REVIEW - Pregnancy and rheumatic disease: by the book or by the doc

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Clin Rheumatol. 2009 Jan;28(1):1-9. Epub 2008 Nov 6.

Pregnancy and rheumatic disease: " by the book " or " by the doc " .

Keeling SO, Oswald AE.

Division of Rheumatology, Department of Medicine, University of

Alberta, 562 Heritage Medical Research Center, Edmonton, Alberta,

Canada, T6G 2S2.

Pregnancy is an important condition that can affect and be affected by

rheumatic disease. Overall, pregnancy is viewed as a Th2-predominant

state, but several Th1-related cytokines are vital to early pregnancy.

In rheumatoid arthritis for example, the majority of women improve by

the beginning of the second trimester, but the majority (90%) will

flare in the first 3 to 4 months postpartum. In contrast, systemic

lupus erythematosus has an unpredictable course in pregnancy, leaving

most rheumatologists to recommend a disease-quiescent state prior to

conception. Other diseases such as scleroderma are less clear because

the disease less commonly presents in the childbearing period. Many

immunosuppressive medications for the rheumatic diseases are

contraindicated in pregnancy because of their mechanisms of action

leaving only a select few " safe " medications. Significant

heterogeneity between the Food and Drug Administration (FDA) category

for a medication and what a rheumatologist does in clinic leads to

confusion on how a patient should be treated for active rheumatic

disease both peripartum and postpartum, particularly if the patient is

breastfeeding. We review the general state of pregnancy and how it is

affected by prototypical rheumatic diseases including rheumatoid

arthritis and systemic lupus erythematosus. In addition, we present

the most commonly used disease-modifying antirheumatic drugs and

immunosuppressants and explain the difference between the FDA category

and clinical practice among rheumatologists. Finally, we provide some

general recommendations on how to manage a rheumatic disease during

pregnancy including: (a) preconception planning to ensure no

teratogenic medications on board, ( early disclosure of pregnancy to

all caregivers including the rheumatologist, family physician,

obstetrician, and maternal-fetal medicine specialist, and © planning

of safe medication use for acute flare-ups and disease suppression

peripartum and postpartum.

PMID: 18987777

http://www.ncbi.nlm.nih.gov/pubmed/18987777

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