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Patients with rheumatic disease commonly have questions regarding conception, pregnancy, and breast-feeding, as well as using medication during all of these phases. In this chapter, these issues are discussed in the context of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), the antiphospholipid syndrome, scleroderma, and the systemic vasculitides Takayasu arteritis and antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis. The use of individual medications is also discussed.

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The classic teaching that RA improves during pregnancy and worsens in the postpartum period has been confirmed in several studies. For reasons that remain incompletely understood, pregnancy ameliorates RA activity in many women, even after the cessation of medications.

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Essentials of Diagnosis

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  • Most pregnant patients with RA report improvement in joint pain and swelling during pregnancy.
  • Clinical improvement is often more pronounced in patients with moderate-high disease activity compared to those with low disease activity.
  • RA generally returns to its prior state of activity postpartum.

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Pathophysiology

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The mechanisms for improvement of disease in RA patients during pregnancy likely involve several mechanisms. HLA disparities, hormonal fluctuations, and changes in innate immunity have all been studied. Higher maternal-fetal incompatibility in HLA class II alloantigens has been associated with good pregnancy outcomes and improvement of clinical disease. Such findings suggest that greater recognition of the fetal allograft by the maternal immune system leads to more tolerance of maternal autoantigens.

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Regulatory T Cells (Treg) are involved in the pathogenesis of RA. These cells promote tolerance both by suppressing the activity of effector T-cells and dendritic cells, and by producing anti-inflammatory cytokines such as interleukin (IL)-10 and tumor growth factor (TGF)-β. In nonpregnant RA patients, Treg activity is impaired, but during pregnancy, these Treg cells regain some activity, thus promoting an anti-inflammatory environment. Other alterations in immunity such as a down-regulation of Th1 cells and subsequent shift toward Th2 responses may also contribute to clinical improvement.

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Pregnancy Effects on Disease

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Up to three quarters of pregnant patients with RA report improvement in joint pain, joint swelling, and total number of joints involved. The average rate of remission in the third trimester nears 30%. Clinical improvement is more pronounced in patients with moderate-high disease activity than in patients with low disease activity. Disease response in previous pregnancies predicts clinical responses for subsequent pregnancies. RA often returns to its prior state of activity postpartum.

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Effect of Disease Activity on Fetus

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Although the data regarding pregnancy morbidity in the literature are mixed, consensus favors mildly increased rates of premature birth, preeclampsia or hypertensive disorders, and lower birth weights. Disease activity in the third trimester has been associated with lower birth weight. Prednisone use during pregnancy is associated with a higher likelihood of preterm delivery (before 37 weeks).

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SLE is a multisystem autoimmune disease with a predisposition for females of reproductive ...

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