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  • Review Article
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Stratifying management of rheumatic disease for pregnancy and breastfeeding

Nature Reviews Rheumatology volume 15, pages 391–402 (2019)Cite this article

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Abstract

The management of inflammatory rheumatic diseases during pregnancy and breastfeeding has undergone considerable change in the past few years. Modern therapeutics, including biologic and targeted synthetic DMARDs, have enabled substantial improvements in the control of rheumatic diseases, resulting in more patients with severe disease considering pregnancy. Therefore, management of disease for these patients needs to be discussed with clinicians before, during and after pregnancy and patients need to know what complications they might experience before they become pregnant. This Review summarizes the effects pregnancy has on various rheumatic diseases and the effects these diseases have on pregnancy, as well as providing advice regarding the alteration and monitoring of therapy before, during and after pregnancy.

Key points

  • Various inflammatory rheumatic diseases carry an increased burden of adverse pregnancy outcomes.

  • Pregnancy can exacerbate some but not all inflammatory rheumatic diseases.

  • Pre-pregnancy counselling is required to evaluate and reduce risks of adverse pregnancy outcomes for each patient.

  • Some therapies must be altered before, during and/or after pregnancy.

  • Careful monitoring is required throughout pregnancy by a multidisciplinary team.

  • Vigilance for disease flare is required post-partum.

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Fig. 1: Transplacental transfer of IgG antibodies from maternal blood into the fetal circulation.
Fig. 2: Treat-to-target strategy for management of inflammatory rheumatic diseases in pregnancy.
Fig. 3: Optimization of management of inflammatory rheumatic diseases in pregnancy.

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Author information

Authors and Affiliations

  1. Centre for Rheumatology Research, UCL Division of Medicine, London, UK

    Ian Giles

  2. Department of Rheumatology, Doncaster Royal Infirmary, Doncaster, UK

    Chee-Seng Yee

  3. Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK

    Caroline Gordon

Authors
  1. Ian Giles
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  2. Chee-Seng Yee
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  3. Caroline Gordon
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Contributions

All authors made substantial contributions to the research and discussion of the content. I.G. drafted the article and C.-S.Y. and C.G. edited/reviewed the article.

Corresponding author

Correspondence to Caroline Gordon.

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Competing interests

I.G. declares that he has received honoraria and travel grants from UCB and Lupus Academy to speak at educational meetings on topics related to pregnancy in rheumatic disease. C.S.Y. declares that he has consulted for Bristol Myers Squibb, Immupharma and EMD Serono. C.G. declares that she has consulted for and received honoraria from Bristol-Myers Squibb, GlaxoSmithKline, EMD Serono and UCB in relation to lupus clinical trial design and analysis, and has been a member of the speakers’ bureau for GlaxoSmithKline and UCB. C.G. also declares that she has participated in clinical trials sponsored by UCB and funded by Arthritis Research UK with drugs supplied by GlaxoSmithKline.

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Glossary

Intrauterine growth restriction

(IUGR). Reduced fetal growth resulting in an estimated weight below the 10th percentile for gestational age.

Cyclophosphamide-induced gonadal toxicity

Gonadal damage induced by cyclophosphamide, leading to reduced ovarian function.

Gestational hypertension

New-onset hypertension presenting after 20 weeks’ gestation without significant proteinuria.

Pre-eclampsia

New-onset hypertension presenting after 20 weeks’ gestation with significant proteinuria. Indicative of maternoplacental dysfunction.

Small for gestational age

Term used to describe a baby who is smaller than usual for the number of weeks of pregnancy. These babies usually have birthweights below the 10th percentile for gestational age.

Endocardial fibroelastosis

A rare heart disorder of infants and children that is characterised by a thickening within the muscular lining of the heart chambers due to an increase in the amount of supporting connective tissue (inelastic collagen) and elastic fibres.

Placental insufficiency

Failure of the placenta to deliver sufficient nutrients and oxygen to the fetus during pregnancy.

Minimum tolerable dose of corticosteroid

The minimum dose required to maintain disease control and reduce complications such as steroid-induced diabetes mellitus, hypertension and infections in the mother.

Rescue therapy

Treatment given after a patient has failed to respond to standard therapy.

Ductus arteriosus

A blood vessel in the fetus connecting the main pulmonary artery to the proximal descending aorta, allowing most blood from the right ventricle to bypass the lungs. Premature closure of this blood vessel leads to progressive right heart dysfunction, congestive heart failure and intrauterine death.

Uterine artery Doppler ultrasound

A technique used to measure uterine artery blood flow between mother and baby.

Thromboprophylaxis

In this context, the prevention of thromboembolic disease by pharmacological means.

Fetal cardiac ultrasound

Technique used to evaluate the structure of the fetal heart.

Screening for congenital heart block

The use of fetal cardiac ultrasound at the 16th to 20th week of pregnancy in anti-SSA/Ro-positive mothers.

Cardiac pacing

Technique used to regulate heart rate involving the fitting of a pacemaker.

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Giles, I., Yee, CS. & Gordon, C. Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 15, 391–402 (2019). https://doi.org/10.1038/s41584-019-0240-8

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