Rheumatoid_Arthritis_Pregnancy_Flashcards
At what age does rheumatoid arthritis (RA) typically develop in women?
Rheumatoid arthritis (RA) typically develops in women of a reproductive age.
What should patients with early or poorly controlled RA be advised regarding conception?
Patients with early or poorly controlled RA should be advised to defer conception until their disease is more stable.
How do RA symptoms tend to change during pregnancy?
RA symptoms tend to improve in pregnancy but only resolve in a small minority.
What happens to RA symptoms following delivery?
Patients tend to have a flare of RA symptoms following delivery.
Is methotrexate safe in pregnancy?
Methotrexate is not safe in pregnancy.
When should methotrexate be stopped before conception?
Methotrexate needs to be stopped at least 6 months before conception.
Is leflunomide safe in pregnancy?
Leflunomide is not safe in pregnancy.
Which medications are considered safe for RA patients in pregnancy?
Sulfasalazine and hydroxychloroquine are considered safe in pregnancy.
What do studies show about pregnancy outcomes in patients treated with TNF-α blockers?
Studies looking at pregnancy outcomes in patients treated with TNF-α blockers do not show any significant increase in adverse outcomes, although many patients stopped taking TNF-α blockers when they found out they were pregnant.
Can low-dose corticosteroids be used in pregnancy to control RA symptoms?
Low-dose corticosteroids may be used in pregnancy to control RA symptoms.
Until when can NSAIDs be used in pregnancy for RA patients?
NSAIDs may be used until 32 weeks of pregnancy.
Why should NSAIDs be withdrawn after 32 weeks of pregnancy?
NSAIDs should be withdrawn after 32 weeks due to the risk of early closure of the ductus arteriosus.
Why should RA patients be referred to an obstetric anaesthetist?
RA patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation.
Summarise RA in pregnancy
Rheumatoid arthritis: pregnancy
Rheumatoid arthritis (RA) typically develops in women of a reproductive age. Issues surrounding conception are therefore commonly encountered. There are no current published guidelines regarding how patients considering conception should be managed although expert reviews are largely in agreement.
Key points
patients with early or poorly controlled RA should be advised to defer conception until their disease is more stable
RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery
methotrexate is not safe in pregnancy and needs to be stopped at least 6 months before conception
leflunomide is not safe in pregnancy
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
interestingly studies looking at pregnancy outcomes in patients treated with TNF-α blockers do not show any significant increase in adverse outcomes. It should be noted however that many of the patients included in the study stopped taking TNF-α blockers when they found out they were pregnant
low-dose corticosteroids may be used in pregnancy to control symptoms
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
A 34-year-old male with rheumatoid arthritis attends his GP practice as he wants counselling regarding starting a family. His wife does not have any medical conditions and has been taking folic acid for the past four weeks. They are keen to start trying for a baby as soon as possible. He has no other medical history and his regular medications are methotrexate, paracetamol, ibuprofen, and lansoprazole. He is aware that his sister had to stop some of her medications for rheumatoid arthritis prior to conceiving and wants to know if he needs to do the same.
What is the appropriate management advice for this patient?
No need to stop methotrexate as he is male
No need to stop methotrexate in males or females attempting conception
Stop methotrexate at least one month before conception
Stop methotrexate at least six months before conception
Stop methotrexate at least three months before conception
Stop methotrexate at least six months before conception
Methotrexate: must be stopped at least 6 months before conception in both men and women
This question assesses the knowledge regarding discontinuation of the dihydrofolate reductase inhibitor methotrexate prior to conception. There is a risk that methotrexate can damage the sperm in males and can cause spontaneous early abortion in females. In order to allow full ‘wash-out’ of the drug and to improve sperm quality, it is advised that methotrexate is stopped at least six months prior to conception.
Methotrexate should be stopped in both male and female patients prior to attempting conception to ensure that both gametes have minimised risk of DNA changes.
While there is some evidence that paternal exposure to methotrexate within 90 days before pregnancy was not associated with congenital malformation/stillbirth/preterm birth (a 2017 study by Eck et al.), the current guidance is to avoid the drug for six months to allow repletion of folic acid. This means that stopping methotrexate for three months before conception is an incorrect answer. Stopping it for only a month is also clearly an incorrect option.
