Rheumatoid Arthritis in

Pregnancy
Anna Salleh
Rheumatology Unit
QEH
 Outline
Case presentation
Diagnosis of RA
Assessment Tools
 30 year old female Management
LMP 19th May 2016
T Prednisolone 5mg
G1P0+1
OD for 2 weeks
Presented in August 2012
Early morning stiffness Started taking T
lasting 30 minutes
Prednisolone 5-
Joint pains and swelling
10mg on for a
PIPs
Knees duration of 1-2 days
ANA, RF and antiCCP were as and when joint
negative pains occured
February 2016
Miscarried Management
Cause for T Prednisolone
miscarriage unknown 20mg OD
Hb during
pregnancy 6-7g/dL

Joint pains worsened

ESR 22mm/1st hour
June 2016

T Prednisolone tapered off to 5mg OD

Discontinued herself as she was concerned about effects of
prednisolone on her pregnancy

Started T Sufasalazine 500mg BD for 1

week. Then 500mg OD for 1-2 weeks
Discontinued 29th June 2016 due to neutropaenia
July 2016
Swelling involving Management
Bilateral wrists
Right first IP joint T Prednisolone 5mg
Left frst MCP OD
Bilateral knees T
Hydroxychloroquine
300mg OD
T CaCO3 500mg BD
T Paracetamol 1g BD
August 2016

Worsening joint pains CRP 48

Debilitating
Admitted for pain control Management
-IV fentanyl T Prednisolone 10mg
BD
Antalgic gait Certolizumab was
Difficulty walking considered
up/down stairs Bilateral wrist
intraarticular injections
September 2016

No early morning stiffness DAS score 1.91

Pain worse towards the
evening especially when
she has had many chores CRP 1
to do

Management
Antalgic gait resolved
T prednisolone 10mg
No more joint tenderness BD
over the knees T Hydrpxychloroquine
300mg OD
 Rheumatoid Arthritis
Autoimmune inflammatory arthritis
2015 ACR Guideline for the treatment of RA

Chronic inflammatory autoimmune

disease of unknown aetiology*
APLAR Rheumatoid Arthritis Treatment Recommendation

*Genetic, hormonal, immunoligc, infectious factors?

 Clinical manifestations
Usually insidious
Typically polycarticular (may be
monoarthritis in the beginning)
Joint pains and swelling (MCP and
PIP)
Morning stiffness
 Extra-articular
manifestations
Osteopenia Sjogrens Syndrome
Muscle weakness (myositis, Nervous system (Carpal
vasculitis, drug-induced tunnel syndrome,
Skin (eg: rheumatoid nodules, compressive myelopathy,
medication)
radiculopathy,
Eye (eg; episcleritis, scleritis) mononeuritis multiplex)
Lungs (interstitial lung
Haematologic (anaemia,
disease)
lymphoproliferative
Cardiac (CAD risk increased.
Heart failure risk is twofold.
disease, Feltys Syndrome
Pericarditis, myocarditis anaemia,
uncommon) thrombocytopaenia,
Kidney (mesangioproliferative enlarged spleen)
glomerulonephritis, drug-
induced nephropathy)
 Effects of Pregnancy on RA
Spontaneous improvement or
stabilisation of disease (weeks or
months into the postpartum period)
90% Flare postpartum (within 3-4
months)
State of immune tolerance

Use of DMARDS and biologics during pregnancy and lactation in rheumatoid arthritis:
what the rheumatolist needs to know
Megan L. Krause, Shreyasee Amin and Ashima
Makol
 Seronegative RA more likely to
improve

Ann Rheum Dis 2010 Feb;69(2):420-3

Diagnosis of Rheumatoid
Arthritis
Assessment
 Treatment
Nonpharmacological
- Education
- Psychosocial interventions
- Physiotherapy/Occupational therapy
- Reduce risks of CVD (eg: quit smoking)
- Vaccinations

Pharmacological
 Treatment
cDMARDs bDMARDs Corticosteroids
Methotrexate TNF inhibitors T Prednisolone 5-
Leflunomide Adalimumab 7.5mg daily
Sulfasalazine Certolizumab
Hydroxychloroquine Etanercept Intraarticular steroid
Golimumab injections
Infliximab -3 injections per joint
per year
NonTNF -Must not be repeated
Abatacept before 3 months
Roituximab
Tocilizumab
Treatment

2015 ACR Guideline for the treatment of rheumatoid

 Recommendations for safety of therapies for
rheumatoid arthritis dring lactation
Safe to continue Inadequate data Contraindicated
Safe to continue TNF inhibitors* Methotrexate
NSAIDs Anakinra Leflunomide
Corticosteroids Abatacept Azathioprine
Hydroxychloroqui Rituximab
ne Tocilizumab
Sulfasalazine Tofacitinib

Use of DMARDS and biologics during pregnancy and lactation in rheumatoid arthritis:
what the rheumatolist needs to know
Megan L. Krause, Shreyasee Amin and Ashima Makol
 NSAIDs
Nonselective NSAIDs
-Used with caution in the 1 st trimester
-Withdrawn at 32 weeks of gestation
(except low dose aspirin)
-COX2 to be avoided

BSR and BHPR guideline on prescribing drugs in pregnancy and

breastfeeding Part II
 Prednisolone
Lowest possible dose
Consider addition of DMARDs or
biologic
 When to stop biologics?
Biologic Suggested gestation to
discontinue
Infliximab 21
Adalimumab 28
Etanercept 32
Cetolizumab Do not discontinue

Insufficient evidence for anakinra, golimumab and tocilizumab

High Risk Pregnancy and the Rheumatologist

Rheumatology. 2015;54(4):572-587.
 Treatment of RA is a shared decision
between clinician and patient