The excitement of the positive pregnancy test, for most expectant mothers, can be clouded with concern for a healthy pregnancy and baby. But, if you have RA or Lupus, it can be multiplied. You also have to worry about if your pregnancy will cause a flare-up, what medicines are safe for your baby, and whether or not your condition will affect your growing fetus or your own long-term health.
This article addresses the issues of two, out of many, rheumatic conditions: rheumatoid arthritis (RA) and systemic lupus erythematosus (lupus).
RA and lupus are autoimmune diseases and in autoimmune diseases the immune system, which is suppose to protect your body from any foreign substances that may harm it, malfunctions and attacks your own body's tissues. If you have RA or lupus you are probably taking medication that reduces the immune systems activity to a greater or lesser degree. But pregnancy has its own impact on the immune system and your system must make some adjustments so that your body won't attack what it perceives to be foreign, the genes that come from the father of your baby. These adjustments make it possible for your baby to grow safely. But there are other effects which can impact your rheumatic conditions such as RA and lupus in different ways.
Something to think about.
It can be hard to determine whether the changes in the way you feel are from the pregnancy or your RA or lupus. Unfortunately when you are pregnant you can become anemic, which can cause you to be tired and have a lack of energy, this also happens when you have RA or lupus. Your pregnancy will also affect certain markers of inflammation, doctors use blood test to measure your inflammation called a erythrocyte sedimentation rate or ESR, which is often high if you have RA or lupus. These markers can also be high when you're pregnant so measuring ESR may not be the best way to gauge how active your RA or lupus is. Also, your pregnancy may make blood clots more likely, but if you have lupus, there is also an increased risk that you will have blood clots because there is a protein called antiphospholipid antibodies in your blood, and these proteins is what increases your risk.
Your pregnancy can also cause musculoskeletal problems because as your baby grows, your ligaments will relax to allow the pelvis to stretch. You will also put on weight, which is a healthy thing but this can cause your posture to change which can result in joint aches and back pain. Another thing is carpal tunnel syndrome (CTS), which causes wrist pain and numbness, is a common complication of your pregnancy, especially during the second and third trimesters but is is also associated with RA and lupus. All these things can make it tricky to figure out whether or not they are problems with the pregnancy or are a part of your rheumatic conditions.
Things to do if you have RA.
RA mainly affects the joints and it will make them stiff, painful, swollen and sometimes, unstable and deformed, but it can also cause fatigue and you may have problems with your heart and your eyes. There is between 1% and 2% of the United States population that have RA, and it is most common among women than men. It will usually appear when you are in your twenties or thirties, the child bearing years, so finding women with RA who are considering pregnancy is not all that surprising.
The first thing you will want to know, if you have RA and are considering having a baby, is whether or not your arthritis is going to flare-up during your pregnancy. The thought of carrying around an extra 20 - 30 pounds of weight on replaced joints or on joints that are sometimes swollen and sore can be a bit discerning. Luckily there are about 70% - 80% of women who have RA that go into remission during their pregnancy, another words their symptoms go away. For the rest of those women with RA who don't go into remission, their symptoms may become milder and easier to manage. It's hard to predict just who will go into remission but despite this uncertainty, some doctors will tell their patients to stop taking their RA medications when they become pregnant because of the high likelihood that they will go into remission and not need treatment. But there are some steps you can take before you get pregnant that can help you during and after the pregnancy.
Work out a plan with your rheumatologist for what medication you will take if you do have a flare during your pregnancy.
You will also have to consider the type of delivery you will have. Most women with RA can safely go through the labor and vaginal delivery, but if your RA affects your pelvis and legs extensively, a vaginal delivery may not be what you want to do. Your doctor may opt for a planned cesarean section.
For some of you with RA, you may find that after you have your baby your arthritis flares up. Because arthritis flares can make it difficult to care for a newborn, you will want to plan very carefully just how you will manage this period. By planning you can ease the adjustment of this postpartum period.
If you are planning on breast feeding you will need to discuss this with your rheumatologist, obstetrician and pediatrician ahead of time. There are some RA medications that are compatible with breast-feeding. Try to decide which one you want to take just in case you have a flare after your baby is born.
If it's possible, try to have someone to help you at home during the transition time. If you are unable to, there are some things you can do to make it easier on yourself, such as; having some extra meals stashed in the freezer so that all you have to do is to pull them out of the freezer when things get difficult.
Planning is the key and it will go a long ways to helping you ease the stress of your worst flare. The good news is that RA doesn't have a negative impact on the baby, it doesn't increase the rate of miscarriages, and it doesn't cause any problems in the baby.
What if you have lupus
If you have systemic lupus erythematosus, it's a bit more complicated. The reason it's more complicated is that lupus can affect many parts of the body, such as the skin, joints, kidneys, blood cells, heart and lungs. The most common symptoms are a rash on the face, pain and swelling in the joints and a fever with kidney disease being the most serious symptom. Lupus is more common in women then men and it will usually show up when you are between the ages of 15 and 45.
Doctors of the past would often counsel women with lupus against getting pregnant based on the assumption that pregnancy would always cause lupus flares, possibly serious flares, and that babies would do so well. These were and are valid concerns, but there is now a better understanding of lupus and how to treat it that has made pregnancy very realistic and a safe option if you decide to get pregnant.
There are several studies that have shown that being pregnant may increase your risk of flares and yet other studies that have found that it doesn't. This confusion in part lies with how the different researchers measure and define a flare. And also, during any nine-month period you may have a flare or flares whether you are pregnant or not, so flares during your pregnancy are not exactly related to your pregnancy. Headaches, fatigue, shortness of breath and joint pain are all symptoms of a lupus flare as well as the possibility being a part of your pregnancy. The most likely risk is that women with lupus have a slightly higher chance of having a flare-up but for many women it can be controlled with medication.
You will most likely flare and not do so well during pregnancy if your lupus was active at the time of conception. This will be the case if your lupus has affected your kidneys because pregnancy will also stress your kidneys. Most doctors will generally not recommend getting pregnant until you have been in remission from kidney disease and active lupus for six months.
The most ideal situation is if when you have decided to become pregnant, that you see your rheumatologist ahead of time so he can run blood tests that will determine just how active your lupus is. The blood test will also establish a baseline that your doctor can refer to later during your pregnancy in case there are any difficulties. If you don't get these test done before you get pregnant then definitely get them done shortly after. You will also want to consult with an obstetrician who has experience with treating women who have lupus or possibly an obstetrician who specializes in high risk pregnancies. It is also a good idea if when you become pregnant, you are taking medication to control you lupus and that you can continue to take them safely during your pregnancy. Although, if you have RA you are able to stop taking your medications during your pregnancy, this may not be the case if you have lupus. You and your rheumatologist will need to plan for what medications you can take if you have a lupus flare during your pregnancy.
If your blood tests show that you have the antibodies called anti-RO (SSA) or anti-La (SSB), you will have a small risk of having a baby born with a rare condition called neonatal lupus. The main symptom of neonatal lupus is a skin rash, and it will usually disappear in six months. There is a very small percentage of babies with neonatal lupus, about 2% to 5%, who will develop heart block, which causes the heart to beat abnormally. If you are known to have the anti-RO or anti-La antibodies, you will probably have an ultrasound at 18 to 24 weeks into the pregnancy to see if there is heart block. The doctor may prescribe a corticosteroid in an attempt to treat the heart block if there is one. Although, research doesn't show a clear benefit of doing this. It may become necessary to deliver the baby early but most babies born with heart block need to have a pacemaker implanted, wither at birth or later in life.
There are other complications that come with lupus and that includes preeclampsia, premature rupture of the membranes, which means the baby will be born prematurely, and low-birth-weight babies. In preeclampsia, or pregnancy-induced hypertension, you will have high blood pressure and retain fluid among other symptoms. Preclampsia is thought to be more common if you have lupus and most often it can be hard to distinguish between preeclampsia and a lupus flare. But if it's not treated appropriately, preeclampsia can damage your kidneys and liver as well as increase the risk for a miscarriage and premature birth or even cause the baby to be very small. If you have preeclampsia your doctor may recommend that you deliver the baby early, either by induced labor or a C-section.
The same advice that applies if you have RA applies to you if you have lupus as far as the period after the birth of your baby. Planning makes all the difference and having help lined up in case you have a lupus flare prevents you from taking care of your baby. As with RA, you will want to have ready-to-eat meals in the freezer and be sure to know what your options are in terms of breast-feeding and medications.
As you can see, there are some very special considerations for you if you have lupus and are considering having a baby, but if you have a clear understanding that your chances are good that our outcome will be nearly as good as someone who doesn't have lupus. Remember that the best approach is to have your health care team, your rheumatologist and obstetrician, working hand in hand and also good communication and close follow-up with this these team members is the key.
Your medications
There are many medicines that are used to treat RA and lupus that are relatively safe during pregnancy, but some of the drugs used for rheumatic conditions increase the risk of birth defects, and it's also important to remember that birth defects occur in about 3% of pregnancies where the mother doesn't take any medications. When you are considering if a medication is safe during pregnancy, you should determine if the risk of birth defects is greater than 3%. Your doctor should be able to help you figure it out.
NSAIDs: Non-steroidal anti-inflammatory drugs treat the pain and inflammation of arthritis. These NSAIDs include the COX-2 inhibitor celecoxib (Clelbrex) and traditional NSAIDs such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn) and the many other, both prescription and over the counter. There are studies in animals that have shown that NSAIDs can cause birth defects, but there hasn't been any findings in humans. It is possible to take these medicines safely during your pregnancy up to the third trimester. Taking NSAIDs during the third trimester, will increase the risk that one of the baby's heart vessels will close prematurely, a good reason to stop taking them at 24 weeks of pregnancy. If you are trying to get pregnant you may want to stop taking the NSAIDs, including COX-2 inhibitors, from the time of ovulation until their next menstrual period because there is a hypothetical risk that these medicines will interfere with the implanting of a fertilized egg.
Corticosteroids: Corticosteroids decreases the inflammation throughout the body and these drugs are often the mainstay of treatment for people with inflammatory conditions such as RA and lupus. Prednisone and prednisolone are the most commonly prescribed drugs that your doctor will give you and you can continue to take these medicines during your pregnancy if you need to. But before you do, remember that if you take the corticosteroids during the first trimester of your pregnancy, your baby could be born with a cleft palate. This risk is still fairly low, with cleft palate happening in roughly 1 in 300 babies exposed to the drugs in the womb compared to 1 in 1,000 when there is no exposure. Babies born to mothers who take corticosteroids during pregnancy are also more likely to be smaller and born prematurely. They also will raise your risk of pregnancy induced hypertension, gestational diabetes, a form of diabetes that happens only during pregnancy, and pregnancy-induced osteopenia or bone thinning. Corticosteroids are often a reasonable choice during pregnancy for the management of both RA and lupus despite the potential side effects.
Hydroxychloroquie: It was thought that hydroxychloroquine or Plaquenil, was not compatible with pregnancy but over the past decade that idea has changed. Right now most rheumatologists in the United States and elsewhere with patients who need hydroxychloroquine to keep their condition stable will keep them on it during their pregnancy. Studies have been done to substantiate the claim that the medicine might cause problems with the development of the fetus's visual and hearing systems, but the studies didn't prove it.
Sulfasalazine: Sulfasalazine or Azulfidine, is considered to be safe to use when you are pregnant.
Azathioprine and cyclosporine: These drugs are immunosuppressive drugs that are used mainly to maintain organ transplants. Doctors will also subscribe them to treat RA and lupus. There is information from world wide transplant registries of literally thousands of babies that were exposed to these medications in the womb. This information shows that there were no increased rates of birth defects, but the babies do seem to be smaller and to be born earlier. There are many doctors will use these medications if they need to control RA or lupus activity in women who are pregnant.
Methotrexate, leflunomide, mycophenolate mofetil, cyclophosphamide: These medications can cause early fetal death and birth defects at a rate higher than what you would expect. You shouldn't take them during your pregnancy and also if you are planning a pregnancy you should stop taking methotrexate or CellCept at least one menstrual cycle before trying to get pregnant. If you're a man taking these medications then you will want to stop taking them three months ahead of time. If you are taking leflunomide you will need to to stop taking it two years before you try to get pregnant, or you could under go a two-week procedure to wash the medicine out of your bloodstream.
Biologics: There isn't enough data to conclude whether or not this newer type of drug is absolutely safe during pregnancy. However, we do know that TNF-alpha blockers, etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) may contribute to birth defects according to recent evidence. You will want to stop taking biologic drugs before trying to become pregnant.
In just about all circumstances, if you have RA or lupus, you can be sure it is safe to become pregnant as long as you are sure your RA and lupus are under control and your pregnancy is planned. If you have lupus it is particularly important to keep the communications open with your rheumatologist and that you have an obstetrician that is experienced in dealing with women with lupus or high risk pregnancies. With careful monitoring and the appropriate use of your medicines, it will be possible to successfully manage your pregnancy when you have RA or lupus.
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