Disease control, safe medications critical to pregnancies for women with rheumatic disease

Pregnant women with active rheumatic disease carry a higher risk of adverse outcomes than the general population including hypertension, preeclampsia, higher cesarean section rate, small for gestational aged infants, preterm delivery, and fetal loss. To decrease the risk of these complications, rheumatic disease should be under control before conception with medications that are safe to use during pregnancy.

Those are among the findings detailed in a recent review article written by UT Southwestern physicians in Rheumatic Disease Clinics of North America.

"Rheumatologic disorders are common amongst women of reproductive age. Understanding the management of rheumatic diseases in pregnant women is an important part of patient care for rheumatologists," said Bonnie Bermas, M.D., Professor of Internal Medicine in the Division of Rheumatic Diseases at UT Southwestern. "If we have a better understanding of pregnancy management in our patients, then we can help patients achieve their family planning goals."

In the article, Dr. Bermas and colleagues outlined the risks of pregnancy in women with rheumatic disease and the safety of medications with pregnancy and lactation. The review focused on three diseases—rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and obstetric antiphospholipid syndrome (APS).

Each carries different risks and considerations:

• About half of RA patients experience disease remission during pregnancy. Conversely, some RA patients experience flares. Active disease prior to conception and discontinuation of RA medication is associated with RA flares during pregnancy while low disease activity prior to conception is associated with disease control.
• For many years, SLE patients were often counseled to avoid pregnancy based on concerns over increased disease activity and adverse outcomes. Poor outcomes are still seen in women with very active disease in the pre-conception period, in particular those with active renal disease. Managing renal flare during pregnancy is challenging as it is difficult to differentiate preeclampsia from an SLE flare. However, many SLE patients can have successful pregnancies with maintenance of low disease activity. Importantly, continuing hydroxychloroquine, a mainstay of therapy, improves pregnancy outcome.
• Obstetric APS is defined by three first trimester pregnancy losses, second or third trimester loss, premature delivery at less than 34 weeks, or severe preeclampsia in women who have the presence of antiphospholipid antibodies. These patients require anticoagulation and low-dose aspirin during pregnancy.

Ultimately, having the disease under good control on pregnancy-safe medication is the best path for a successful pregnancy. While some antirheumatic drugs cannot be used during pregnancy, many can.

"Our knowledge regarding the safety of medications during pregnancy is limited because pregnant women are excluded from the majority of clinical trials," said Dr. Bermas. Efforts over the past few years have led to the publication of guidelines on the use of medications during pregnancy and lactation in rheumatic disease. Of note, hydroxychloroquine, immunosuppressive agents such as azathioprine, cyclosporine, and tacrolimus, as well as low-dose aspirin are all safe for use during pregnancy and lactation. Pre-conception counseling with a rheumatologist knowledgeable in this area or a maternal-fetal medicine specialist is an important part of reproductive rheumatology care.