What Should I Know About Rheumatoid Arthritis and Pregnancy?

Rheumatoid arthritis (RA) is an autoimmune disease with joint synovium as the main target organ. Mainly manifested as symmetry, chronic, progressive polyarthritis. Chronic inflammation, proliferation, and formation of vascular crests of the synovial membrane, invasion of articular cartilage, subchondral bone, ligaments, and tendons, etc., cause destruction of articular cartilage, bone and joint capsule, and eventually lead to joint deformity and loss of function. More common in middle-aged women, the incidence of women during pregnancy is not uncommon.

Basic Information

Visiting department: Division of Rheumatology
Multiple groups: Middle-aged woman
Common locations: Proximal interphalangeal joints, metacarpophalangeal, wrist, elbow, shoulder, knee and toe joints

Common symptoms: Chronic inflammation, hyperplasia of the synovial membrane, formation of vascular crests, or even joint deformities and loss of function

Causes of pregnancy with rheumatoid arthritis

70% to 80% of patients can be relieved in the first few weeks of pregnancy, especially in the first three months of pregnancy, and a small part can be relieved in the second and third trimesters. However, about a quarter of patients remain active during pregnancy. status. Moreover, RA activity may increase postpartum, especially in the first 3 months after delivery. Therefore, for pregnant women with unstable conditions, medical intervention is still needed during pregnancy, which can reduce the risk of postpartum recurrence. The effect of RA on pregnancy is often considered to have no effect on the fetus.

Clinical manifestations of rheumatoid arthritis in pregnancy

Joint performance

It is divided into symptoms of synovial inflammation and destruction of joint structure. The former can be relieved by drug treatment, and the latter is generally difficult to reverse. RA manifestations vary widely, ranging from transient, mild oligoarthritis to rapidly progressive polyarthritis. The affected joints are the proximal interphalangeal joints. The metacarpophalangeal joints, wrists, elbows, shoulders, knees, and toes joints are the most common; cervical spine, temporomandibular joints, acromioclavicular and sternoclavicular joints can also be affected; hip joint involvement is rare. Arthritis often manifests as symmetry, persistent swelling, and tenderness. It may have morning stiffness and eventually develop joint deformities and joint dysfunction.

2. Extra-articular manifestations

Rheumatoid nodules, rheumatoid vasculitis, and multiple organ damage such as lung, heart, gastrointestinal tract, kidney, eye, nervous system, and blood system appear.

Pregnancy with rheumatoid arthritis

Hematological index

It can be manifested as orthocytic hypochromic anemia, elevated erythrocyte sedimentation and reactive protein (CRP), the latter two being markers of the disease's activity, but lacking specificity. Serum immunoglobulin IgG, IgM, IgA can be increased. Rheumatoid factor is positive in 60% to 80% of patients, antinuclear antibodies are positive in 20% of patients, anti-keratin antibodies, anti-cyclic citrullinated peptides and other autoimmune antibodies have RA. Higher diagnostic specificity but lower sensitivity.

2. Imaging examination

Early soft tissue swelling, joint space narrowing, unclear edge erosion, osteoporosis, and joint deformity can be seen. This test is not suitable for pregnant women.

Diagnosis of pregnancy with rheumatoid arthritis

In 2009, ACR and the European Union Against Rheumatism (EULAR) proposed a new RA classification standard and scoring system, that is, at least 1 joint swelling and pain, and evidence of synovitis (clinical or ultrasound or MRI); and other diseases were excluded. The resulting arthritis, which has typical changes in bone destruction in conventional radiological RA, can be diagnosed as RA. In addition, the criteria scored 4 parts of joint involvement, serological indicators, duration of synovitis, and acute phase reactants. RA with a total score of 6 or more can also be diagnosed (Table 1).

1. Taxonomy and scoring system < br Table 1ACR / EULAR 2009 RA taxonomy and scoring system

	Grading items	Number of affected joints (pieces)	Score
Affected joints Score ( 0 to 5 points)	Medium and large joints	1	0
	Medium and large joints	2 10	1
	Small joint	1 3	2
	Small joint	4 to 10	3
	At least one facet joint	> 10	5
Serology Score ( 0 to 3 )	RF or anti-CCP antibodies are negative		0
	RF or anti-CCP antibody positive for at least one low titer		2
	RF or anti-CCP antibody positive for at least one high titer (> 3 times the upper limit of normal)		3
Synovitis duration Score ( 0 to 1 point)	<6 weeks		0
Synovitis duration Score ( 0 to 1 point)	> 6 weeks		1
Acute phase reactant Score ( 0 to 1 point)	CRP or ESR are normal		0
Acute phase reactant Score ( 0 to 1 point)	Increased CRP or ESR		1

2. Mitigation criteria

There are several criteria for judging the remission of RA. Table 2 lists the criteria for RA clinical remission proposed by ACR. However, clinical remission cannot be considered with active vasculitis, pericarditis, pleurisy, myositis, and recent physical decline or fever due to RA.
Table 2 RA clinical response criteria

Those who meet 5 or more of the following 6 items and have at least 2 consecutive months are considered as clinical remissions

1 Morning stiffness is less than 15 minutes

2 No fatigue

3 No joint pain

4 No arthralgia or joint pain

5 No swollen joints or tendon sheaths

6 ESR (Weiss method) female <30mm / h, male <20mm / h

Note: Quoted from ArthritisRheum, 1981, 24: 1308-1315

Treatment of pregnancy with rheumatoid arthritis

The treatment of RA includes general treatment, drug treatment and surgical treatment.
General treatments include rest, joint braking during the acute phase, joint function exercises during the recovery phase, and psychological rehabilitation.

Drug treatment

At present, domestic and foreign drug treatments cannot completely control joint destruction, but can only relieve pain and reduce or delay the development of inflammation. Commonly used drugs for treating RA include non-steroidal anti-inflammatory drugs, anti-rheumatic drugs to improve the condition, glucocorticoids and botanical drugs.

(1) Non-steroidal anti-inflammatory drugs (NSAIDs ) include aspirin, indomethacin, ibuprofen, diclofenac, analgin, piroxicam, celecoxib, and other drugs that mainly inhibit cyclooxygenase ( COX) activity, reducing prostaglandin synthesis and having anti-inflammatory, analgesic, antipyretic and joint swelling effects, without delaying the disease.

(2) Anti-rheumatic drugs such drugs include methotrexate, sulfasalazine, leflunomide, antimalarial drugs, penicillamine, gold preparations, azathioprine, cyclosporine A, cyclophosphamide, etc. . Most drugs have severe effects on the fetus.

Clinically, early application of DMARDs should be emphasized in patients with RA. Patients with severe prognosis, multiple joint involvement, extra-articular manifestations or early joint destruction may have poor prognostic factors such as the combined application of two or more DMARDs. The main combination methods include any two or three combinations of methotrexate (MTX), leflunomide (LEF), hydroxychloroquine (HCQ), and sulfasalazine (SASP). It is also conceivable to use cyclosporin A, penicillamine, etc. in combination with the above-mentioned drugs. However, different combinations should be selected based on the patient's condition and individual circumstances.

(3) Biological agents Biological agents that can treat RA mainly include tumor necrosis factor (TNF) - antagonists, interleukin (IL) -1 and IL-6 antagonists, anti-CD20 monoclonal antibodies, and T-cell co-stimulatory signal suppression Agent.

(4) Plant medicine

1) Tripterygium wilfordii is effective in alleviating joint swelling and pain, and there is no research on whether to slow down joint destruction. Triptolide is usually given after meals. The main adverse reaction is gonad suppression, which leads to male infertility and female amenorrhea. Generally not used for patients during childbearing period. Other adverse reactions include rash, pigmentation, soft nails, hair loss, headache, anorexia, nausea, vomiting, abdominal pain, diarrhea, bone marrow suppression, elevated liver transaminase enzymes, and elevated serum creatinine.

2) Total glucosides of paeony are effective in reducing joint swelling and pain. Its adverse reactions are less, mainly abdominal pain, diarrhea, anorexia and so on.

3) Sinomenine can reduce joint swelling and pain. The main adverse reactions were pruritus, rash and leukocytopenia.
Studies on this class of medicine are relatively rare, and do not advocate use during pregnancy. Botanicals can relieve joint swelling and pain with fewer adverse reactions.

2. Surgical treatment

Including joint replacement, synovectomy, joint fusion, and soft tissue surgery, the surgeon makes a decision after assessing the patient's condition and recommends postpartum surgery.

3. Psychological rehabilitation treatment

Joint pain, fear of disability or already facing disability, inability to take care of themselves, economic loss, changes in family, friends and other relationships, and suspension of social entertainment activities, and many other factors inevitably bring mental stress to rheumatoid arthritis patients, who are eager for treatment , But also worried about adverse drug reactions or lack of confidence in the actual effect of the drug, which in turn increased the psychological burden on patients. Depression is the most common psychiatric symptom in patients with rheumatoid arthritis, and severe depression prevents the recovery of the disease. Therefore, at the same time of active and reasonable drug treatment, psychological treatment of rheumatoid arthritis should also be emphasized.