The interaction of pregnancy and the
rheumatic diseases varies, ranging from life-threatening conditions such as thromboembolic events and progressive renal disease in some autoimmune disorders, to minor flares of peripheral
arthritis in inflammatory
rheumatic disease. As a consequence, treatment strategy will vary according to the maternal or fetal compromise expected. All nonsteroidal anti-inflammatory drugs (
NSAIDs), including high dose
aspirin (
acetylsalicylic acid), can cause adverse effects during pregnancy related to the inhibition of
prostaglandin synthesis. Prolongation of gestation and labour, constriction of the ductus arteriosus,
persistent fetal circulation, impairment of renal function and
bleeding are risks of third trimester exposure of pregnant women to all inhibitors of
cyclo-oxygenase. Most of these adverse effects can be prevented by discontinuing
NSAIDs 8 weeks prior to delivery. Low dose
aspirin has not been associated with fetal or neonatal toxicity. Some
corticosteroids such as
prednisone and
prednisolone do not readily cross the placenta and can be safely used during pregnancy as immunosuppressive drugs. Maternal complications related to
corticosteroids may occur and close monitoring is therefore mandatory. There is limited information on the safety of
disease-modifying antirheumatic drugs including
gold,
antimalarials,
penicillamine (
D-penicillamine),
sulfasalazine and
cyclosporin. Of these agents,
sulfasalazine has the best record for tolerability and can be used by pregnant patients.
Gold compounds and
penicillamine should be discontinued when pregnancy is recognised.
Hydroxychloroquine has not been associated with congenital malformations and seems preferable to
chloroquine in patients requiring treatment with
antimalarials. Use of
cyclosporin may be an alternative to other
therapy in pregnant patients with severe
rheumatic disease. Indications for treatment with
colchicine during pregnancy are few, except for
familial Mediterranean fever.
Azathioprine can be used when the maternal condition requires a cytotoxic
drug during the first trimester.
Cyclophosphamide,
chlorambucil and
methotrexate are contraindicated during pregnancy because of their teratogenic potential. Their use may be considered in late pregnancy if the mother has a life-threatening condition.