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For medical professionals to read and reference
introduction
Pregnant women with rheumatism have a number of unique clinical problems during pregnancy that are of concern
to obstetricians and rheumatologists.
In addition to rheumatism itself, such pregnant women face a variety of serious obstetric complications, such as recurrent miscarriage, preeclampsia, small-for-gestational-age infants, intrauterine distress and premature birth
.
Therefore, optimizing the management of pregnant women with rheumatism during pregnancy requires the joint efforts
of obstetricians and rheumatologists.
This article aims to review obstetric problems and management
during pregnancy in women with rheumatism.
Obstetric problems [1].
01
About 20% to 30% of patients with SLE with systemic lupus erythematosus (SLE) may develop gestational hypertension, the most common of which is preeclampsia.
It is more likely to occur
in patients with a history of hypertension or renal insufficiency prior to pregnancy.
Severe high blood pressure in pregnancy can lead to stroke, heart failure, kidney failure, eclampsia, and even death
.
Hypertension during pregnancy is rare before 20 weeks' gestation, whereas maternal blood pressure and 24-hour urine protein quantification should be intensified from 20 weeks
' gestation, at least once every 2 weeks.
For high-risk patients with a history of hypertension or renal insufficiency prior to pregnancy, blood pressure should be monitored daily and patients should be alerted to symptoms of preeclampsia such as persistent headache, blurred vision, and right upper quadrant or epigastric pain, and the frequency
of antenatal visits should be increased appropriately between 28 and 32 weeks' gestation.
For severe hypertension in pregnancy, childbirth is the most effective and safest treatment for the mother
.
Antihypertensive medication controls the mother's blood pressure within a relatively safe range until delivery
.
Angiotensin-converting enzyme inhibitors (ACEI) antihypertensive drugs are contraindicated because of their fetal nephrotoxicity
.
Magnesium sulfate should be used during and after delivery to prevent epilepsy
.
Placental insufficiency is another concern for mothers with SLE, which is often associated with hypertension during pregnancy and may cause intrauterine growth restriction and respiratory insufficiency, ultimately leading to fetal distress and death
.
02
Antiphospholipid syndrome (APS) Theobstetric management of APS is similar
to SLE.
Hypertension and placental insufficiency during pregnancy are also the most important concerns
for mothers with APS.
Severe placental insufficiency is more common
in mothers with APS than SLE.
03
Rheumatoid arthritis (RA) Because about 50% of RA mothers may experience disease improvement during pregnancy, there are not many obstetric risks of concern for RA mothers during pregnancy, including an increasedrisk of pregnancy loss.
Regarding medication during pregnancy, glucocorticoids may be used in patients whose
illness does not improve during pregnancy.
Methotrexate and leflunomide are contraindicated
.
TNF inhibitors, particularly percelilizumab, as recommended by several guidelines, can be used for the treatment of RA throughout the periconceptional course [2-4].
Prenatal and laboratory tests [5].
Pregnant women with rheumatism who are undergoing a first-time antenatal examination are usually examined and evaluated
for blood picture, renal function, prenatal screening, etc.
And the frequency of prenatal examinations for pregnant women with rheumatism should be higher than that of ordinary pregnant women
.
In addition, it is difficult to distinguish lupus nephritis from preeclampsia, both of which can present with proteinuria, hypertension, and multiorgan failure
.
Laboratory tests can help differentiate, but diagnosis still depends on renal pathologic biopsy
.
Table 1 Laboratory tests to differentiate SLE from preeclampsiaNote: + indicates the extent to which this test is helpful in diagnosing the
disease.
Obstetric ultrasound and fetal heart rate monitoring[1].
All pregnant women with rheumatism should undergo obstetric ultrasound to clarify gestational age and monitor fetal development
.
Pregnant women with a history of intrauterine distress or death in the second trimester should be tested
early.
Fetal growth restriction and amniotic fluid insufficiency suggest placental insufficiency and require more frequent ultrasound evaluation
.
The details are as follows:
01
At 18 to 20 weeks' gestation in SLE, obstetric ultrasonography should be performed every 3 to 4 weeks to identify fetal growth restriction or oligohydramnios, and fetal heart rate monitoring should be performed to detect fetal hypoxia.
The fetal heart rate
should be monitored closely from 24 weeks' gestation.
After 32 weeks' gestation, fetal heart rate monitoring
is performed once a week.
02
Obstetric ultrasound should be started from 20 weeks' gestation in APS to check for fetal growth restriction or oligohydramnios.
The fetal heart rate
should be monitored closely from 23 to 24 weeks' gestation.
Conclusion: Through the use of a variety of clinical examinations and monitoring and treatment methods, rheumatism is no longer a contraindication to pregnancy and childbirth in such pregnant women
.
References:
[1] Branch DW.
Pregnancy in patients with rheumatic diseases:obstetric management and monitoring.
Lupus,2004,13(9):696-698.
[2] Gotestam Skorpen C,Hoeltzenbein M,Tincani A,Fischer-Betz R,Elefant E,Chambers C,da Silva J,Nelson-Piercy C,Cetin I,Costedoat-Chalumeau N,Dolhain R,Forger F,Khamashta M, Ruiz-Irastorza G,Zink A,Vencovsky J,Cutolo M,Caeyers N,Zumbuhl C,Ostensen M.
The EULAR points to consider for use of antirheumatic drugs before pregnancy,and during pregnancy and lactation.
Annals of the rheumatic diseases,2016,75(5):795-810.
[3] Sammaritano LR,Bermas BL,Chakravarty EE,Chambers C,Clowse MEB,Lockshin MD,Marder W,Guyatt G,Branch DW,Buyon J,Christopher-Stine L,Crow-Hercher R,Cush J,Druzin M,Kavanaugh A,Laskin CA ,Plante L,Salmon J,Simard J,Somers EC,Steen V,Tedeschi SK,Vinet E,White CW,Yazdany J,Barbhaiya M,Bettendorf B,Eudy A,Jayatilleke A,Shah AA,Sullivan N,Tarter LL,Birru Talabi M, Turgunbaev M,Turner A,D'Anci KE.
2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases.
Arthritis& rheumatology,2020,72(4):529-556.
[4] Rheumatology Branch of Chinese Medical Association.
Code of Diagnosis and Treatment of Rheumatology (2021).
2021.
[5] Dudley DJ,Branch DW.
Pregnancy in the patient with rheumatic disease:the obstetrician's perspective.
Bailliere's clinical rheumatology,1990,4(1):141-156.
- End -
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, nor does it assume any responsibility
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