Gebelik ve Romatolojik Hastalıklar
Özet
Gebelik ve romatolojik hastalıklar, hem maternal hem de fetal açıdan yüksek riskler taşıdığından prekonsepsiyonel dönemden itibaren multidisipliner bir yönetim gerektirir. Sistemik Lupus Eritamatozus (SLE) hastalarında gebeliğin, hastalığın en az 6 ay remisyonda olduğu bir dönemde planlanması obstetrik sonuçları optimize eder. Aktif SLE ve lupus nefriti varlığı; preeklampsi, preterm doğum ve fetal gelişim kısıtlılığı riskini belirgin şekilde artırır. Anti Ro-La antikorlarının varlığı fetusta neonatal lupus ve konjenital kalp bloğuna yol açabilirken, Hidroksiklorokin kullanımı bu riski azaltır. Antifosfolipid Antikor Sendromu (APS) ise tromboz ve gebelik morbiditesi ile karakterizedir; yönetiminde düşük doz aspirin ve LMWH kombinasyonu ile yüksek obstetrik başarı sağlanır. Romatoid Artrit (RA) semptomları gebelikte %50-70 oranında düzelme gösterirken, Ankilozan Spondilitte iyileşme görülmez ve postpartum dönemde alevlenmeler sık yaşanır. Vaskülitler ve Sistemik Skleroz da maternal-fetal takibin sıkı yapılması gereken diğer durumlardır. Gebelikte ilaç kullanımı kategorize edilmiştir; Hidroksiklorokin, sülfasalazin ve düşük doz aspirin minimal riskli kabul edilirken; metotreksat, mikofenalat mofetil ve leflunomid teratojenik etkilerinden dolayı kesinlikle kontrendikedir.
Pregnancy and rheumatologic diseases require multidisciplinary management starting from the preconception period due to high maternal and fetal risks. In patients with Systemic Lupus Erythematosus (SLE), planning pregnancy during a period where the disease has been in remission for at least 6 months optimizes obstetric outcomes. The presence of active SLE and lupus nephritis significantly increases the risks of preeclampsia, preterm birth, and fetal growth restriction. While the presence of anti Ro-La antibodies can lead to neonatal lupus and congenital heart block in the fetus, the use of Hydroxychloroquine reduces this risk. Antiphospholipid Antibody Syndrome (APS) is characterized by thrombosis and pregnancy morbidity; its management with a combination of low-dose aspirin and LMWH achieves high obstetric success. Rheumatoid Arthritis (RA) symptoms show improvement in 50-70% of cases during pregnancy, whereas no improvement is observed in Ankylosing Spondylitis, and flares are common in the postpartum period. Vasculitis and Systemic Sclerosis are other conditions requiring close maternal-fetal monitoring. Medication use during pregnancy is categorized; Hydroxychloroquine, sulfasalazine, and low-dose aspirin are considered to have minimal risk, while methotrexate, mycophenolate mofetil, and leflunomide are strictly contraindicated due to their teratogenic effects.
Referanslar
Clowse ME, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum. 2005;52(2):514-21.
Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, et al. Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med. 2015;163(3):153-63.
Clowse ME, Magder L, Witter F, Petri M. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum. 2006;54(11):3640-7.
Izmirly P, Saxena A, Buyon JP. Progress in the pathogenesis and treatment of cardiac manifestations of neonatal lupus. Curr Opin Rheumatol. 2017;29(5):467-72.
Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, Davis EM, et al. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: US Preventive Services Task Force Recommendation Statement. Jama. 2021;326(12):1186-91.
Lateef A, Petri M. Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol. 2013;27(3):435-47.
Gladman DD, Tandon A, Ibañez D, Urowitz MB. The effect of lupus nephritis on pregnancy outcome and fetal and maternal complications. J Rheumatol. 2010;37(4):754-8.
Yasmeen S, Wilkins EE, Field NT, Sheikh RA, Gilbert WM. Pregnancy outcomes in women with systemic lupus erythematosus. J Matern Fetal Med. 2001;10(2):91-6.
Wagner SJ, Craici I, Reed D, Norby S, Bailey K, Wiste HJ, et al. Maternal and foetal outcomes in pregnant patients with active lupus nephritis. Lupus. 2009;18(4):342-7.
Carvalheiras G, Vita P, Marta S, Trovão R, Farinha F, Braga J, et al. Pregnancy and systemic lupus erythematosus: review of clinical features and outcome of 51 pregnancies at a single institution. Clin Rev Allergy Immunol. 2010;38(2-3):302-6.
Wang X, Chen C, Wang L, Chen D, Guang W, French J. Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study. Fertil Steril. 2003;79(3):577-84.
Ambrosi A, Wahren-Herlenius M. Congenital heart block: evidence for a pathogenic role of maternal autoantibodies. Arthritis Res Ther. 2012;14(2):208.
Bertsias GK, Tektonidou M, Amoura Z, Aringer M, Bajema I, Berden JH, et al. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771-82.
Fischer-Betz R. [Rheumatic diseases in pregnancy]. Dtsch Med Wochenschr. 2013;138(31-32):1589-91.
Cuneo BF, Sonesson SE, Levasseur S, Moon-Grady AJ, Krishnan A, Donofrio MT, et al. Home Monitoring for Fetal Heart Rhythm During Anti-Ro Pregnancies. J Am Coll Cardiol. 2018;72(16):1940-51.
Colombo GL, Di Matteo S, Martinotti C, Jugl SM, Gunda P, Naclerio M, et al. Budget impact model of secukinumab for the treatment of moderate-to-severe psoriasis, psoriatic arthritis, and ankylosing spondylitis in Italy: a cross-indication initiative. Clinicoecon Outcomes Res. 2018;10:477-91.
Lockshin MD, Sammaritano LR. Lupus pregnancy. Autoimmunity. 2003;36(1):33-40.
Andrade RM, McGwin G, Jr., Alarcón GS, Sanchez ML, Bertoli AM, Fernández M, et al. Predictors of post-partum damage accrual in systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (XXXVIII). Rheumatology (Oxford). 2006;45(11):1380-4.
ACOG Committee Opinion No. 743: Low-Dose Aspirin Use During Pregnancy. Obstet Gynecol. 2018;132(1):e44-e52.
Clowse ME, Magder LS, Petri M. The clinical utility of measuring complement and anti-dsDNA antibodies during pregnancy in patients with systemic lupus erythematosus. J Rheumatol. 2011;38(6):1012-6.
Buyon JP, Tamerius J, Ordorica S, Young B, Abramson SB. Activation of the alternative complement pathway accompanies disease flares in systemic lupus erythematosus during pregnancy. Arthritis Rheum. 1992;35(1):55-61.
Anderson J, Caplan L, Yazdany J, Robbins ML, Neogi T, Michaud K, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012;64(5):640-7.
Silman A, Kay A, Brennan P. Timing of pregnancy in relation to the onset of rheumatoid arthritis. Arthritis Rheum. 1992;35(2):152-5.
Jakobsson GL, Stephansson O, Askling J, Jacobsson LT. Pregnancy outcomes in patients with ankylosing spondylitis: a nationwide register study. Ann Rheum Dis. 2016;75(10):1838-42.
Steen VD, Medsger TA. Changes in causes of death in systemic sclerosis, 1972-2002. Ann Rheum Dis. 2007;66(7):940-4.
Cooper WO, Cheetham TC, Li DK, Stein CM, Callahan ST, Morgan TM, et al. Brief report: Risk of adverse fetal outcomes associated with immunosuppressive medications for chronic immune-mediated diseases in pregnancy. Arthritis Rheumatol. 2014;66(2):444-50.
Mogadam M, Dobbins WO, 3rd, Korelitz BI, Ahmed SW. Pregnancy in inflammatory bowel disease: effect of sulfasalazine and corticosteroids on fetal outcome. Gastroenterology. 1981;80(1):72-6.
Datta P, Rewers-Felkins K, Kallem RR, Baker T, Hale TW. Transfer of Low Dose Aspirin Into Human Milk. J Hum Lact. 2017;33(2):296-9.
Askie LM, Duley L, Henderson-Smart DJ, Stewart LA. Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet. 2007;369(9575):1791-8.
Moretti ME, Verjee Z, Ito S, Koren G. Breast-feeding during maternal use of azathioprine. Ann Pharmacother. 2006;40(12):2269-72.
Østensen M, Khamashta M, Lockshin M, Parke A, Brucato A, Carp H, et al. Anti-inflammatory and immunosuppressive drugs and reproduction. Arthritis Res Ther. 2006;8(3):209.
Indraratna PL, Virk S, Gurram D, Day RO. Use of colchicine in pregnancy: a systematic review and meta-analysis. Rheumatology (Oxford). 2018;57(2):382-7.
Pinsky L, Digeorge AM. CLEFT PALATE IN THE MOUSE: A TERATOGENIC INDEX OF GLUCOCORTICOID POTENCY. Science. 1965;147(3656):402-3.
Heller MM, Wu JJ, Murase JE. Fatal case of disseminated BCG infection after vaccination of an infant with in utero exposure to infliximab. J Am Acad Dermatol. 2011;65(4):870.
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2016;55(9):1693-7.
Perez-Aytes A, Ledo A, Boso V, Sáenz P, Roma E, Poveda JL, et al. In utero exposure to mycophenolate mofetil: a characteristic phenotype? Am J Med Genet A. 2008;146a(1):1-7.
