Some studies report a protective efect of pregnancy against developing new-onset rheumatoid arthritis. In a case-control study of 88 afected women, there was a protective efect of pregnancy in the long term, but the likelihood of new-onset rheumatoid arthritis was increased sixfold during the irst 3 postpartum months (Silman, 1992). Pikwer and colleagues (2009) reported a significant reduction in the risk of subsequent arthritis in women who breastfed longer than 12 months.
hese indings may reflect the interference of sex hormones with several putative processes involved in arthritis pathogenesis, including immunoregulation (Haupl, 2008a,b). First, Unger and associates (1983) reported that amelioration of rheumatoid arthritis correlated with serum levels of pregnancyassociated apha2-gycoprotein. his compound has immunosuppressive properties. Second, Nelson and coworkers (1993) noted that amelioration of disease was associated with a disparity in HLA class II antigens between mother and fetus. They s�ggested that the maternal immune response to paternal HLA antigens may play a role in pregnancy-induced remission of arthritis. In addition to monocyte activations, there also may be T -lymphocyte activation (Forger, 2008).
This group of diseases is the most frequent cause of chronic arthritis in children and persists into adulthood. In 76 pregnancies of 51 afected Norwegian women, pregnancy had no efects on clinical presentation, but disease activity usually became quiescent or remained so during pregnancy (0stensen, 1991). Postpartum flares were common as was discussed for rheumatoid arthritis. Joint deformities often developed in these women, and 15 of 20 cesarean deliveries were done for contracted pelves or joint prostheses. Results from a summary of 39 Polish women with juvenile rheumatoid arthritis were similar (Musiej-Nowakowska, 1999).
This arthritis portends few adverse pregnancy outcomes. The risk for preterm birth is increased, but later fetal development is normal (Mohamed, 2016; Rom, 2014; Wallenius, 2014). Disease severity in early pregnancy was predictive of preterm delivery and fetal-growth restriction in a cohort study (Bharti, 2015). nother study of 190 pregnancies followed from first trimester to delivery found patients with low disease activity scores in the first trimester were likely to have low disease activity or remission in the third trimester (Ince-Askan, 2017). In a study of 1807 births, Remaeus and associates (2017) reported increased incidences of preterm birth, fetal-growth restriction, and preeclampsia.
Primary treatment of symptomatic women during pregnancy is with aspirin and NSAIDs. These are used with appropriate concerns for irst-trimester efects, impaired hemostasis, prolonged gestation, premature ductus arteriosus closure, and persistent pulmonary circulation. Low-dose corticosteroids are also prescribed as indicated. Gold compounds have been administered in pregnancy (Almarzouqi, 2007).
Immunosuppressive therapy with azathioprine, cyclophosphamide, or methotrexate is not routinely used during pregnancy. Only azathioprine is considered during early pregnancy because the other agents are teratogens (Briggs, 2015). As discussed on page 1147, DMARDs including sulfasalazine and hydroxychloroquine are acceptable for use in pregnancy.