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A Clinician's Pearls and Myths in Rheumatology pp 181–190Cite as

Pregnancy in the Rheumatic Diseases

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Abstract

Few conditions in rheumatology are fraught with greater concern and more unknowns than those of fertility and pregnancy. Patients with rheumatologic disease are not at higher risk for infertility than the general population, unless they have received cyclophosphamide. In general, the inflammation from active rheumato-logic disease is more dangerous to a pregnancy than immunosuppressant medications. Medications to continue if needed to control disease: hydroxychloroquine, azathioprine, sulfasalazine, and prednisone. Medications to discontinue prior to pregnancy: metho-trexate, leflunamide, mycophenolate mofetil, cyclophos-phamide. Normal pregnancy can alter laboratory findings. In particular, the creatinine should fall and proteinuria may increase mildly. The sedimentation rate and complement may increase. Flares in lupus during pregnancy tend to be mild. Patients at highest risk for a severe flare have active lupus at the time of conception. Even treated with low molecular weight heparin and aspirin 81mg a day, up to 25% of pregnancies in women with antiphospholipid syndrome will result in a pregnancy loss. Maternal SSA/Ro and SSB/La antibodies put a baby at risk for neonatal lupus. Up to 50% of these mothers do not fit criteria for a rheumatologic disease. Rheumatoid arthritis will improve in many women during pregnancy, but often flares post-partum. Medications may be tapered during pregnancy but should be restarted following delivery to avoid a severe flare.

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References

  • Armenti VT, Radomski JS, et al Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 2004;103–114

    Google Scholar 

  • Baethge, B. A. and R. E. Wolf (1989). “Successful pregnancy with scle-roderma renal disease and pulmonary hypertension in a patient using angiotensin converting enzyme inhibitors.” Ann Rheum Dis 48(9): 776–8

    Article  PubMed  CAS  Google Scholar 

  • Barr, M., Jr. (1994). “Teratogen update: angiotensin-converting enzyme inhibitors.“ Teratology 50(6): 399–409

    Article  PubMed  CAS  Google Scholar 

  • Barrett JH, Brennan P, et al Does rheumatoid arthritis remit during pregnancy and relapse postpartum? Results from a nationwide study in the United Kingdom performed prospectively from late pregnancy. Arthritis Rheum 1999; 42:1219–1227

    Google Scholar 

  • Brun JG, Nilssen S, Kvale G. Breast feeding, other reproductive factors and rheumatoid arthritis: A prospective study. Br J Rheumatol 1995; 34:542–546

    Google Scholar 

  • Chakravarty EF, Sanchez-Yamamoto D, Bush TM. The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: A survey of practice patterns and pregnancy outcomes. J Rheumatol 2003; 30:241–246

    PubMed  Google Scholar 

  • Chakravarty, E. F., D. Khanna, et al (2008). “Pregnancy outcomes in systemic sclerosis, primary pulmonary hypertension, and sickle cell disease.” Obstet Gynecol 111(4): 927–34

    Article  PubMed  Google Scholar 

  • Cooper W. O., S. Hernandez-Diaz, et al (2006). “Major congenital malformations after first-trimester exposure to ACE inhibitors.” N Engl J Med 354(23): 2443–51

    Article  PubMed  CAS  Google Scholar 

  • Clowse M. Lupus activity in pregnancy. Rheum Dis Clin N Amer 2007; 33:237–252

    Article  Google Scholar 

  • Clowse MEB, Witter F, et al Complement and anti-double stranded DNA antibodies predict pregnancy outcomes in lupus patients. Arthritis Rheum 2004; 50(suppl):S689

    Article  Google Scholar 

  • Clowse ME, Magder LS, et al The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum 2005; 52:514–521

    Article  PubMed  Google Scholar 

  • Clowse ME, Magder L, et al Hydroxychloroquine in lupus pregnancy. Arthritis Rheum 2006a; 54:3640–3647

    Article  Google Scholar 

  • Clowse ME, Magder LS, et al Early risk factors for pregnancy loss in lupus. Obstet Gynecol 2006b; 107(2 Pt 1):293–299

    Article  Google Scholar 

  • Clowse ME, Jamison M, et al A national study of the complications of lupus in pregnancy. Am J Obstet Gynecol 2008; 199:127.e1–e6

    Article  Google Scholar 

  • Costa M, Colia D. Treating infertility in autoimmune patients. Rheumatology (Oxford) 2008; 47(Suppl 3):38–41

    Google Scholar 

  • Costedoat-Chalumeau N, Amoura Z, Duhaut P, et al Safety of dyroxy-chlroroquine in pregnant patients with connective tissue diseases: A study of one hundred thirty-three cases compared with a control group. Arthritis Rheum 2003; 48:3207–3211

    Article  PubMed  CAS  Google Scholar 

  • Costenbader KH, Feskanich D, Stampfer MJ, Karlson EW. Reproductive and menopausal factors and risk of systemic lupus erythematosus in women. Arthritis Rheum 2007; 56:1251–1262

    Article  PubMed  Google Scholar 

  • Duley L, Henderson-Smart DJ, et al Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev 2007; (2):CD004659

    Google Scholar 

  • Empson M, Lassere M, et al Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Cochrane Database Syst Rev 2005; (2):CD002859

    Google Scholar 

  • FDA, 2007. www.fda.gov/cder/drug/InfoSheets/HCP/mycophelolate-HCP.htm

    Google Scholar 

  • Gayed, M. and C. Gordon (2007). “Pregnancy and rheumatic diseases.” Rheumatology (Oxford) 46(11): 1634–40

    Article  CAS  Google Scholar 

  • Gordon PA. Congenital heart block: Clinical features and therapeutic options. Lupus 2007; 16:642–646

    Article  PubMed  CAS  Google Scholar 

  • Izmirly PM, Rivera TL, Buyon JP. Neonatal lupus syndromes. Rheum Dis Clin N Amer 2007; 33:267–285

    Article  Google Scholar 

  • Karlson EW, Mandl LA, Hankinson SE, Grodstein F. Do breast-feeding and other reproductive factors influence future risk of rheumatoid arthritis. Arthritis Rheum 2004; 50:3458–3467

    Article  PubMed  Google Scholar 

  • Katz PP. Childbearing decisions and family size among women with rheumatoid arthritis. Arthritis Rheum 2006; 55:217–223

    Article  PubMed  Google Scholar 

  • Kikuchi K, Shibahara H, et al Antinuclear antibody reduces the pregnancy rate in the first IVF-ET treatment cycle but not the cumulative pregnancy rate without specific medication. Am J Reprod Immunol 2003; 50:363–367

    Article  PubMed  Google Scholar 

  • Levy M, Buskila D, Gladman DD, Urowitz MB, Koren G. Prengnancy outcome following first trimester exposure to chloroquine. Am J Perinatol 1991; 8:174–178

    Article  PubMed  CAS  Google Scholar 

  • Lin P, Bonaminio P, Ramsey-Goldman R. Pregnancy & rheumatic diseases. In: Imboden J, Hellmann D, Stone J (eds) Current diagnosis & treatment. Rheumatology (2nd edn). New York, McGraw-Hill, 2007, pp. 146–159

    Google Scholar 

  • Lockshin MD. Autoimmunity, infertility and assisted reproductive technologies. Lupus 2004; 13(9):669–672

    Article  PubMed  CAS  Google Scholar 

  • Martin V, Lee LA, Askanase AD, Katholi M, Buyon JP. Long-term fol-lowup of children with neonatal lupus and their unaffected siblings. Arthritis Rheum 2002; 46:2377–2383

    Article  PubMed  Google Scholar 

  • McKay DB, Josephson MA, et al Reproduction and transplantation: Report on the AST Consensus Conference on reproductive issues and transplantation. Am J Transplant 2005; 5:1592–1599

    Article  PubMed  Google Scholar 

  • Meads CA, Cnossen, et al Methods of prediction and prevention of pre-eclampsia: Systematic reviews of accuracy and effectiveness literature with economic modelling. Health Technol Assess 2008; 12(6):iii–iv, 1–270

    CAS  Google Scholar 

  • Merlino LA, Cerhan JR, Criswell LA, Mikuls TR, Saag KG. Estrogen and other female reproductive risk factors are not strongly associated with the development of rheumatoid arthritis in elderly women. Semin Arthritis Rheum 2003; 33:72–82

    Article  PubMed  CAS  Google Scholar 

  • Milunsky A, Graef JW, Gaynor MF. Methotrexate-induced congenital malformations. Med J Aust 1968; 2:1076–1077

    Google Scholar 

  • Miniati, I., S. Guiducci, et al (2008). “Pregnancy in systemic sclerosis.” Rheumatology (Oxford) 47 Suppl 3: iii16–8

    Article  Google Scholar 

  • Moak JP, Barron KS, Hougen TJ, et al Congenital heart block: Development of late-onset cardiomyopathy, a previously underappreciated sequela. J Am Coll Cardiol 2001; 37:238–242

    Article  PubMed  CAS  Google Scholar 

  • Neville CE, McNally J. Maternal exposure to leflunomide associated with blindness and cerebral palsy (letter). Rheumatol 2007; 46:1506

    Article  CAS  Google Scholar 

  • Østensen M, Khmashta M, Lockshin M, et al. Anti-inflammatory and immunosuppressive drugs in reproduction. Arthritis Res Ther 2006; 8:1–19

    Article  Google Scholar 

  • Østensen M, Lockshin M, Doria A, et al Update on safety during pregnancy of biological agents and some immunosuppressive anti-rheumatic drugs. Rheumatol 2008; 47:iii28–iii31

    Article  Google Scholar 

  • Parke AL, West B. Hydroxychloroquine in pregnant patients with systemic lupus erythematosus. J Rheumatol 1996; 23:1715–1718

    PubMed  CAS  Google Scholar 

  • Paufique L, Magnard P. Retinal degeneration in 2 children following preventive anitmalarail treatment of the mother during pregnancy. Bull Soc Ophtalmol Fr 1969; 69:466–467

    PubMed  CAS  Google Scholar 

  • Petri M, Allbritton J. Fetal outcome of lupus pregnancy: A retrospective case-control study of the Hopkins Lupus Cohort. J Rheumatol 1993; 20:650–656

    PubMed  CAS  Google Scholar 

  • Petri M, Kim MY, et al Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med 2005; 353(24): 2550–2558

    Article  PubMed  CAS  Google Scholar 

  • Pikwer M, Bergströom U, Nilsson J-Å, Jacobsson L, Berglund G, Turesson C. Breast feeding, but not use of oral contraceptives, is associated with a reduced risk of rheumatoid arthritis. Ann Rheum Dis online May 14, 2008 as 10.1136/aard.2007.084707

    Google Scholar 

  • Ramsey-Goldman R, Schilling E. Optimum use of disease-modifying and immunosuppressive antirheumatic agents during pregnancy and lactation. Clin Immunother 1996; 5:40–58

    Article  Google Scholar 

  • Ramsey-Goldman R, Mientus JM, Kutzer JE, Mulvihill JJ, Medsger TA Jr. Pregnancy outcome in women with systemic lupus erythemato-sus (SLE) treated with immunosuppressive drugs (ISD). J Rheumatol 1993; 20:1152–1157

    PubMed  CAS  Google Scholar 

  • Raptopoulou A, Sidiropoulos P, Boumpas D. Ovarian failure and strategies for fertility preservation in patients with systemic lupus erythematosus. Lupus 2004; 13(12):887–890

    Article  PubMed  Google Scholar 

  • Schwarz, E. B. and S. Manzi (2008). “Risk of unintended pregnancy among women with systemic lupus erythematosus.” Arthritis Rheum 59(6): 863–6

    Article  PubMed  Google Scholar 

  • Simaard JF, Karlson EW, Costenbader KH, Hernán MA, Stampfer MJ, Liang MH, Mittlemen MA. Perinatal factors and adult-onset lupus. Arthritis Rheum (Arthritis Care Res) 2008; 59: 1155–1161

    Article  Google Scholar 

  • Soares PMF, Borba EF, Bonfa E, Hallak J, Corrêa AL, Silva CAA. Gondal evalution in male systemic lupus erythematosus. Arthritis Rheum 2007; 56:2352–2361

    Article  PubMed  Google Scholar 

  • Somers EC, Marder W, Christman GM, et al Use of a gonadotro-pin-releasing hormone analog for protection against premature ovarian failure failure during cyclophosphamide therapy in women with severe lupus. Arthritis Rheum 2005; 52(9): 2761–2767

    Article  PubMed  CAS  Google Scholar 

  • Steen, V. D. (1999). “Pregnancy in women with systemic sclerosis.” Obstet Gynecol 94(1): 15–20

    Article  PubMed  CAS  Google Scholar 

  • Steen, V. D., C. Conte, et al (1989). “Pregnancy in women with systemic sclerosis.” Arthritis Rheum 32(2): 151–7

    Article  PubMed  CAS  Google Scholar 

  • Taguchi N, Rubin ET, Hosokawa A, et al Prenatal exposure to HMG-CoA reductase inhibitors: Effects on fetal and neonatal outcomes. Reproductive Toxicology 2008 [Epub]

    Google Scholar 

  • Wilson JG, Scott WJ, Ritter EJ, Fradkin R. Comparative distribution and embryo toxicity of methotrexate in pregnant rats and rhesus monkeys. Teratology 1979; 19:71–98

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Medicine, Division of Rheumatology and Immunology, Duke University, Trent Dr., Box 3535, Durham, NC, 27710, USA

    Megan E. B. Clowse

  2. Northwestern University, Division of Rheumatology FSM-300 240, E. Huron Street, Chicago, Illinois, 60611, USA

    Rosalind Ramsey-Goldman

Authors
  1. Megan E. B. Clowse
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  2. Rosalind Ramsey-Goldman
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Editors and Affiliations

  1. Clinical Rheumatology, Massachusetts General Hospital, 55 Fruit Street / Yawkey 2, Boston, MA, 02114

    John H. Stone (Director) (Director)

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Clowse, M.E.B., Ramsey-Goldman, R. (2009). Pregnancy in the Rheumatic Diseases. In: Stone, J.H. (eds) A Clinician's Pearls and Myths in Rheumatology. Springer, London. https://doi.org/10.1007/978-1-84800-934-9_17

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  • DOI: https://doi.org/10.1007/978-1-84800-934-9_17

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-84800-933-2

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