TREATMENT OF INFLAMMATORY RHEUMATIC DISORDERS IN PREGNANCY - WHAT ARETHE SAFEST TREATMENT OPTIONS

The interaction of pregnancy and the rheumatic diseases varies, rangin g from life-threatening conditions such as thromboembolic events and p rogressive renal disease in some autoimmune disorders, to minor flares of peripheral arthritis in inflammatory rheumatic disease. As a conse quence, treatment strategy will vary according to the maternal or feta l compromise expected. All nonsteroidal anti-inflammatory drugs (NSAID s), including high dose aspirin (acetylsalicylic acid), can cause adve rse effects during pregnancy related to the inhibition of prostaglandi n synthesis. Prolongation of gestation and labour, constriction of the ductus arteriosus, persistent fetal circulation, impairment of renal function and bleeding are risks of third trimester exposure of pregnan t women to all inhibitors of cyclo-oxygenase. Most of these adverse ef fects can be prevented by discontinuing NSAIDs 8 weeks prior to delive ry. Low dose aspirin has not been associated with fetal or neonatal to xicity. Some corticosteroids such as prednisone and prednisolone do no t readily cross the placenta and can be safely used during pregnancy a s immunosuppressive drugs. Maternal complications related to corticost eroids may occur and close monitoring is therefore mandatory. There is limited information on the safety of disease-modifying antirheumatic drugs including Sold, antimalarials, penicillamine (D-penicillamine), sulfasalazine and cyclosporin. Of these agents, sulfasalazine has the best record for tolerability and can be used by pregnant patients. Gol d compounds and penicillamine should be discontinued when pregnancy is recognised. Hydroxychloroquine has not been associated with congenita l malformations and seems preferable to chloroquine in patients requir ing treatment with antimalarials. Use of cyclosporin may be an alterna tive to other therapy in pregnant patients with severe rheumatic disea se. Indications for treatment with colchicine during pregnancy are few , except for familial Mediterranean fever.Azathioprine can be used whe n the maternal condition requires a cytotoxic drug during the first tr imester. Cyclophosphamide, chlorambucil and methotrexate are contraind icated during pregnancy because of their teratogenic potential. Their use may be considered in late pregnancy if the mother has a life-threa tening condition.