Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario ) questions and answers

2. Clinical Scenario
R h e u ma t o i d
p a t i e n t
&
Pr e g n a n c y
Ahmed EL-Belasy

4. Personal History

5. Present History
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for
the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315---24.

6. Past History

7. Family History
Menstrual History

8. On the Current Medications

9. Examination

10. Examination

11. Joints Examination
Tender swollen joints.
Tender joints.

14. Does RA affect the chances RA affect the
Does
Am I ready for pregnancy?
Does RA affect the Baby ?
of getting pregnant ?
pregnancy outcome ?

16. Does RA affect the pregnancy outcome?
There is no increase in the rate of miscarriage or
stillbirth in patients with RA
Ostenson M et al Pregnancy and reproduction in autoimmune rheumatic diseases Rheumatology. 2011;50(4):657-664

17. Does RA affect the chances of getting
pregnant?
No, RA does not affect fertility .. Unlike lupus it
does not affect the chances of getting or staying
pregnant.
Ostenson M et al Pregnancy and reproduction in autoimmune rheumatic diseases Rheumatology. 2011;50(4):657-664

18. Does RA affect the Baby?
• No , RA does not affect the unborn baby. R.A
need not to be inherited by the baby from the
mother even if it is active during pregnancy.
• Our concern is all about the medications which
will need to be changed.
Ostenson M et al Pregnancy and reproduction in autoimmune rheumatic diseases Rheumatology. 2011;50(4):657-664

19. Am I ready for pregnancy ?
1. Your RA has to be fairly controlled for 3-4
months before getting pregnant.
2. New laboratory investigations.
3. Reviewing your current medications.

20. Is my RA controlled?

21. Remission criteria
Felson, D.T., et al., American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid
arthritis for clinical trials. Arthritis Rheum, 2011. 63(3): p. 573-86.

22. • Yes, your RA is considered
clinically controlled for the
past 3 month.

23. What about my Lab results?

24. Laboratory
Investigations:
Routine
Investigations
Hb : 14.2 gm
WBC: 5,300
PLT: 279.000
S.Creatinine: 0.6 mg/dl (N. 0.5-1.2)
SGPT: 35 U/L (N. up to 65 )
SGOT:25U/L (N. up to 37 )

25. Laboratory
Investigations:
Specific
Investigations
C – Reactive protein (CRP): 2 mg/l ( normal : 6 mg/l)
ESR: 10-18 mm/hr
Rheumatoid factor: Negative 6( normal 12mg/l)
Anti CCP: Negative 6mg/l ( normal 20mg/l)

26. • Your Lab results are all
considered
normal range.
within
the

27. I will stop all medications
during pregnancy ?

28. Medication during Pregnancy
• Sources for the pregnancy data presented come
from the FDA classification of drugs and experts
reporting.
FDA category
Classification
A
B
C
D
X
N
Controlled studies showed no risk
No evidence of risk in humans
Risk cannot be ruled out
Positive evidence of risk
Contraindicated in pregnancy
Not rated
Temprano KK, Bandlamudi R, Moore TL. Antirheumatic drugs in pregnancy and lactation. Semin Arthritis Rheum. Oct
2005;35(2):112-21

29. Medications used by the patient
Drug
Steroids
NSAIDs
Methotrexate
Leflunomide
FDA category
C
B or C
X
X
Temprano KK, Bandlamudi R, Moore TL. Antirheumatic drugs in pregnancy and lactation. Semin Arthritis Rheum. Oct
2005;35(2):112-21

30. Anti TNF α
Orozco C, Dao K, Cush JJ, Kavanaugh A: Safety of TNF- inhibitors during pregnancy in patients with inflammatory arthritis.
Arthritis Rheum 2005, Suppl:22-23

31. Anti TNF α
Orozco C, Dao K, Cush JJ, Kavanaugh A: Safety of TNF- inhibitors during pregnancy in patients with inflammatory arthritis.
Arthritis Rheum 2005, Suppl:22-23

32. Anti TNF α
Drug
FDA
Category
TNF α blockers B
Concerns
Minimal data but not
documented increased
rate of malformation
to date
Clinical practice
Use until plan
or confirm
pregnancy
then
discontinue

33. • We
will
need
to
stop
Methotrexate & Leflunomide.

34. • How to stop them?
• when will I be ready for
pregnancy?

35. Protocol of stopping
Drugs.

36. Protocol of stopping
Drugs.

37. • Then I will be on a drug
holiday during pregnancy ?

38. • No
• There are Drugs considered
safe during pregnancy.

39. Short term therapies
Medication
steroids
FDA
category
C
NSAIDs
B or C
concerns
Clinical
opinion
Conflicting reports:
Safe <10mg
cleft palate,HTN
daily
,GDM
Caution >20mg
daily
Premature closure Avoid after 32
of patent ductus
weeks
arteriosus

40. Conventional DMARDs
Medication
FDA
category
Concerns
Clinical opinion
Hydroxychloroquine
C
Theoretical effect to fetal
eye-ear but not seen: no
increased risk of
malformation clinically
Used commonly
in RA
pregnancies
without problems
Sulphasalazine
B
Conflicting studies
:malformation but
generally felt to be safe
Used in Ra
pregnancy

41. • Here is your prescription …

42. • S u l p h a s a l a z i n e 500m g
t a b s
•
d a i l y
3
o r a l l y
H y d r o x y c h l o r o q u i n e 200m g 2
t a b s
d a i l y
o r a l l y
5m g
1 t a b
• C a l c i u mc a r b o n a t e
1200m g +400I U
• Pr e d n i s o l o n e
d a i l y
o r a l l y

43. o NSAI Ds
f o r
a n a l g e s i a
wh e n n e e d e d .
o o n l y
i n t h e f i r s t
s e c o n d t r i me s t e r
i n t e r mi t t e n t
a n d
,
u s e , s h o r t
a c t i n g .
o c o n t r a i n d i c a t e d i n t h e

44. o C h o l e s t r y r a mi n e
t i me s d a i l y f o r
•
8g
3
11 d a y s
Sa c h e t s
d i s s o l v e d
g l a s s o f
wa t e r
i n
a

45. Follow up is important by the
Rheumatologist and Obstetrician
during the pregnancy

46. • What to expect during
pregnancy?

47. Pathogenesis of RA
-Forger F, Marcoli N, Gadola S, et al. Pregnancy induces numerical and functional changes of CD4+CD25 high regulatory T cells in
patients with rheumatoid arthritis. Ann Rheum Dis 2008;67:984–90.
-Munoz-Valle JF, Vazquez-Del Mercado M, Garcia-Iglesias T, et al. T(H)1/T(H)2 cytokine profile,metalloprotease-9 activity and
hormonal status in pregnant rheumatoid arthritis and systemic lupus erythematosus patients. Clin Exp Immunol 2003;131:377–84.
-Alavi A, Arden N, Spector TD, et al. Immunoglobulin G glycosylation and clinical outcome in rheumatoid arthritis during
pregnancy. J Rheumatol 2000;27:1379–85.

48. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.

49. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.

50. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.

51. What to expect during
pregnancy
First
trimester
&
second
trimester:
RA tends to improve and
patients
more
who
likely
improve
to
are
stay
remission during pregnancy.
in

52. What to expect during
pregnancy
Third trimester:
• You may experience fatigue
due to weight gain.
• Swelling of feet / ankles
• Hand numbness / tingling.
They need not always mean a
flare, Consult Rheumatologist.

53. Delivery

54. • What
to
pregnancy?
expect
after

55. What to expect after pregnancy
•
Hygiene and wound care after delivery
is extremely important. You may be on
steroids or other DMARDs which may
impair immunity & make you prone to
infections if appropriate care is not
taken.

56. What to expect after pregnancy
•
Caring for the baby requires a great
deal of energy, feeding multiple times
in the night can add up to the fatigue &
exhaustion.
•
Carrying the baby around can be
difficult if the hand joints are inflamed.

57. What to expect after pregnancy
•
Sleep deprivation happens to every
Mom; however can add to your joint
pain & fatigue
•
You will not be able to take MTX /
Leflunomide to control RA activity
when you are breast feeding.

58. - Orbach H, Shoenfeld Y. Hyperprolactinemia and autoimmune diseases. Autoimmun Rev 2007;6:537–42.
- Barrett JH, Brennan P, Fiddler M, et al. Breastfeeding and postpartum relapse in women with rheumatoid and inflammatory
arthritis. Arthritis Rheum 2000;43:1010–15

59. - Orbach H, Shoenfeld Y. Hyperprolactinemia and autoimmune diseases. Autoimmun Rev 2007;6:537–42.
- Barrett JH, Brennan P, Fiddler M, et al. Breastfeeding and postpartum relapse in women with rheumatoid and inflammatory
arthritis. Arthritis Rheum 2000;43:1010–15

60. What to expect after pregnancy
• RA tends to flare up in most of
the patients during the lactation
phase..

61. • Will I stop lactation then?

62. • No
• There are Drugs considered
safe during Lactation.

63. Breast Feeding
Drug
Official recommendation
Clinical practice
recommendation
NSAIDs
Considered safe; small
Safe except acetyl
amounts in breast milk ;
salicylic acid.
avoid acetyl salicylic acid
due to bleeding risk in infant
Steroids
Excreted in milk but still
Safe (consider
safe; wait 4 hr if on
delaying feed by 4 hr)
prednisolone >20mg

64. Breast Feeding
Drug
Official
recommendation
Clinical practice
recommendation
Sulfasalazine
Probably safe,
One case of bloody
diarrhea
Safe
Hydroxychloroquine Small amount 2% in
breast milk; but
generally safe
Safe

65. • If these safe medication failed
to control RA activity we may
need to stop lactation and
switch back to
MTX / Leflunomide.

66. Take Home Message