL and/or other risk factors such as moderate–severe active disease, and a history of thrombosis, hypertension, smoking or obesity.[203] Progesterone-only preparations are safe and do not affect disease activity or thrombosis risk,[139] but may reduce bone density when used for >2 years.[140] The latter effect seems to be reversible after discontinuation. Interactions between hormonal contraceptives and other medications the patient may be taking may provoke contraceptive failure and/or alterations in metabolism of such drugs.

Intrauterine device (either nonhormonal devices – e.g., copper coil – or progesterone intrauterine system [IUS] – e.g., Mirena® hormonal devices) are also safe. IUSs are extremely effective (98% success) and reduce menstrual bleeding, which is useful in women on warfarin. Intrauterine devices have a 5% chance of expulsion and confer a higher pelvic infection risk (1%), and are thus generally preferred in patients with a single sexual partner.[141]

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