A softening stance on pregnancy advice

4 minute read

Rheumatology patients can benefit from planning their pregnancies when the disease is quiescent

Women with rheumatologic diseases are no longer being given the hardline advice that they should not become pregnant, or that they must take no medications if they do. 

Dr Bonnie Bermas, a rheumatologist at UT Southwestern in Dallas with a longstanding interest in reproductive issues, said at the American College of Rheumatology annual meeting in Atlanta that she was excited by the growing focus on the area over the past five to 10 years. 

Speaking to Rheumatology Republic, Dr Bermas drew attention to work presented at the conference that showed that rheumatoid arthritis patients who stopped TNF inhibitors before pregnancy had more flares and higher rates of complications, including pre-term births. 

“The take-home message is that we should keep our patients on their TNFα blockers – consider discontinuation later in pregnancy, usually we say by the third trimester – but in general, patients can and probably should remain on these medications because they’ll likely do better and their babies will do better,” she said. 

“When I first started in this area, we would tell our patients with rheumatoid arthritis or inflammatory arthritis, it’s likely your disease will go into remission, you don’t need any medication. And we’re finding more and more data from multiple groups across the world that have shown that actually rheumatoid arthritis patients are at greater risk for pregnancy complications, in particular if their disease is active. 

“So you can imagine as someone stops their TNFα blocker, their disease may become more active than that translates into poor outcomes for the developing fetus including preterm birth. It is [not only] associated with increased steroid use, it’s also the disease activity itself.”

Dr Bermas said half of all pregnancies in the US were unplanned, and rheumatology patients in particular benefited from planning their pregnancies, so they could get their disease under control and get off teratogenic agents in plenty of time. 

“We would like them to have really effective contraception and we do not do a good job on that,” she said. “We don’t talk to them about contraception, it is not what we were trained to do and often it’s out of our comfort zone.”

She pointed out a study assessing rheumatologists’ takeup of the registered initiative “One Key Question” – simply, “Do you plan on becoming pregnant in the next 12 months?” – which channels “yes” patients towards obstetrician/gynaecologist appointments and pregnancy-compatible mediations and “no” patients towards contraception counselling. 

It found male rheumatologists were less likely to use the tool, though that could be confounded by age as more women had entered the profession lately. 

In a presentation on pregnancy in lupus patients, Dr Bermas said recent work had debunked the old strategies of no oestrogens, no pregnancy, no medications and “hope for the best”. 

Now the best advice was to plan a pregnancy for when the disease was quiescent, to maintain good disease control, to maintain management by a rheumatologist throughout the pregnancy, and to transition patients to pregnancy-compatible drugs ahead of time. 

Lupus still increased the risks of pre-eclampsia, hypertension, pre-term birth, low birth weight and small-for-gestational-age infants, fetal loss and death of the mother or fetus – but the gaps in the worst outcomes had narrowed over the past two decades. 

“We used to tell lupus patients you shouldn’t get pregnant,” Dr Bermas said. “We used to tell patients you should be on no medications, and that includes medications like hydroxychloroquine. There is a plethora of data now to suggest that women with lupus do much better if they remain on their hydroxychloroquine during pregnancy.”

The medications to avoid in pregnancy, and also in lactation, were methotrexate, leflunomide, mycophenolate mofetil, cyclophosphamide and, of course, thalidomide, which is effective at treating lupus skin lesions. 

NSAIDs should be stopped by week 30. 

Belimumab and rituximab had some limited data to suggest they were better avoided, as did baricitinib and tofacitinib. 

But hydroxychloroquine and low-dose aspirin were safe and had been shown to minimise flares and reduce pre-eclampsia risk.

Tacrolimus, azathioprine, cyclosporin, IVIG and sulfasalazine were all compatible with pregnancy. Prednisone could be used but should be kept as low-dose as possible. 

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