Pregnancy and other
Rheumatological Diseases
Dr Subramanian R, MD PDF
JSS Medical College
Mysore
Case Scenarios
Case A
• 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
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
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
• Rheumatoid arthritis
• Seronegative
spondyloarthritides
• Undifferentiated connective
tissue diseases (UCTD)
• Mixed connective tissue
diseases (MCTD)
• Polymyositis–
dermatomyositis (PM–DM)
Vasculitides
• Wegener’s granulomatosis
• Churg–Strauss syndrome
• Microscopic polyangitis
• Polyarteritis nodosa
• Takayasu arteritis
• Behcet ‘s disease
• 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
Ostensen M, Villiger PM. The remission of rheumatoid arthritis during pregnancy. Semin
Immunopathol 2007;29:185–91 Nelson JL, Ostensen M. Pregnancy and rheumatoid
arthritis. Rheum Dis Clin North Am 1997;23:195–212
Pregnancy suppresses disease activity?
Upregulation of T regs inhibits the
generation of TH 17
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
Ankylosing spondylitis
• 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
Percentage
Long standing
SSc
42
Other subjects
15
RR
95% CI
P value
2.8
1.23 – 6.37
< 0.05
…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), polyarteritis nodosa
(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 Takayasu arteritis (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 nonteratogenic drugs