AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY 28:235-237 © 1992 MUNKSGAARD
The Effect of Pregnancy on Ankylosing Spondylitis, Psoriatic Arthritis, and Juvenile Rheumatoid Arthritis MONIKA OSTENSEN Department ofRheumatology, University Hospital of Trondheim, Trondheim, Norway ABSTRACT: It has long been established that rheumatoid arthritis improves during pregnancy. The gestational course of other inflammatory arthritides like ankylosing spondylitis (AS), psoriatic arthritis (PsA), and juvenile rheumatoid arthritis (JRA) has been less well studied. The present review summarizes the results of our retrospective and prospective studies on the interaction between these diseases and pregnancy. The results showed clear differences for their gestational course. Patients with PsA improved or even remitted in 80% of the pregnancies, whereas 80% of the AS patients had unaltered or aggravated disease symptoms. The 20% of AS patients who markedly improved while pregnant all had AS with accompanying diseases like psoriasis, ulcerative arthritis, or small joint arthritis. Quiescent JRA was "not reactivated by pregnancy, and active disease at conception ameliorated in about 60%. Fetal outcome was not adversely affected by AS, PsA, or JRA nor did there occur serious intercurrent diseases during pregnancy. In AS and PsA patients delivery was mainly uncomplicated. Sequelae of JRA were a frequent cause for cesarean section in JRA patients. A postpartum flare during the first 3 months after delivery occurred in about 90% of the AS pregnancies, 70% of the PsA pregnancies, and about 50% of the JRA pregnancies. (Am J Reprod Immunol. 1992; 28:235-237.) Key words: Ankylosing spondylitis, psoriatic arthritis, juvenile rheumatoid arthritis, pregnancy INTRODUCTION
Women of childbearing age with rheumatic diseases have a number of concerns when consulting their physician on the advisability of pregnancy. Patients with conditions like ankylosing spondylitis (AS), psoriatic arthritis (PsA), and juvenile rheumatoid arthritis (JRA) wonder if pregnancy will provide a temporary cure for arthritis as has been shown in rheumatoid arthritis. Patients with AS sometimes worry if their inflamed sacroiliac joints will tolerate the pregnancy load of a growing fetus. For women with a history of JRA it is important to know if quiescent disease can be reactivated during or after a pregnancy. In addition to these questions, possible hazards of drug treatment, and the impact of the rheumatic disease on the fetus and neonate were among the issues addressed in our retrospective and prospective studies of patients with AS, PsA, and JRA.
Submitted for publication June 28, 1992; accepted July 6, 1992. Address reprint requests to Monika Ostensen M.D., Ph.D., Professor of Rheumatology, Head, Department of Rheumatology, University Hospital ofTrondheim, N·7006 Trondheim, Norway.
PATIENTS AND METHODS
The following patients were included in the retrospective and prospective studies: 77 patients with AS, 15 patients with PsA and 61 patients with a history of JRA. l -4 The main issues studied in relation to any influence of pregnancy on rheumatic disease were: activity (course) of disease (articular and extra-articular manifestations) during pregnancy, effect of rheumatic disease on pregnancy, complications at delivery, neonatal health, drug treatment during and after pregnancy, and activity of rheumatic disease after pregnancy. Assessments were made according to the following definitions: active disease was defined as the presence of painful and tender joints, active synovitis, occurrence of extra-articular symptoms, significant morning stiffness, and impairment of daily functions. Spinal disease was judged active when back pain at rest and/or at activity, nocturnal pain, significant morning stiffness, extraarticular symptoms, and impairment of daily functions was present. Among laboratory tests, C-reactive protein (CRP) was chosen to assess inflammatory activity," Retrospective data were obtained by a semi-structured questionnaire and a personal interview. 1,4 In the prospective studies, the patients met for clinical visits at 6-week intervals throughout pregnancy and at least one year after delivery.2,3 They were assessed according to the clinical criteria mentioned above. In addition, a variety of laboratory tests was performed.P-"
Ankylosing Spondylitis Until 1970, the effect of pregnancy on AS received little attention. At the start ofthe 1980s, case reports and small series of pregnant patients comprising about 100 pregnancies stated that pre~ancy in general did not improve the symptoms of AS. Disease activity was found largely unaltered during pregnancy, but tended to aggravate in about 50% of the patients in the postpartum period. The 77 patients included in our retrospective and prospective studies had radiologic bilateral sacroiliitis, but none had developed ankylosis of the sacroiliac joints at the start of their pregnancy. Radiographs of the dorsolumbar spine showed inflammatory changes, but no significant spinal deformity. Two patients had reduced mobility of their hip joints. . An analysis of the 119 completed pregnancies showed that the activity of AS was not changed or aggravated in the majority of cases (Table 1).1--3 The typical pattern was fluctuating signs and symptoms during pregnancy, not different from the prepregnant state. In 15 prospectively studied pregnancies, a midgestational flare around week 20 occurred.v" The patients complained of inere asing low back pain, spinal stiffness, marked tenderness at the enthesopathy sites, and nocturnal pain. Two
236
OSTENSEN
TABLE I. Activity of Ankylosing Spondylitis During Pregnancy
Studied retrospectively Studied prospectively
No. of pregnancies
Remission (%)
Aggravation (%)
No change (%)
87
20 22
20
60 50
32
patients had episodes of acute knee joint arthritis, and two got anterior uveitis. One patient with chest pain also experienced extrasystoles. Elevations of CRP accompanied the clinical manifestations of disease aggravation.v" During this period, treatment with nonsteroidal antiinflammatory drugs was given to 13 of the patients. The last trimester of pregnancy varied with regard to the activity of AS. In some patients, the symptoms eased, while others had active signs and symptoms throughout requiring treatment and sometimes discontinuation of their job. I - 3 Seven ofthe prospectively studied AS patients improved in respect to spinal and extraspinal symptoms of AS, and actually had their best period in late pregnancyv'' Of these, five had accompanying psoriasis and two had ulcerative colitis. Back pain, bony tenderness, and morning stiffness diminished from 5 to 10 weeks of gestation and did not flare, not even in late pregnancy. In two women, synovitis ofthe knee joint which had been present at conception disappeared during the second trimester. In our own studies, the majority of patients experienced an aggravation of symptoms 4 to 12 weeks after delivery (Table 11).1-3 This was unrelated to disease activity during pregnancy, and also unrelated to the duration of breast-feeding or the return of menses after delivery. Symptoms observed were episodes of acute peripheral joint arthritis, anterior unveitis, and increasing spinal symptoms. 1-3 Clinical signs were accompanied by elevations of acute phase reactants.P:" Only 45% of the retrospectively studied patients recalled a postpartum flare of AS. 1 This may reflect the fact that disease activity returns to the prepregnancy level during the year following delivery, an observation proven by the prospective study.
Psoriatic Arthritis There are very few reports on the interaction between pregnancy and PsA. The only prospective study on 20 pregnancies in 15 patients with PsA has been published by us. 3 Included in this prospective follow-up during pregnancy and one year after delivery were patients with psoriatic oligoarthritis. All patients had a relapsing course of their disease before pregnancy. The disease was active before 19 ofthe pregnancies and inactive at start of one. During pregnancy, improvement was noted in 16 cases that was apparent during the first trimester. Synovitis in affected joints diminished or disappeared. In eight
28
patients, all signs and symptoms of arthritis resolved completely. Low back pain which had been present at the start of pregnancy in five patients also improved. A relapsing course of arthritis was observed in four pregnancies, accompanied by aggravation of synovitis and back pain in two of them. Skin disease was mild in all patients and had a tendency to subside during pregnancy. Most PsA patients experienced a reappearance of arthritis during the first 10 weeks following delivery, and later had a mild relapsing course. The typical event was a transient knee joint arthritis responding well to NSAID or intraarticular corticosteroids. In two patients, a marked exacerbation with involvement of previously nonaffected joints occurred. Two other patients enjoyed a prolonged period of remission for more than one year after delivery.' PREGNANCY OUTCOME IN AS AND PsA
Pregnant AS patients in particular raise questions on pregnancy outcome. They wonder if the inflammation in the sacroiliac joints will interfere with normal delivery. In our own studies, the mode of delivery was normal in 111 of the completed AS pregnancies, and there were no complications due to rheumatic disease. Ankylosis ofthe sacroiliac joints is an extremely rare event in young AS female patients. Ankylosis of the hip joints as a hindrance for normal delivery has been described twice in the literature." No serious intercurrent disease occurred in any of the pregnant patients during gestation. 1-3 Premature labor occurred in one patient with AS. One PsA patient had a still birth due to a nuchal cord, but had a healthy baby one year later. All other pregnancies concluded with the delivery of live, healthy children of normal birth weight. 1 ,2 ,7 In spite of treatment with NSAID at some time of pregnancy in altogether 30 patients with AS and four with PsA, no harmful effects in the mothers or the babies were observed. 1-3 JUVENILE RHEUMATOID ARTHRITIS
Juvenile rheumatoid arthritis is often a self-limiting disease with a remission rate of approximately 60%, allowing most patients to conduct a normal life during adulthood. However, chronic disease during childhood may have an impact on life events like pregnancy and motherhood. Complications during delivery may arise
TABLE II. Activity of Ankylosing Spondylitis After Pregnancy
Studied retrospectively Studied prospectively "Maximum follow-up 2.5 years.
No. of pregnancies
Improvement (%)
Aggravation (%)
No change (%)
87
4.5 4
45
50
87
13
32
PREGNANCY AND AS, PSA, AND JRA
237
TABLE III. Activity of JRA During and After 92 Pregnancies
During pregnancy Within 1 year postpartum
No change (%)
Amelioration (%)
Aggravation (%)
46 42
45
9 58
from growth inhibition ofthe pelvis or early involvement of the hip joints. Included in this retrospective study were 61 patients with a history of JRA, identified from hospital files (reference 4 and unpublished data). A polyarticular disease course had been present in 42 patients while 19 had pauci-articular JRA. Prior to pregnancy, 10 patients had undergone hip joint replacement. Disease duration at the start of the index pregnancy was on average 19 years. One patient was diagnosed having amyloidosis, and had received a renal allograft. The 61 women had borne altogether 92 children. Long-lasting periods of remission are common in JRA, especially at the entrance to adulthood. Therefore disease activity during pregnancy was correlated to activity prior to conception. Data about prepregnancy activity could be obtained for 60 pregnancies. Assessment of the course of JRA during pregnancy showed that inactive disease was not reactivated during pregnancy. When disease symptoms of the pauci- or polyarticular type were present at conception, amelioration was experienced in 57% of the pregnancies. Patients with minor symptoms like joint tenderness and moderate stiffness and the majority of those with active synovitis experienced improvement or total remission in the second half of gestation. Aggravation of disease symptoms occurred only seven times. When all pregnancies were taken together, improvement was noted in 46%, no change in 48% and aggravation in 9% (Table III). Six patients had chronic uveitis at the start of pregnancy. Active eye disease persisted during pregnancy in four of them. Two patients developed renal symptoms during pregnancy: one preeclampsia, the other proteinuria. Eighty-nine of the pregnancies resulted in the delivery oflive, normal children of normal birth weight. There was one stillbirth. One infant born to a mother with very active disease throughout pregnancy was premature with low birth weight. Twenty-three children were delivered by cesarean section, and in 17 cases this was related to sequelae of JRA, including contracted pelvis and hip prosthesis. When pregnancy was diagnosed, treatment with the following drugs was stopped: hydroxychloroquine (five patients), aurothiomalate (one patient), and penicillamine (one patient)." Drug treatment continued during 16 pregnancies including nonsteroidal, antiinflammatory drugs, analgesics, and prednisolone. No congenital mal-
o
formations occurred. The patient with a renal allograft was treated before and during pregnancy with cyclosporine A, azathioprine, and prednisolone. Her pregnancy concluded at term with the spontaneous delivery of a healthy child of normal birth weight. At latest count, the mean age of the JRA offspring was 5 years. All children, including the premature infant, were physically and mentally normal. A postpartum flare occurred 3 to 6 months after delivery after 58% of the pregnancies (Table III). Three women developed renal symptoms during or after pregnancy which subsequently were proven by renal biopsy to be due to amyloidosis. CONCLUSION
The gestational course of rheumatic diseases differs. From clinical observations, it appears that rheumatic disease with involvement of peripheral joints in general fares better than axial arthritis. However, the effect of pregnancy is at best a temporary suppression of the signs and symptoms of arthritis. The majority of patients should expect a relapse of disease during the first six months after delivery. This does not usually imply a permanent worsening of arthritis, but rather a return to the prepregnancy disease activity. Patients with a history of JRA are not likely to get a disease flare during pregnancy. A temporary relapse of JRA, however, must be expected after a pregnancy for about 50% of women with a history of JRA. The data indicate that AS, PsA, and JRA do not compromise fetal outcome. REFERENCES 1. Ostensen M, Romberg 0, Husby G. Ankylosing spondylitis and motherhood. Arthritis Rheum. 1982; 25:140-143. 2. Ostensen M, Husby G. A prospective clinical study of the effect of pregnancy on rheumatoid arthritis and ankylosing spondylitis. Arthritis Rheum. 1983; 26:1155-1159. :;I. Ostensen M. Pregnancy in psoriatic arthritis. Scand J Rheumatol. 1988; 17:67-70. 4. Ostensen M. Pregnancy in patients with a history of juvenile rheumatoid arthritis. Arthritis Rheum. 1991; 34:881-887. 5. Ostensen M. The influence of pregnancy on blood parameters in patients with rheumatic disease. ScandJ Rheum. 1984; 13:203-208. 6. Ostensen M, Marhaug G, Husby G. Amyloid-related serum protein (SAA) during and after pregnancy in healthy women and women with rheumatic disease. Acta Pathol Microbiol Immunol Scand [C]. 1985; 93:1-5. 7. Ostensen M, Husby G. Ankylosing spondylitis and pregnancy. Pregnancy in patients with rheumatic diseases. Rheum Dis Clin of N Am. 1989; 15:214-254.
The Effect of Pregnancy on Ankylosing Spondylitis, Psoriatic Arthritis, and Juvenile Rheumatoid Arthritis MONIKA OSTENSEN Department ofRheumatology, University Hospital of Trondheim, Trondheim, Norway ABSTRACT: It has long been established that rheumatoid arthritis improves during pregnancy. The gestational course of other inflammatory arthritides like ankylosing spondylitis (AS), psoriatic arthritis (PsA), and juvenile rheumatoid arthritis (JRA) has been less well studied. The present review summarizes the results of our retrospective and prospective studies on the interaction between these diseases and pregnancy. The results showed clear differences for their gestational course. Patients with PsA improved or even remitted in 80% of the pregnancies, whereas 80% of the AS patients had unaltered or aggravated disease symptoms. The 20% of AS patients who markedly improved while pregnant all had AS with accompanying diseases like psoriasis, ulcerative arthritis, or small joint arthritis. Quiescent JRA was "not reactivated by pregnancy, and active disease at conception ameliorated in about 60%. Fetal outcome was not adversely affected by AS, PsA, or JRA nor did there occur serious intercurrent diseases during pregnancy. In AS and PsA patients delivery was mainly uncomplicated. Sequelae of JRA were a frequent cause for cesarean section in JRA patients. A postpartum flare during the first 3 months after delivery occurred in about 90% of the AS pregnancies, 70% of the PsA pregnancies, and about 50% of the JRA pregnancies. (Am J Reprod Immunol. 1992; 28:235-237.) Key words: Ankylosing spondylitis, psoriatic arthritis, juvenile rheumatoid arthritis, pregnancy INTRODUCTION
Women of childbearing age with rheumatic diseases have a number of concerns when consulting their physician on the advisability of pregnancy. Patients with conditions like ankylosing spondylitis (AS), psoriatic arthritis (PsA), and juvenile rheumatoid arthritis (JRA) wonder if pregnancy will provide a temporary cure for arthritis as has been shown in rheumatoid arthritis. Patients with AS sometimes worry if their inflamed sacroiliac joints will tolerate the pregnancy load of a growing fetus. For women with a history of JRA it is important to know if quiescent disease can be reactivated during or after a pregnancy. In addition to these questions, possible hazards of drug treatment, and the impact of the rheumatic disease on the fetus and neonate were among the issues addressed in our retrospective and prospective studies of patients with AS, PsA, and JRA.
Submitted for publication June 28, 1992; accepted July 6, 1992. Address reprint requests to Monika Ostensen M.D., Ph.D., Professor of Rheumatology, Head, Department of Rheumatology, University Hospital ofTrondheim, N·7006 Trondheim, Norway.
PATIENTS AND METHODS
The following patients were included in the retrospective and prospective studies: 77 patients with AS, 15 patients with PsA and 61 patients with a history of JRA. l -4 The main issues studied in relation to any influence of pregnancy on rheumatic disease were: activity (course) of disease (articular and extra-articular manifestations) during pregnancy, effect of rheumatic disease on pregnancy, complications at delivery, neonatal health, drug treatment during and after pregnancy, and activity of rheumatic disease after pregnancy. Assessments were made according to the following definitions: active disease was defined as the presence of painful and tender joints, active synovitis, occurrence of extra-articular symptoms, significant morning stiffness, and impairment of daily functions. Spinal disease was judged active when back pain at rest and/or at activity, nocturnal pain, significant morning stiffness, extraarticular symptoms, and impairment of daily functions was present. Among laboratory tests, C-reactive protein (CRP) was chosen to assess inflammatory activity," Retrospective data were obtained by a semi-structured questionnaire and a personal interview. 1,4 In the prospective studies, the patients met for clinical visits at 6-week intervals throughout pregnancy and at least one year after delivery.2,3 They were assessed according to the clinical criteria mentioned above. In addition, a variety of laboratory tests was performed.P-"
Ankylosing Spondylitis Until 1970, the effect of pregnancy on AS received little attention. At the start ofthe 1980s, case reports and small series of pregnant patients comprising about 100 pregnancies stated that pre~ancy in general did not improve the symptoms of AS. Disease activity was found largely unaltered during pregnancy, but tended to aggravate in about 50% of the patients in the postpartum period. The 77 patients included in our retrospective and prospective studies had radiologic bilateral sacroiliitis, but none had developed ankylosis of the sacroiliac joints at the start of their pregnancy. Radiographs of the dorsolumbar spine showed inflammatory changes, but no significant spinal deformity. Two patients had reduced mobility of their hip joints. . An analysis of the 119 completed pregnancies showed that the activity of AS was not changed or aggravated in the majority of cases (Table 1).1--3 The typical pattern was fluctuating signs and symptoms during pregnancy, not different from the prepregnant state. In 15 prospectively studied pregnancies, a midgestational flare around week 20 occurred.v" The patients complained of inere asing low back pain, spinal stiffness, marked tenderness at the enthesopathy sites, and nocturnal pain. Two
236
OSTENSEN
TABLE I. Activity of Ankylosing Spondylitis During Pregnancy
Studied retrospectively Studied prospectively
No. of pregnancies
Remission (%)
Aggravation (%)
No change (%)
87
20 22
20
60 50
32
patients had episodes of acute knee joint arthritis, and two got anterior uveitis. One patient with chest pain also experienced extrasystoles. Elevations of CRP accompanied the clinical manifestations of disease aggravation.v" During this period, treatment with nonsteroidal antiinflammatory drugs was given to 13 of the patients. The last trimester of pregnancy varied with regard to the activity of AS. In some patients, the symptoms eased, while others had active signs and symptoms throughout requiring treatment and sometimes discontinuation of their job. I - 3 Seven ofthe prospectively studied AS patients improved in respect to spinal and extraspinal symptoms of AS, and actually had their best period in late pregnancyv'' Of these, five had accompanying psoriasis and two had ulcerative colitis. Back pain, bony tenderness, and morning stiffness diminished from 5 to 10 weeks of gestation and did not flare, not even in late pregnancy. In two women, synovitis ofthe knee joint which had been present at conception disappeared during the second trimester. In our own studies, the majority of patients experienced an aggravation of symptoms 4 to 12 weeks after delivery (Table 11).1-3 This was unrelated to disease activity during pregnancy, and also unrelated to the duration of breast-feeding or the return of menses after delivery. Symptoms observed were episodes of acute peripheral joint arthritis, anterior unveitis, and increasing spinal symptoms. 1-3 Clinical signs were accompanied by elevations of acute phase reactants.P:" Only 45% of the retrospectively studied patients recalled a postpartum flare of AS. 1 This may reflect the fact that disease activity returns to the prepregnancy level during the year following delivery, an observation proven by the prospective study.
Psoriatic Arthritis There are very few reports on the interaction between pregnancy and PsA. The only prospective study on 20 pregnancies in 15 patients with PsA has been published by us. 3 Included in this prospective follow-up during pregnancy and one year after delivery were patients with psoriatic oligoarthritis. All patients had a relapsing course of their disease before pregnancy. The disease was active before 19 ofthe pregnancies and inactive at start of one. During pregnancy, improvement was noted in 16 cases that was apparent during the first trimester. Synovitis in affected joints diminished or disappeared. In eight
28
patients, all signs and symptoms of arthritis resolved completely. Low back pain which had been present at the start of pregnancy in five patients also improved. A relapsing course of arthritis was observed in four pregnancies, accompanied by aggravation of synovitis and back pain in two of them. Skin disease was mild in all patients and had a tendency to subside during pregnancy. Most PsA patients experienced a reappearance of arthritis during the first 10 weeks following delivery, and later had a mild relapsing course. The typical event was a transient knee joint arthritis responding well to NSAID or intraarticular corticosteroids. In two patients, a marked exacerbation with involvement of previously nonaffected joints occurred. Two other patients enjoyed a prolonged period of remission for more than one year after delivery.' PREGNANCY OUTCOME IN AS AND PsA
Pregnant AS patients in particular raise questions on pregnancy outcome. They wonder if the inflammation in the sacroiliac joints will interfere with normal delivery. In our own studies, the mode of delivery was normal in 111 of the completed AS pregnancies, and there were no complications due to rheumatic disease. Ankylosis ofthe sacroiliac joints is an extremely rare event in young AS female patients. Ankylosis of the hip joints as a hindrance for normal delivery has been described twice in the literature." No serious intercurrent disease occurred in any of the pregnant patients during gestation. 1-3 Premature labor occurred in one patient with AS. One PsA patient had a still birth due to a nuchal cord, but had a healthy baby one year later. All other pregnancies concluded with the delivery of live, healthy children of normal birth weight. 1 ,2 ,7 In spite of treatment with NSAID at some time of pregnancy in altogether 30 patients with AS and four with PsA, no harmful effects in the mothers or the babies were observed. 1-3 JUVENILE RHEUMATOID ARTHRITIS
Juvenile rheumatoid arthritis is often a self-limiting disease with a remission rate of approximately 60%, allowing most patients to conduct a normal life during adulthood. However, chronic disease during childhood may have an impact on life events like pregnancy and motherhood. Complications during delivery may arise
TABLE II. Activity of Ankylosing Spondylitis After Pregnancy
Studied retrospectively Studied prospectively "Maximum follow-up 2.5 years.
No. of pregnancies
Improvement (%)
Aggravation (%)
No change (%)
87
4.5 4
45
50
87
13
32
PREGNANCY AND AS, PSA, AND JRA
237
TABLE III. Activity of JRA During and After 92 Pregnancies
During pregnancy Within 1 year postpartum
No change (%)
Amelioration (%)
Aggravation (%)
46 42
45
9 58
from growth inhibition ofthe pelvis or early involvement of the hip joints. Included in this retrospective study were 61 patients with a history of JRA, identified from hospital files (reference 4 and unpublished data). A polyarticular disease course had been present in 42 patients while 19 had pauci-articular JRA. Prior to pregnancy, 10 patients had undergone hip joint replacement. Disease duration at the start of the index pregnancy was on average 19 years. One patient was diagnosed having amyloidosis, and had received a renal allograft. The 61 women had borne altogether 92 children. Long-lasting periods of remission are common in JRA, especially at the entrance to adulthood. Therefore disease activity during pregnancy was correlated to activity prior to conception. Data about prepregnancy activity could be obtained for 60 pregnancies. Assessment of the course of JRA during pregnancy showed that inactive disease was not reactivated during pregnancy. When disease symptoms of the pauci- or polyarticular type were present at conception, amelioration was experienced in 57% of the pregnancies. Patients with minor symptoms like joint tenderness and moderate stiffness and the majority of those with active synovitis experienced improvement or total remission in the second half of gestation. Aggravation of disease symptoms occurred only seven times. When all pregnancies were taken together, improvement was noted in 46%, no change in 48% and aggravation in 9% (Table III). Six patients had chronic uveitis at the start of pregnancy. Active eye disease persisted during pregnancy in four of them. Two patients developed renal symptoms during pregnancy: one preeclampsia, the other proteinuria. Eighty-nine of the pregnancies resulted in the delivery oflive, normal children of normal birth weight. There was one stillbirth. One infant born to a mother with very active disease throughout pregnancy was premature with low birth weight. Twenty-three children were delivered by cesarean section, and in 17 cases this was related to sequelae of JRA, including contracted pelvis and hip prosthesis. When pregnancy was diagnosed, treatment with the following drugs was stopped: hydroxychloroquine (five patients), aurothiomalate (one patient), and penicillamine (one patient)." Drug treatment continued during 16 pregnancies including nonsteroidal, antiinflammatory drugs, analgesics, and prednisolone. No congenital mal-
o
formations occurred. The patient with a renal allograft was treated before and during pregnancy with cyclosporine A, azathioprine, and prednisolone. Her pregnancy concluded at term with the spontaneous delivery of a healthy child of normal birth weight. At latest count, the mean age of the JRA offspring was 5 years. All children, including the premature infant, were physically and mentally normal. A postpartum flare occurred 3 to 6 months after delivery after 58% of the pregnancies (Table III). Three women developed renal symptoms during or after pregnancy which subsequently were proven by renal biopsy to be due to amyloidosis. CONCLUSION
The gestational course of rheumatic diseases differs. From clinical observations, it appears that rheumatic disease with involvement of peripheral joints in general fares better than axial arthritis. However, the effect of pregnancy is at best a temporary suppression of the signs and symptoms of arthritis. The majority of patients should expect a relapse of disease during the first six months after delivery. This does not usually imply a permanent worsening of arthritis, but rather a return to the prepregnancy disease activity. Patients with a history of JRA are not likely to get a disease flare during pregnancy. A temporary relapse of JRA, however, must be expected after a pregnancy for about 50% of women with a history of JRA. The data indicate that AS, PsA, and JRA do not compromise fetal outcome. REFERENCES 1. Ostensen M, Romberg 0, Husby G. Ankylosing spondylitis and motherhood. Arthritis Rheum. 1982; 25:140-143. 2. Ostensen M, Husby G. A prospective clinical study of the effect of pregnancy on rheumatoid arthritis and ankylosing spondylitis. Arthritis Rheum. 1983; 26:1155-1159. :;I. Ostensen M. Pregnancy in psoriatic arthritis. Scand J Rheumatol. 1988; 17:67-70. 4. Ostensen M. Pregnancy in patients with a history of juvenile rheumatoid arthritis. Arthritis Rheum. 1991; 34:881-887. 5. Ostensen M. The influence of pregnancy on blood parameters in patients with rheumatic disease. ScandJ Rheum. 1984; 13:203-208. 6. Ostensen M, Marhaug G, Husby G. Amyloid-related serum protein (SAA) during and after pregnancy in healthy women and women with rheumatic disease. Acta Pathol Microbiol Immunol Scand [C]. 1985; 93:1-5. 7. Ostensen M, Husby G. Ankylosing spondylitis and pregnancy. Pregnancy in patients with rheumatic diseases. Rheum Dis Clin of N Am. 1989; 15:214-254.
