The Medical Management of the Rheumatology Patient During Pregnancy

Abstract

Congenital anomalies occur in 3 % of normal pregnancies [ 1 ]. Therefore, risk assessment of any particular agent during pregnancy needs to take into account this background rate of teratogenicity. For many years, clinicians relied on the FDA risk categories (A, B, C, D, and X) to assess drugs for safety for use in pregnancy. As Briggs, author of the major textbook in this fi eld, points out, these risk assessments are limited because they are "confusing and simplistic" and incorrectly gave the impression that risk increases from category to category [ 2 ]. The FDA is currently considering new labeling for pregnancy risk. The approach this chapter will take is to present the available data on medication safety in pregnancy and lactation and to synthesize the information regarding drug safety.Each pregnant woman has her own view about assuming risk during her pregnancy. For example, some women will avoid any substance that could have potential risk during pregnancy (caffeine, over-the-counter medications, food-additives) while other women will be willing to assume some risk and modify their ingestion of these substances. Similarly, treating physicians have varying tolerance to risk. While one clinician may be willing to prescribe TNF-α blockers during pregnancy, others will be uncomfortable recommending these medications. Therefore, when approaching management decisions of rheumatic diseases during pregnancy, it is helpful for the treating clinician to be aware of both the patient's and their own risk tolerance, in addition to the available medical data. To this end, up-front discussions prior to conception or early in pregnancy regarding what medications may be used safely and comfortably in the case of a disease fl are are ideal.

Undifferentiated Connective Tissue Disease in Pregnancy: A Topic Yet to be Explored

“…During pregnancy, it not only may improve clinical manifestations of rheumatic disease and other inflammatory disorders but may also be used for the management of antiphospholipid syndrome and for the prevention of PE. Salicylates in low doses are compatible with nursing, but high-dose aspirin should be avoided ( Bermas, 2020 ).…”

“…However, in a Danish cohort study evaluating corticosteroids exposure during the first trimester in 51,973 pregnancies, this association was not confirmed ( Hviid and Mølgaard-Nielsen, 2011 ). Therefore, the lowest effective dose of glucocorticoids should be used to control disease activity during pregnancy, while high-dose schemes should be limited to women with organ-threatening disease ( Bermas, 2020 ).…”

“…Glucocorticoids are compatible with breastfeeding. They are excreted in breastmilk in low concentration, but it is advised discarding breast milk for the first 4 h following ingestion of a dose of prednisone ≥20 mg, as the peak concentration in breast milk is achieved 2 h after maternal ingestion ( Bermas, 2020 ).…”

“…SSZ possesses both antinflammatory properties mediated by its 5-aminosalicylic acid moiety and antibacterial characteristics ( Bermas, 2020 ). SSZ and its metabolite sulfapyridine cross the placenta; however, no increase in miscarriage or congenital malformations are reported ( Marder et al, 2016 ).…”

“…SSZ is transferred in low concentration in milk and is considered compatible with breastfeeding in healthy, full-term infants. However, women taking SSZ should avoid breastfeeding premature infants or those with hyperbilirubinemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency ( Bermas, 2020 ).…”