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Pregnancy and other Rheumatological Diseases . Dr Subramanian R, MD PDF JSS Medical College Mysore . Case Scenarios . Case A. Case B . 25 yr old patient 2 nd pregnancy , in her 7 th month Diagnosed as Rheumatoid arthritis 4 years of disease Previous pregnancy 2 years back
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Pregnancy and other Rheumatological Diseases Dr Subramanian R, MD PDF JSS Medical College Mysore
Case Scenarios Case A Case B 25 yr old patient 2nd pregnancy , in her 7th month Diagnosed as Rheumatoid arthritis 4 years of disease Previous pregnancy 2 years back Currently on hydroxychloroquine Has mild joint pains in the hands with early morning stiffness • 23 yr old patient • 3 months amenorrhoea • Diagnosed case of vasculitis • Had renal involvement 1 year back • Currently on low dose steroids and azathioprine • Skin lesions in the lower limbs : biopsy s/o vasculitis
Outline • Common connective tissue disorders and vasculitis in pregnancy • Outcome of pregnancy • Problems that need to be anticipated • Safety of the drugs • Future pregnancies
Autoimmune disorders Connective tissue disorders Vasculitides Wegener’s granulomatosis Churg–Strauss syndrome Microscopic polyangitis Polyarteritisnodosa Takayasuarteritis Behcet ‘s disease • Rheumatoid arthritis • Seronegativespondyloarthritides • Undifferentiated connective tissue diseases (UCTD) • Mixed connective tissue diseases (MCTD) • Polymyositis–dermatomyositis (PM–DM)
Flares • Drugs • Mode of delivery
Organ involvement • Inflammation of blood vessels and organ ischemia • Abortions, IUGR • Drugs • Flares of the disease
RA and pregnancy • Majority of pregnancies in women with RA are without complication • the mother has a decrease in her arthritis pain • the baby is born healthy • 75% of women experienced improvement in their disease during pregnancy (range 54–86%) and 90% of women reported a relapse in disease within 3 months of delivery OstensenM, Villiger PM. The remission of rheumatoid arthritis during pregnancy. SeminImmunopathol2007;29:185–91 Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis. Rheum DisClin North Am 1997;23:195–212
Pregnancy outcomes for women with Rheumatoid arthritis Scand J Rheumatol 2010;39:99–108
Premature delivery and Preeclampsia • risk for preterm birth, however does seem to be increased for women with RA • one out of every four women with RA delivered early compared to 1 in 10 women without RA • Preeclampsia and caesarean section rates have been shown to be higher in mothers with RA • Having increased RA activity and using disease-modifying anti-rheumatic drugs (DMARDs) and steroid medications increases the risks for these complications
Influence of treatment change • Women may change or cease treatment during or after pregnancy for a variety of reasons, including improvement in symptoms and fear of harming the fetus
Subsequent pregnancy previous experience postpartum was not predictive of deterioration after the current pregnancy
Ankylosingspondylitis • Compared to pregnant women with RA, women with AS generally experience unchanged or increased disease activity • increased morning stiffness • spinal tenderness • pain at night and need for non-steroidal medications during pregnancy
…contd • AS associated with small joint disease ,psoriasis, or ulcerative colitis have improvement • Postpartum flares are also common, especially during the first 3 months after delivery • The postpartum flare is independent of level of disease activity during pregnancy, period of lactation, or the return of menses • Disease activity during the year following delivery seems to return to the same level as before conception • There appears to be no increase in frequency of miscarriage, premature labour, or delivery complications in this population of women
…contd • Of note, women with AS experience a similar increase in Tregs during pregnancy as women with RA • However, Tregs in pregnant woman with AS secrete less IL-10 and have lower suppression of INF-g and TNFa secretion by effector T cells • This may account for the difference in disease activity experienced during pregnancy among women with AS and RA
Pregnancy other connective tissue disorders and vasculitis • Outcome of pregnancy depends on • organ involvement • Status of immunosuppressive drugs • Previous pregnancy related complications • Comorbidities
Scleroderma and pregnancy • Successful pregnancy could be achieved with good outcomes both in the mother and infant
…contd • Scleroderma disease activity does not change in pregnancy • Raynaud’s phenomenon may improve with pregnancy secondary to a physiological increase in cardiac output • Gastroesophageal reflux disease (GERD) worsens, especially during the latter part of pregnancy
…contd • Scleroderma renal crisis is a feared complication during pregnancy • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are life-saving treatments for scleroderma renal crisis • renal atresia, pulmonary hypoplasia, and foetal death • Prior episode of renal crisis is not a strict contraindication for future pregnancy, but it is recommended that a woman wait several years until her disease is stable before trying to conceive
Pulmonary hypertension is another serious complication and is associated with 50% maternal mortality, and most vigilance is required 48 to 72 hours after delivery
Vasculitides • Vasculitides can occur at any age but are generally more frequent in men and in women beyond their reproductive period • Planning conception at a time of disease inactivity usually allows women with Wegener granulomatosis (WG), polyarteritisnodosa (PAN), or Churg-Strauss syndrome to remain well during pregnancy
They are at risk of deterioration during pregnancy and the first 6 weeks after delivery should conception occur when the disease is inadequately treated or newly active • In Takayasuarteritis (TA), severe aortic valvular disease and aortic aneurysm are risk factors for maternal morbidity and fatality; therefore, pregnancy is discouraged in these patients
Pregnancy effects • Hypertensive disease is more common in women with WG and renal involvement than in normal pregnant women • Pregnancy complications and cesarean section were significantly higher in BD patients than in controls , as with most other vasculitides, particularly TA and WG
Other diseases • UCTD • Polymyositis and dermatomyositis • MCTD
What to do when disease is active in pregnancy ? • Trimester • Fetal status • Drugs • Organ involvement • Safe pregnancy Abortion , early delivery • IUGR , abnormalities • High dose steroids / Azathioprine , IVIG • Major or minor
Autoantibodies and pregnancy • Anti-thyroid antibodies (ATAs) have been suggested to be independent markers of ‘at-risk’ pregnancy • Euthyroid women with recurrent miscarriage have increased levels of autoantibodies either against thyroglobulin (aTG) or thyroid peroxidase (TPO) while the probability of abortion in women with ATA has been shown to be greater than in controls
the prevalence of ATA has been reported to be 15–20% in normal pregnant women, compared with 20–25% in women with recurrent miscarriages • Anti-laminin antibodies : IgG anti-laminin antibodies have been associated with infertility and recurrent first-trimester miscarriages in humans
Conclusion • With careful planning, most women with inflammatory rheumatological diseases can have successful pregnancies • It is important that conception occur when the disease has been inactive for at least 6 months and while the mother is taking non-teratogenic drugs