Use Of Drugs During Pregnancy

Inflammatory rheumatic diseases usually (in 75-95% patients) become less severe from second or third month of pregnancy and remain so till delivery. The disease neither leads to abortions nor has any effect on growth of child. Patients with inflammatory arthritis need not take any special precautions and no special monitoring is required during pregnancy. It is very unlikely that every child born to such mother will develop arthritis as these are not hereditary diseases. Rheumatoid arthritis is known to flare up after delivery. New onset of disease following delivery is also common.

The disease must be adequately controlled by optimal usage of effective drugs prior to planning conception. One needs to shift to drugs that can be safely used during pregnancy as most drugs reach fetus through circulating blood. One must take into account the risk of morbidity in the form of joint deformities as well as long term life risk due to vascular events following untreated or inadequately controlled disease. All drugs should be taken in lowest possible dose and for shortest period of time during pregnancy. Inadvertent exposure of drug during this period is not an indication for termination of pregnancy. Decision regarding termination must be based on potential risk to the fetus as determined by ultrasound examination (for structural abnormalities) and amniocentesis (for chromosomal abnormalities). Medical termination of pregnancy is indicated only in cases with fetal abnormalities.

Drugs for use during pregnancy are classified as safe (A), safe in animals-no risk in studies (B), unsafe in animals-risk cannot be ruled out (C), positive evidence of risk in humans (D) and unsafe (X). Drugs from category B need to be used with caution whereas those from categories C and D are required to be used only if benefits outweigh risks (see table). A detailed doctor-patient discussion about use of all drugs is necessary to plan their appropriate usage.

  Drug   Remark
1 Paracetamol A Safe
2 Anti-inflammatory Painkillers B Safe till 26 weeks. Use lowest dose intermittently. Risk of fetal loss. Concern of premature closure of a heart vessel – ultrasound monitoring advisable. (Celecoxib is Category C)
3 Steroids B Use smallest dose. Use prednisone only as it does not reach fetus. Small risk of cleft palate. Monitor blood pressure and blood sugar. Intra-articular injections safe.
4 Hydroxychloroquin C No risks reported. Do not use Chloroquin.
5 Sulphasalazine B No effect on fertility. No pregnancy risks reported. Folic acid supplementation necessary.
6 Methotrexate X Contraindicated. Stop 3 months before conception. Few cases of fetal abnormalities reported. Normal births also reported. Monitor in case of inadvertent exposure.
7 Leflunomide X Toxic in animal studies. Stop for 2 years before conception or go for Cholestyramine detoxification 3 months in advance. Normal births reported.
8 Azathioprine D Safer option. Very rare reports of congenital abnormalities.
9 Cyclophosphamide D Unsafe
10 Mycophenolate D Unsafe. Conception allowed after 3 drug-free months.
11 Biologic drugs B/C Inadequate data. Stop during pregnancy. Few reports on Etanercept, Rituximab.