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 OD
• G1P0+1 for 2 weeks

• Presented in August • Started taking T

2012 Prednisolone 5-10mg
• Early morning stiffness on for a duration of 1-2
lasting 30 minutes days as and when joint
pains occured
• Joint pains and swelling
– PIPs
– Knees
• ANA, RF and antiCCP
were negative
February 2016
• Miscarried • Management
• Cause for miscarriage • T Prednisolone 20mg
unknown 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 OD
– Left frst MCP
• T Hydroxychloroquine
– Bilateral knees
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
• Certolizumab was
Antalgic gait
considered
Difficulty walking
• Bilateral wrist
up/down stairs
intraarticular injections
September 2016
DAS score 1.91
No early morning stiffness
Pain worse towards the CRP 1
evening especially when
she has had many chores
to do Management
T prednisolone 10mg BD
Antalgic gait resolved T Hydrpxychloroquine
300mg OD
No more joint tenderness
over the knees
 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
• Muscle weakness (myositis,
vasculitis, drug-induced
• Skin (eg: rheumatoid nodules,
medication)
• Eye (eg; episcleritis, scleritis)
• Lungs (interstitial lung disease)
• Cardiac (CAD – risk increased.
Heart failure – risk is twofold.
Pericarditis, myocarditis –
uncommon)
• Kidney (mesangioproliferative
glomerulonephritis, drug-induced
nephropathy)
• Sjogren’s Syndrome
• Nervous system (Carpal tunnel
syndrome, compressive
myelopathy, radiculopathy,
mononeuritis multiplex)
• Haematologic (anaemia,
lymphoproliferative disease,
Felty’s Syndrome – anaemia,
thrombocytopaenia, enlarged
spleen)
 Effects of Pregnancy on RA
• ¾ 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 5-7.5mg
Leflunomide Adalimumab 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 arthritis

 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
Hydroxychloroquine Rituximab
Sulfasalazine Tocilizumab
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 1st 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