Pregnancy and Rheumatism: How to Plan and Carry a Healthy Baby

Rheumatic diseases, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS), frequently affect women of childbearing age [3, 5]. In the past, patients with such diagnoses were often advised to abstain from pregnancy due to concerns for maternal and fetal health. However, thanks to significant advancements in understanding the interaction between pregnancy and rheumatic diseases, as well as the development of new treatment approaches, the majority of women today can successfully carry and give birth to a healthy child [4]. A careful planning and multidisciplinary management of pregnancy are the key factors for success.

Why is pregnancy planning so important in rheumatism?

Pregnancy in the presence of rheumatic diseases presents unique clinical challenges [1, 2]. Physiological and immunological changes in a woman's body during pregnancy can influence the activity of the underlying disease [4]. Without proper control and planning, rheumatic diseases can flare up (so-called "flares" or "exacerbations") during pregnancy, significantly increasing the risk of various complications [1, 2, 5].

• Risk of flares: Active maternal disease status in the months leading up to conception increases the likelihood of flares during pregnancy [3].
• Pregnancy complications: Exacerbations can lead to serious problems such as preeclampsia (a severe complication characterized by high blood pressure and organ damage), the birth of small-for-gestational-age infants, and preterm birth [1, 2, 5].
• Drug therapy: Many medications used to treat rheumatic diseases may be unsafe during pregnancy and require discontinuation or replacement before conception [1, 2]. Unplanned pregnancy can put fetal health at risk if the woman continues taking contraindicated medications.
• Fertility issues: The diseases themselves can affect fertility and the ability to conceive [5].

Therefore, it is crucial that the disease is under control before conception [1, 2, 3].

Major rheumatic diseases and their specific features during pregnancy

Although data on some rare rheumatic diseases are limited, the most studied and frequently encountered during pregnancy are the following:

• Rheumatoid Arthritis (RA): Women with RA may experience flares during pregnancy. However, many antirheumatic drugs can be used safely [1, 2].
• Systemic Lupus Erythematosus (SLE): SLE is one of the most thoroughly researched diseases in the context of pregnancy. SLE flares during pregnancy can be particularly dangerous and require careful control. Disease activity should be minimal or absent prior to conception [1, 2, 5].
• Antiphospholipid Syndrome (APS): This condition, often associated with SLE, requires special attention. Women with obstetric APS need to receive anticoagulant therapy (blood-thinning medications) throughout pregnancy to prevent thrombosis and related complications such as miscarriages and preterm birth [1, 2, 5].

Preparation for conception: key steps

A successful pregnancy outcome in a rheumatic disease begins long before conception. Pre-conception counseling is mandatory and includes risk stratification for each patient [5].

1. Control of disease activity: This is the most important step. The disease must be in remission or well-controlled for at least 3–6 months prior to planned conception [1, 2, 3].
2. Risk and health status assessment: A rheumatologist will perform a comprehensive evaluation, which includes:
   • Determining current disease activity.
   • Assessing organ damage (e.g., kidneys, heart, lungs).
   • Analyzing the serological profile (presence of specific antibodies).
   • Identifying comorbidities and risk factors [5].
3. Review of drug therapy: Many, but not all, antirheumatic drugs are safe for use during pregnancy and breastfeeding [1, 2]. Some medications must be discontinued a certain period before conception, while others should be replaced with safer alternatives. This process must take place under strict medical supervision.
4. Discussion of the pregnancy management plan: Together with a rheumatologist and an obstetrician-gynecologist, an individualized pregnancy management plan is developed, which includes regular check-ups and potential adjustments to therapy.

Pregnancy management: a multidisciplinary approach

Successful pregnancy management in women with rheumatic diseases requires close collaboration among multiple specialists: a rheumatologist, an obstetrician-gynecologist, and, when necessary, other physicians (e.g., a nephrologist, cardiologist) [4, 5].

The main goals of pregnancy management are:

• Prevention of flares: Maintaining the disease in remission using safe medications.
• Treatment of flares: Prompt and effective management of any disease flare-ups using approved methods [5].
• Prevention of maternal and fetal complications: Reducing the risks of preeclampsia, preterm birth, and fetal loss [5].
• Close monitoring: Regular examinations of the mother and fetus throughout pregnancy and the postpartum period are mandatory [5]. This includes blood tests, ultrasounds, Doppler studies, and other tests as indicated.

Risk of rheumatic disease flares persists in the postpartum period as well [3, 5]. Therefore, monitoring and, if necessary, continuation of therapy remain important after childbirth. Breastfeeding issues should also be discussed with a doctor, as many, but not all, antirheumatic drugs are compatible with lactation [1, 2]. A specialist will help select an optimal treatment regimen that is safe for the baby.

Conclusion

Pregnancy in the presence of rheumatic diseases is not a sentence, but a challenge that modern medicine successfully overcomes. Careful preparation, achieving disease control before conception, and a multidisciplinary approach to pregnancy management are the keys to a successful outcome for both mother and child. Do not postpone your visit to the doctor if you are planning a pregnancy and have a rheumatic disease—timely preparation will help you enjoy the joy of motherhood.

Sources

1. Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome. https://pubmed.ncbi.nlm.nih.gov/33589107/
2. Pregnancy and Management in Women with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Obstetric Antiphospholipid Syndrome. https://pubmed.ncbi.nlm.nih.gov/35400376/
3. The Course of Rheumatic Diseases During Pregnancy. https://pubmed.ncbi.nlm.nih.gov/31507122/
4. Evaluation and management of systemic lupus erythematosus and rheumatoid arthritis during pregnancy. https://pubmed.ncbi.nlm.nih.gov/23773975/
5. Reproductive Health in RA, Lupus, and APS. https://pubmed.ncbi.nlm.nih.gov/39325124/

Disclaimer: The information in this article is for reference purposes only and does not replace professional medical advice. All decisions regarding your health and treatment must be made after consulting a qualified medical specialist.