The pregnant pause...
Reproduced from Issue 103 of Arthritis Today
Pregnancy can be tough even when the mother-to-be is in good health.
Patricia Le Gallez, rheumatology nurse practitioner
at Dewsbury and District Hospital, looks at the potential pitfalls for
pregnant women who have arthritis.
Many problems face the young when considering a pregnancy, especially if they have a chronic arthritic condition. The decision to have a baby is usually taken because the mother-to-be is well, and the disease under control. Even so, couples still have worries. Will the drugs they take damage the baby? Can the disease they have be passed onto the baby? Moreover, mothers are concerned in case they cannot cope with the physical demands of a new baby.
As a chronic illness requires taking drugs continuously, it is important to think carefully about which drugs to take, not only while pregnant but also before becoming pregnant, and again after the pregnancy if breast feeding is intended. This is just as important for a man as it is for a woman, though this only applies to the six months prior to starting a baby.
Drugs can damage the unborn baby, yet the period during which damage is most likely to occur is during the first three months of pregnancy. As many women do not realise they are pregnant until they reach this stage,
Perhaps the most difficult hurdle most couples face is knowing that one or both of them must stop taking their drugs in order to conceive without causing damage. On stopping the drugs their condition may well deteriorate, and therefore it is a great sacrifice for them to make.
Drugs taken during pregnancy are always taken because of the needs of the mother. While beneficial and harmless to her they may prove harmful to the unborn baby. Strict guidelines govern drugs which can be taken before and during pregnancy. Should a painkiller be required while pregnant then paracetamol is recommended. Non steroidal anti-inflammatory drugs (NSAIDS) of which Brufen, Indocid, Voltarol, Piroxicam and Naprosyn are examples, are best avoided if at all possible, especially during the early months, and towards the end of the pregnancy, particularly during labour because of possible complications occurring during delivery, or to the infant after delivery. A low dose NSAID is sometimes prescribed if pain is a problem and paracetamol is not sufficient.
Steroids and disease-modifying anti-rheumatic drugs (DMARDs) will only be prescribed for those people who have an inflammatory arthritis, for example juvenile chronic arthritis, rheumatoid arthritis, ankylosing spondylitis, scleroderma, psoriatic arthritis or lupus (SLE), all of which are known to affect both young men and women in particular.
Disease-modifying anti-rheumatic drugs (DMARDs) are Myocricin (gold injections), Auranofin (gold tablets), sulphasalazine, penicillimine, hydroxychloroquine, methotrexate, azathioprine, cyclosporin and cyclophosphamide. These are best avoided if at all possible during pregnancy. This is because some are known to damage the unborn baby, whilst for the remainder the effect they may have during pregnancy is still unknown. The advice given is to stop all DMARDs before becoming pregnant.
Methotrexate and cyclophosphamide should be stopped as early as six months before starting a pregnancy as these drugs are known to damage the mother's eggs or the father's sperm. Because of this a contraceptive must be used during the six months prior to starting a baby. If the arthritis remains active, and particularly so in young women with SLE (lupus) then certain DMARDs may be continued, though in a very low dose. Not to take them could put the life of the mother or baby at risk. Men with an arthritic condition who take methotrexate or cyclophosphamide are advised, as are the woemn, to come off these drugs six months before attempting to start a family and to use a contraceptive during this period. Men who are taking sulphasalazine have a decrease in the number of sperm they produce. The sperm count will return to normal on stopping the sulphasalazine.
Steroids, of which prednisolone is an example, are considered safe during pregnancy if taken in low doses of between 5 and 10 mg daily.
If deciding to breast feed the following should be considered. The most commonly used drugs, taken by all mothers immediately after a birth, are painkillers, sedatives and antibiotics. In addition, women suffering from an arthritic condition may also need to take a DMARD, NSAID or steroid. All drugs – and this includes alcohol – taken by the mother when breast feeding, will pass into the breast milk, though only in small amounts. It is sensible then to take only those drugs which are essential to maintain health, and to take only a minimum of alcohol. There are further considerations for anyone breast-feeding and also taking drugs. First is the baby's health, and second the number of feeds.
As the baby grows and becomes stronger, it will cope more easily with any drug passed to it. Finally, as the baby grows older breast milk will be given less frequently or in smaller quantities, so there is less chance of the drugs taken by the mother passing to the baby.
Only certain DMARDs, NSAIDs and painkillers are allowed when breast-feeding. Painkillers or NSAIDs will be at their highest levels in the blood 30 to 60 minutes after being taken. If these drugs must be taken, take them soon after the baby has been fed, this will allow time for the drug to clear from the breast milk before the next feed is due, so reducing the chances of the drug passing to the infant.
But there is no danger to the unborn child except for those women with lupus. While many women with lupus have successful pregnancies there is an added risk. This usually applies if the disease is active and difficult to control. If it is not active and the woman is well and has no kidney involvement, then there are usually no difficulties.
Avoid having X-rays during pregnancy. Even if a pregnancy is only suspected, it is very important that women tell their doctor.
Once a baby is born, two important health professionals need to be involved in the after care. The physiotherapist and the occupational therapist. Contact with them should be made as soon as possible after becoming pregnant. Holding, dressing, washing and feeding a baby can present difficulties. So can night feeds, mainly because of stiffness. If young children are already a part of the family then additional help in caring for them needs to be arranged. Extra support from partners in every aspect of daily life will be required. Extended family and social services should be asked to help where appropriate, and if friends and neighbours offer help, take advantage of their generosity.
Starting Points Damage to the mother's eggs or father's sperm can occur even before a baby is conceived or to the unborn baby at any time during the pregnancy. It is wise to plan a pregnancy, then certain drugs taken by the mother or the father can be stopped before the baby is started. The healthier the baby, the better it will cope with any drugs passed to it in the breast milk. A number of women will have a degree of remission from the arthritis while pregnant, while others may get worse. |
