Pregnancy and Lactation

Many rheumatologic diseases affect young women of childbearing age. Pregnancy alters immune status and is always a cause of concern in this age group. Effective use of better drugs and rigorous monitoring can now lead to remission of disease activity in many cases. Safe pregnancy and healthy child are thus possible in most cases with controlled disease activity. This issue must be carefully discussed before planning pregnancy in every patient desirous of child bearing. Pregnancy in rheumatic diseases requires a multidisciplinary coordinated approach for best possible outcome.

Pregnancy related issues of some important rheumatologic diseases are listed below:

  • Rheumatoid Arthritis (RA) : A lower birthrate in patients with RA is possibly due to choices of patients to limit family size rather than effect of the disease on fertility. Disease activity decreases during pregnancy in 75-95% patients. The improvement starts in first trimester and continues till delivery. There is no evidence of fetal growth retardation or increased incidence of abortions. No special monitoring is required during pregnancy. Drugs such as methotrexate and leflunomide must be discontinued 2 and 24 month respectively before planning pregnancy. Pain control during pregnancy with RA should be achieved with safe drugs and non-pharmacologic measures (rest, splints, fomentation, icepack, etc). RA is known to flare up after delivery. New onset of RA following delivery is also common. Use of routine anti-rheumatic drugs is possible after delivery with properly timed breast feeding.
  • Systemic Lupus Erythematosus (SLE) :Patients with SLE appear to be less fertile due to disease effect (irregular or no menses) or due to effect of drugs (glucocorticoids and cyclophosphamide). Patients on cyclophosphamide are less likely to develop infertility (failure of ovaries) if cyclophosphamide is started at a younger age (<26 years). Ovarian failure is more likely with higher cumulative dose. Concurrent use of Gonadotropin Releasing Hormone reduces the risk of premature ovarian failure. SLE patients are more likely to develop flares during pregnancy (unproven observation) which are usually mild and respond to standard therapy. Patients with inactive disease are less likely to develop flares. Pregnancy, therefore, should be planned during quiescent disease. Risk of intrauterine growth retardation, abortions and stillbirth is generally higher in SLE patients.
    Antibodies are transmitted to fetus during weeks 16-32 of gestation and can be harmful to fetus. Careful monitoring after week 16 is, therefore, advisable. These antibodies are usually destroyed with first 6 months of life.
  • Ankylosing spondylitis and other spondyloarthropathies : Pregnancy improves peripheral arthritis and eye problems but worsens back pain. Increase in back pain is possibly due to mechanical causes.
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  • Fatherhood

    Sufasalazine reduces sperm counts in up to 70% patients. Sperm count returns to normal 3 months after stopping this drug. Cyclophosphamide therapy, too, reduces sperm counts in a dose and duration dependant manner. Testosterone injection appears to normalize sperm counts in such cases. A recent report of 40 men taking methotrexate at the time of conception did not appear to cause any congenital malformations.