Pregnancy management in women with Rheumatic and Musculoskeletal Disease (Part 1)
It is really helpful to have a sound understanding of basic pregnancy physiology for rhuematologists, so that the doctor can easily identity active rheumatic and musculoskeletal disease (RMD) that occurs during pregnancy. This way the rheumatologist can properly coordinate with the medical care with obstetrics and gynecology (Ob-Gyne) doctors and other medical experts.
Changes that happen during pregnancy may have an impact with the RMD manifestations.
Increased intravascular volumes that are pregnancy-related may result to a worse situation where there are problems with cardiac or renal function.
It is expected that there would be a 50% hike in glomerular filtration rate in women who are pregnant and it could worsen if the patient has an existing stable proteinuria.
The RMD-linked thromobosis risk may increase due to pregnancy-induced hypercoagulability.
Moreover, the calcium demand of fetal bone development and breastfeeding may cause a huge problem leading to maternal osteoporosis.
Usual pregnancy symptoms like malar erythema, chloasma gravidarum, anemia, elevated erythrocyte sedimentation, and diffuse arthralgias may falsely manifest the symptoms of an active RMD.
Hypertension syndromes induced by pregnancy, (pre-eclampsia) could be confused with lupus nephritis, scleroderma renal crisis, or vasculitis flare.
HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) or eclampsia may exhibit serious disease flare.
The expertise of the rheumatologist and the Ob-Gyne should be in sync to properly manage RMD in pregnant women.
The information about managing pregnancy among women with RMD are observations coming from females with systemic lupus erymathosus (SLE) and antiphospholipid antibody syndrome (APS). The fact is that there are very few controlled trials.
Furthermore, the data regarding rare rheumatic diseases are usually coming from small case series.
With these situations, the recommendations made to manage pregnancy in women with RMD are most often conditional, supported by the experience of some experts and patient input.
As part of management of pregnancy, experts highly recommend giving advice to women with RMD who are considering getting pregnant about outcomes that affect the mother and the ottspring, depending on the level of disease activity.
As an additional form of good practice, experts suggest maintaining care and monitoring through a multi-disciplinary approach, consulting as many experts as needed.
The doctors should consider family planning options early and often with the women with RMD, including the formulation of plans if the patient is considering to become pregnant soon.
It is part of good practice to discuss with the patient, information about the medicines and the impact of disease activity, autoantibodies, and organ system abnormalities on maternal and fetal health.
In situations, although these can occur rarely, when there are significant disease-related damage, such as pulmonary arterial hypertension, renal dysfunction, heart failure, or other severe organ damage, pregnancy should be not considered due to high risk of maternal morbidity and mortality.
Fpr women with RMD and who are taking medicines that could make pregnancy risky, the recommendation is to use medicines that are compatible with pregnancy, and at the same time, observing the efficiency of the new set of drugs.
Usually, the observation period of the new set of drugs will depend on individual clinical factors. More often, the observation period may take several months.
In women with RMD who are already pregnant and currently have an active disease, which needs medical therapy, the recommendation of experts is to initiate or continue pregnancy-compatible steroid-sparing drugs, as both active RMD and continuous use of glucocorticoid may increase the risk of harm, both to the mother and the fetus.
Next week, we will continue with the discussion on pregnancy management of women with RMD.