The document discusses management of rheumatic diseases during pregnancy. It notes that remission of the rheumatic disease leads to healthy child in over 90% of cases. It provides screening recommendations and lists medications that are generally considered safe during pregnancy like hydroxychloroquine and low-dose aspirin. Specific rheumatic diseases like SLE, APS, and vasculitis are discussed in terms of risks during pregnancy and monitoring recommendations. Male fertility is also briefly covered.

1. Management Of
Rheumatic Diseases
During Pregnancy
Marwa Abo Elmaaty Besar
Lecturer Of Internal Medicine
(Rheumatology & immunology Unit)
(Pediatric Rheumatologist)

6. OTHER CHANGES:
• Th2 cytokine is dominant during pregnancy; shift cytokine .
• IgG cross placenta at 13 to 16 weeks of gestation.
• Increase hepatic protein synthesis; risk for thrombosis.
• Risk of osteoporosis increase during pregnancy.
• Oedema of pregnancy can worsen Carpal tunnel syndrome.

7. Request for safe pregnancy:
Timing
Medication
supplementatio
n

10. • Remission of rheumatic disease = healthy child in >90%.
• Patients with SLE have an increased risk of
• Preeclampsia,
• Intrauterine growth restriction
• Hypertension during pregnancy prior or current renal disease and/or
aplas.
• Approximately 30% of patients with SLE have aPLAs but may or may not have
other criteria for the antiphospholipid antibody syndrome (APS).

11. SCREENING:
• The Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid syndrome and Systemic
Lupus (PROMISSE) study poor outcomes occurred in 19% of pregnancies with five major
predictors:
1. Lupus anticoagulant positive.
2. Hypertensive medication use.
3. Physician global assessment >1 (greater disease activity).
4. Non-Caucasian.
5. Thrombocytopenia (per 50K decrease).
• A history of LN or current LN correlates with poor fatal and maternal outcomes.
• Maternal hypertension and aPLAs may increase these risks as well as the risk of preeclampsia.

12. MEDICATION:
• Add low-dose aspirin (ASA) for prevention of preeclampsia in SLE pregnancy.
• Hydroxychloroquine is thought to be safe in pregnancy, may help prevent
intrauterine growth restriction.
• Stop renin–angiotensin blockade medications prior to conception.

15. Timing:
• Patients should be in remission for at least 6 months.
• Follow proteinuria off angiotensin-converting enzyme inhibitor or angiotensin-
receptor blocker prior to pregnancy; expect baseline proteinuria to increase with
increased glomerular filtration rate during pregnancy.
• Anti-dsDNA levels are not affected by pregnancy and can be followed as a sign of
disease flare in some individuals with increasing proteinuria.
• The risk of renal biopsy is likely not increased for patients in the first and second
trimester, (if aPLA-negative and not on anticoagulation), but best done prior to
pregnancy if there is a concern for active nephritis.

16. Serology:-
• Antibodies to Ro/SSA = neonatal lupus syndrome.
• Antibodies to La/SSB; less commonly neonatal lupus syndrome.
• aPLAs;
 Recurrent first trimester spontaneous abortion
Stillbirths, preeclampsia, intrauterine growth restriction, and preterm birth
Neurocognitive delay in children born to mothers with APS.
• Antiplatelet antibodies; autoimmune thrombocytopenia in the fetus.

17. Neonatal lupus erythematous (NLE):
• Congenital heart block (CHB) is the most common cardiac manifestation of NLE.
• The accompanying myocarditis accounts for the major morbidity and mortality.
• Clinical manifestations of NLE occur in 5% to 20% of offspring of mothers with high
circulating levels of these antibodies.
• The risk of CHB is 2% in the offspring of seropositive mothers.
• The risk of recurrent heart bock is 15% to 20%.
• Hydroxychloroquine use was associated with a decreased rate of recurrent CHB in
subsequent pregnancies.

19. SLE Or Eclampsia???
• Preeclampsia typically occurs in late pregnancy (after 20 weeks of gestation) of
primigravida.
• LN can occur at any time during pregnancy and is associated with active urine
sediment.
• Patients with SLE have an increased risk of preeclampsia at baseline.
• The PROMISSE study, the measurement of angiogenic factors such as placental
growth factor (PGF) and soluble fms-like tyrosine kinase 1 (sflt1) measured early
in pregnancy (12–19 weeks) predicted preeclampsia (low PGF and high sFlt1)

21. ANTIPHOSPHOLIPID SYNDROME
• Patients with APS with or without SLE are at risk for poor pregnancy outcomes:
 Recurrent early miscarriage.
 Intrauterine growth restriction
 Preeclampsia.
 Thrombosis.
 Early and late fetal loss.
• The addition of heparin plus ASA provided an estimated 54% reduced risk of
pregnancy loss.
• It is recommended to start as 4 weeks prior to conception if possible

25. Contraception:
• Contraception is the key to ensuring optimized timing and safety of pregnancy.
• Risk of venous thromboembolism with pregnancy is higher than with any contraceptive.
• Long-acting reversible contraceptives (implants and intrauterine devices (IUDs) have the highest
efficacy.
• Both progesterone-containing implants and IUDs are safe in women with high clotting risk.
• Estrogen-containing contraceptives should be avoided in women with aPLAs, even with no history of
clot or
other clotting risk factors.
• Women with stable SLE, no aPLAs or clotting risk factors, and no history of clot may use estrogen-
containing
oral contraceptives.
• Contraceptive decisions should include the patient, gynecology, and rheumatology

27. RA:-
• 2/3 patients with RA have improvement in RA symptoms during pregnancy, but
<20% achieve drug-free remission.
• Symptom improvement is highest during the third trimester.
• 2/3 RA patients have a flare of RA symptoms in the first 6 months postpartum.
• Erythrocyte sedimentation rate increases during pregnancy and should not be used
in the measurements of disease activity.

28. SPONDYLOARTHROPATHIES:-
• Fertility is unaffected.
• The course of ankylosing spondylitis varies during pregnancy (33% improve, 33%
worsen) and up to 60% worsen postpartum (mostly low back pain).
• Newer data suggests that women may have increased risk of
caesarean section
preterm birth
infants born small for gestational age.

29. • Up to 50% of patients with psoriatic arthritis may improve.
• Elevated disease activity and antitumor necrosis factor discontinuation in early
pregnancy are associated with increased risk of disease flare later in pregnancy.
• Patients with severe back and/or hip disease should be assessed for their
capability to deliver vaginally.

30. SYSTEMIC SCLEROSIS (SSC)
• Fertility is unaffected.
• Pulmonary hypertension is a contraindication to pregnancy.
• Women with early disease should delay pregnancy until disease stabilization.
• Increased risk:
(1) preterm delivery
(2) intrauterine growth restriction
(3) low birth weight.

31. • Risk factors for worse outcomes:
• early disease.
• diffuse cutaneous SSc.
• anti-Scl-70 ab,
• anti-RNA polymerase III ab.
• Pregnancy does not cause progressive visceral involvement or increased risk of
scleroderma renal crisis.
• Raynaud’s symptoms often improve and gastrointestinal reflux and arthralgias
often worsen.

32. Inflammatory myositis:
• There is limited data about pregnancy in these patients.
• Active disease, especially in early pregnancy, is associated with adverse outcomes.
• Patients with new onset of poly/dermatomyositis during pregnancy have a high
risk of fatal loss.
• The most common complications are
preterm delivery
infants born small for gestational age.

33. • Clinical improvement frequently occurs during pregnancy, but postpartum relapse
is common.
• There is no evidence that pregnancy is a trigger for myositis.

34. Vasculitis
Q; Should patients with a history of vasculitis get pregnant?
• There is limited data to guide management of pregnancy in vasculitis.
• Pregnancies are most likely to succeed:-
When vasculitis is well controlled.
Patient is on low risk medications.
• These patients should be followed by obstetricians experienced with high-risk
pregnancies and deliveries.

35. Vasculitis
Antineutrophil cytoplasmic antibody-associated vasculitis:
• Even if conception occurs with controlled disease, up to 40% of patients will flare
during pregnancy.
• Disease activity during pregnancy is associated with
 Preterm delivery
 Miscarriage.
 More serious outcomes.
Polyarteritis nodosa (PAN):
• Conception during remission results in good outcomes with rare flares.
• Onset of disease during pregnancy has a very high maternal mortality.

36. Vasculitis
Takayasu’s arteritis:
• Pregnancies are more likely to be complicated by hypertension and
preeclampsia (40% versus 8% in the general population).
• Pregnancy does not affect Takayasu’s arteritis in most cases, but complications
may be devastating (e.g., aneurysmal rupture).
• Most adverse effects are not due to disease flares but due to vascular sequelae
from previously active disease.

37. Vasculitis
Behçet’s disease:
• pregnancy outcomes are similar to general population.
• Up to 30% have disease relapse during pregnancy.
• Patients with prior thrombosis should be considered for intrapartum
anticoagulation.

38. Male fertility:-
Vasculitis:
Decreased fertility if testicular involvement in PAN.
Patients with behçet’s disease have normal fertility.
Data is lacking for other forms of vasculitis.
Ankylosing spondylitis:
 higher rates of varicocele, but no other changes in sperm.

39. Male fertility:-
RA:
• Active RA is associated with hypogonadism as well as decreased sperm production and
function.
SLE:
• Decreased libido, erectile dysfunction, and failure to ejaculate, though it is difficult to sort out
medication effect.
Common comorbidities
• Affect fertility and libido including obesity, chronic kidney disease, and depression.

41. Hormonal replacement therapy (HRT):
Vasomotor symptoms:
defined by (The North American Menopause Society) include hot flashes and night
sweats.
• Hot flashes are recurrent, transient episodes of flushing, perspiration and a
sensation ranging from warmth to intense heat on the upper body and face,
sometimes followed by chills.
• Night sweats are hot flashes that occur with perspiration during sleep.