Pregnancy in the rheumatic diseases

Few conditions in rheumatology are fraught with greater concern and more unknowns than those of fertility and pregnancy. Patients with rheumatologic disease are not at higher risk for infertility than the general population, unless they have received cyclophosphamide. In general, the inflammation from active rheumato-logic disease is more dangerous to a pregnancy than immunosuppressant medications. Medications to continue if needed to control disease: hydroxychloroquine, azathioprine, sulfasalazine, and prednisone. Medications to discontinue prior to pregnancy: metho-trexate, leflunamide, mycophenolate mofetil, cyclophos-phamide. Normal pregnancy can alter laboratory findings. In particular, the creatinine should fall and proteinuria may increase mildly. The sedimentation rate and complement may increase. Flares in lupus during pregnancy tend to be mild. Patients at highest risk for a severe flare have active lupus at the time of conception. Even treated with low molecular weight heparin and aspirin 81mg a day, up to 25% of pregnancies in women with antiphospholipid syndrome will result in a pregnancy loss. Maternal SSA/Ro and SSB/La antibodies put a baby at risk for neonatal lupus. Up to 50% of these mothers do not fit criteria for a rheumatologic disease. Rheumatoid arthritis will improve in many women during pregnancy, but often flares post-partum. Medications may be tapered during pregnancy but should be restarted following delivery to avoid a severe flare.