Abstract
The management of reproductive issues in women with inflammatory arthritis has greatly changed over decades. In the 1980–1990s, women with refractory forms of arthritis were either not able to get pregnant or did choose not to get pregnant because of their disabling disease. Hence, the traditional belief that pregnancy can induce a remission of arthritis. The availability of biologic agents has allowed a good control of aggressive forms of arthritis. The main topic of discussion during preconception counselling is the use of drugs during pregnancy and breastfeeding. Physicians are now supported by international recommendations released by the European League Against Rheumatism and the American College of Rheumatology, but still they must face with cultural reluctance in accepting that a pregnant woman can take medications. Patient-physician communication should be centered on the message that active maternal disease during pregnancy is detrimental to fetal health. Keeping maternal disease under control with drugs which are not harmful to the fetus is the best way to ensure the best possible outcome for both the mother and the baby. However, there might be concerns about the influence of the in utero exposure to medications on the newborn’s health conditions. Particularly, studies suggesting an increased risk of autism-spectrum-disorders in children born to women with rheumatoid arthritis has raised questions about neuropsychological impairment in the offspring of women with chronic arthritis. As a multidisciplinary group of rheumatologists and child neuropsychiatrists, we conducted a study on 16 women with chronic forms of arthritis whose diagnosis was determined before pregnancy and their 18 school-age children. The children underwent a complete neurological examination and validated tests/questionnaires. Behavioral aspects of somatization and anxiety/depression (internalizing problem) or an “adult profile” were found in nearly one third of children. Children at a high risk of neurodevelopmental problems were born to mothers with a longer history of arthritis and were breastfeed for less than 6 months of age or were not breastfeed at all. No association was found with other maternal characteristics such as autoantibody existence and disease activity during and after the pregnancy.
Highlights
In the past decades, young women affected by chronic inflammatory arthritis were discouraged of a pregnancy due to the joint pains, fatigue, disability, skeletal deformity and the loss of self-esteem
According to the published data, even if no randomized clinical trials are available in the field of pregnancy, an effective treatment of chronic arthritis is possible with an acceptable safety profile during pregnancy and lactation
Similar results were described in a French study that reported no increased risk of pediatric infections in a large cohort of children born to women with IBD treated with anti-TNFα during pregnancy (Luu et al, 2018)
Summary
Young women affected by chronic inflammatory arthritis were discouraged of a pregnancy due to the joint pains, fatigue, disability, skeletal deformity and the loss of self-esteem. According to the published data, even if no randomized clinical trials are available in the field of pregnancy, an effective treatment of chronic arthritis is possible with an acceptable safety profile during pregnancy and lactation The dissemination of this evidence among health professionals and patients is important in order to improve the management of pregnant and lactating mothers with rheumatic diseases. About 30% of the patients did not know that hydroxychloroquine can be taken during pregnancy and lactation without any harm to the child These findings underline the need of young women with inflammatory arthritis of an exhaustive counselling focusing on reproductive issues but, in particular, on the consequence of treating or not treating their disease (Chew et al, 2019). In contrast with the traditional belief that pregnancy related immunomodulation was able to induce disease remission at least in patients affected by RA, several recent reports underlined that this is true only for a part of the patients, while flares during gestation are recorded in about 29% of TABLE 1 | Classification of drug administration to pregnant patients with inflammatory arthritis and their restrictions during pregnancy [adapted from Østensen (2017a)]
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