Pregnancy and ArthritisDz

Definition: The hormonal alterations accompanying pregnancy may affect disease activity in patients with several rheumatic conditions. In addition, anatomic changes associated with pregnancy may produce musculoskeletal symptoms.

Disease Improvement: Amelioration in the activity of RA has been noted anecdotally for more than half a decade. It has been reported that most patients with RA experience improvement in their arthritis during pregnancy. In approximately half of the cases, the improvement occurs in the first trimester, although some patients improve only in the third trimester. The improvement in symptoms is almost always transient; recurrence of arthritis after delivery is the rule. Other disorders reported to improve during pregnancy include psoriasis, psoriatic arthritis, and sarcoidosis.

Disease Exacerbation: Patients with other rheumatic diseases may have increased activity during pregnancy. Although there is some controversy, a large body of literature suggests that many patients with SLE experience a flare during pregnancy. Controversy comes from the fact that any group of patients with SLE, not only pregnant ones, observed over a 9-month period, is likely to include many with flares of disease during that period. Nevertheless, it does appear that some patients with SLE flare during their third trimester and in the immediate postpartum period. Moreover, patients with an increased level of disease activity before pregnancy appear to be susceptible to flare during pregnancy. Thus, many rheumatologists recommend that patients wait until their disease has been quiescent for at least 6 months before becoming pregnant. This is also relevant because many medications used to treat severe SLE are contraindicated during pregnancy. Patients with lupus also have a higher incidence of spontaneous abortion, prematurity, and intrauterine death. Distinguishing between a lupus renal flare and preeclampsia may be difficult. Although the data are less clear, other diseases reported to worsen during pregnancy include PM and DM.

Back Pain: Changes in posture related to pregnancy are thought to play some role in the high prevalence of low back pain among pregnant women. Approximately 50% of pregnant women complain of low back pain during pregnancy, typically during the late second and third trimesters. Pain is usually sacral or lumbar. Excess lumbar lordosis, direct pressure on the spine, the weight of the fetus, and pelvic ligament laxity have all been suggested as potential contributing factors. Lastly, poor sleep may lead to secondary fibromyalgia.

Therapy: Most pharmacologic agents are best avoided during pregnancy. However, if necessary, corticosteroids may be used throughout pregnancy. Acetaminophen and NSAIDs may also be used, but NSAIDs should be discontinued beyond the 30th week to avoid premature closure of the ductus arteriosus. Drugs contraindicated during pregnancy include MTX, leflunomide, penicillamine, gold, cyclophosphamide, and cyclosporine. Use of azathioprine during pregnancy is controversial. It appears that corticosteroids, sulfasalazine, and hydroxychloroquine may be used safely, if necessary, during pregnancy. Although newer agents, anakinra and the TNF inhibitors, have not been systematically studied in pregnant women, these are a class B pregnancy risk and pregnant women have sporadically been exposed to these medicines without overt toxicity or teratogenicity.

BIBLIOGRAPHY

Cecere FA, Persellin RH. The interaction of pregnancy and the rheumatic diseases. Clin Rheum Dis 1981;2:747–768.