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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
Personal History
Present History

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Associa...
Past History
Family History

Menstrual History
On the Current Medications
Examination
Examination
Joints Examination

Tender swollen joints.
Tender joints.
Does RA affect the chances RA affect the
Does
Am I ready for pregnancy?
Does RA affect the Baby ?
of getting pregnant ?
pr...
Does RA affect the pregnancy outcome?

There is no increase in the rate of miscarriage or
stillbirth in patients with RA

...
Does RA affect the chances of getting
pregnant?

No, RA does not affect fertility .. Unlike lupus it
does not affect the c...
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
moth...
Am I ready for pregnancy ?

1. Your RA has to be fairly controlled for 3-4
months before getting pregnant.
2. New laborato...
Is my RA controlled?
Remission criteria

Felson, D.T., et al., American College of Rheumatology/European League Against Rheumatism provisional ...
• Yes, your RA is considered
clinically controlled for the

past 3 month.
What about my Lab results?
Laboratory
Investigations:
Routine
Investigations
Hb : 14.2 gm
WBC: 5,300
PLT: 279.000
S.Creatinine: 0.6 mg/dl (N. 0.5...
Laboratory
Investigations:
Specific
Investigations
C – Reactive protein (CRP): 2 mg/l ( normal : 6 mg/l)
ESR: 10-18 mm/h...
• Your Lab results are all
considered

normal range.

within

the
I will stop all medications
during pregnancy ?
Medication during Pregnancy
• Sources for the pregnancy data presented come
from the FDA classification of drugs and exper...
Medications used by the patient
Drug
Steroids
NSAIDs
Methotrexate
Leflunomide

FDA category
C
B or C
X
X

Temprano KK, Ban...
Anti TNF α

Orozco C, Dao K, Cush JJ, Kavanaugh A: Safety of TNF- inhibitors during pregnancy in patients with inflammator...
Anti TNF α

Orozco C, Dao K, Cush JJ, Kavanaugh A: Safety of TNF- inhibitors during pregnancy in patients with inflammator...
Anti TNF α
Drug

FDA
Category

TNF α blockers B

Concerns

Minimal data but not
documented increased
rate of malformation
...
• We

will

need

to

stop

Methotrexate & Leflunomide.
• How to stop them?
• when will I be ready for

pregnancy?
Protocol of stopping
Drugs.
Protocol of stopping
Drugs.
• Then I will be on a drug

holiday during pregnancy ?
• No
• There are Drugs considered

safe during pregnancy.
Short term therapies
Medication
steroids

FDA
category
C

NSAIDs

B or C

concerns

Clinical
opinion
Conflicting reports:
...
Conventional DMARDs
Medication

FDA
category

Concerns

Clinical opinion

Hydroxychloroquine

C

Theoretical effect to fet...
• Here is your prescription …
• 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 ...
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...
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 ...
Follow up is important by the
Rheumatologist and Obstetrician
during the pregnancy
• What to expect during

pregnancy?
Pathogenesis of RA

-Forger F, Marcoli N, Gadola S, et al. Pregnancy induces numerical and functional changes of CD4+CD25 ...
Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
What to expect during
pregnancy
First

trimester

&

second

trimester:
RA tends to improve and
patients
more

who
likely
...
What to expect during
pregnancy
Third trimester:
• You may experience fatigue
due to weight gain.

• Swelling of feet / an...
Delivery
• What

to

pregnancy?

expect

after
What to expect after pregnancy
•

Hygiene and wound care after delivery
is extremely important. You may be on
steroids or ...
What to expect after pregnancy
•

Caring for the baby requires a great
deal of energy, feeding multiple times
in the night...
What to expect after pregnancy
•

Sleep deprivation happens to every
Mom; however can add to your joint
pain & fatigue

•
...
- Orbach H, Shoenfeld Y. Hyperprolactinemia and autoimmune diseases. Autoimmun Rev 2007;6:537–42.
- Barrett JH, Brennan P,...
- Orbach H, Shoenfeld Y. Hyperprolactinemia and autoimmune diseases. Autoimmun Rev 2007;6:537–42.
- Barrett JH, Brennan P,...
What to expect after pregnancy

• RA tends to flare up in most of

the patients during the lactation
phase..
• Will I stop lactation then?
• No
• There are Drugs considered
safe during Lactation.
Breast Feeding
Drug

Official recommendation

Clinical practice
recommendation

NSAIDs

Considered safe; small

Safe excep...
Breast Feeding
Drug

Official
recommendation

Clinical practice
recommendation

Sulfasalazine

Probably safe,
One case of ...
• If these safe medication failed
to control RA activity we may
need to stop lactation and
switch back to
MTX / Leflunomid...
Take Home Message
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
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Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )

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Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )
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Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )

  1. 1. 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
  2. 2. Personal History
  3. 3. 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.
  4. 4. Past History
  5. 5. Family History Menstrual History
  6. 6. On the Current Medications
  7. 7. Examination
  8. 8. Examination
  9. 9. Joints Examination Tender swollen joints. Tender joints.
  10. 10. Does RA affect the chances RA affect the Does Am I ready for pregnancy? Does RA affect the Baby ? of getting pregnant ? pregnancy outcome ?
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. Is my RA controlled?
  16. 16. 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.
  17. 17. • Yes, your RA is considered clinically controlled for the past 3 month.
  18. 18. What about my Lab results?
  19. 19. 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 )
  20. 20. 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)
  21. 21. • Your Lab results are all considered normal range. within the
  22. 22. I will stop all medications during pregnancy ?
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. • We will need to stop Methotrexate & Leflunomide.
  29. 29. • How to stop them? • when will I be ready for pregnancy?
  30. 30. Protocol of stopping Drugs.
  31. 31. Protocol of stopping Drugs.
  32. 32. • Then I will be on a drug holiday during pregnancy ?
  33. 33. • No • There are Drugs considered safe during pregnancy.
  34. 34. 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
  35. 35. 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
  36. 36. • Here is your prescription …
  37. 37. • 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
  38. 38. 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
  39. 39. 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
  40. 40. Follow up is important by the Rheumatologist and Obstetrician during the pregnancy
  41. 41. • What to expect during pregnancy?
  42. 42. 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.
  43. 43. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
  44. 44. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
  45. 45. Straub RH. The complex role of estrogens in inflammation. Endocr Rev 2007;28:521–74.
  46. 46. 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
  47. 47. 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.
  48. 48. Delivery
  49. 49. • What to pregnancy? expect after
  50. 50. 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.
  51. 51. 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.
  52. 52. 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.
  53. 53. - 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
  54. 54. - 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
  55. 55. What to expect after pregnancy • RA tends to flare up in most of the patients during the lactation phase..
  56. 56. • Will I stop lactation then?
  57. 57. • No • There are Drugs considered safe during Lactation.
  58. 58. 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
  59. 59. 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
  60. 60. • If these safe medication failed to control RA activity we may need to stop lactation and switch back to MTX / Leflunomide.
  61. 61. Take Home Message

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