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

RA & Other Chronic Inflammatory Arthritides

RA is less common in women of child-bearing age than in older women (0.1–0.2% vs 2–5%), but its incidence in pregnancy is increasing as women delay child-bearing.[52]

Contrary to previous research,[53] recent prospective studies show that only 48–66% of women with RA experience improvement in pregnancy, with only approximately 20% becoming quiescent by the third trimester.[54,55] This change may be due to new treatment regimes, as women receive more aggressive treatments and enter pregnancy with more stable disease so they have less margin to improve.[54,55] A recent prospective study that included 118 pregnant women with RA showed that those with positive rheumatoid factor and anti-cyclic citrullinated antibody (anti-CCP) were less likely to improve during pregnancy. However, all women had the same chance of flare postpartum regardless of their serological profile, and antibody levels had no relationship with activity either pre- or post-natally.[56]

Most women with psoriatic arthritis (PsA) generally improve or even remit in pregnancy, whereas the majority with ankylosing spondylitis (AS) stay unaltered or worsen during pregnancy.[57,58] The minority of AS patients who markedly improve while pregnant usually have AS with accompanying diseases, such as psoriasis, ulcerative colitis or small joint arthritis. In cases of juvenile RA, quiescent disease is not generally reactivated by pregnancy, and active disease at conception ameliorates in approximately 60%.[57,58] Postpartum flares occur within the first 4 months in most patients with chronic inflammatory arthritides.[55,59] Furthermore, new-onset of RA is three- to five-fold more likely during this postpartum period.[54,60] A prospective study including 112 women showed that pregnancy and oral contraceptive use do not significantly influence long-term joint damage or disability in RA. Interestingly, patients with multiple pregnancies and long-term oral contraception had less radiographic joint damage and better functional levels.[61]

The few available studies on pregnancies in women with RA suggest that outcomes are worse than in the general population,[62,63] and some have found that hypertensive disorders, including preeclampsia, are more frequent[62–65] and often related to preterm deliveries, although this may be confounded by corticosteroid use or underlying disease severity.

Children born to women with inflammatory arthritides, including RA, are more likely to be small for gestational age, to be born preterm (<37 weeks) and to have lower birth weight,[63–66] which seems to be particularly associated with disease activity and corticosteroid treatment.[62,67] Women with RA may have higher risk for fetal deaths.[66] Cesarean section is more common in RA, and probably related to the high rates of induction of labor and elective sections chosen by obstetricians.[62,63,65,66]

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