Pregnancy and Nursing

Patients with Rheumatoid Arthritis may be concerned about becoming pregnant due to the toll it may take on an already damaged body. Some patients may worry about increasing the damage to their joints due to more inflammation or the extra weight placed on the joints. Although valid concerns, research has shown that pregnancy is actually beneficial to the Rheumatoid Arthritis patient. Patients at highest risk for developing Rheumatoid Arthritis are nulliparous females. Unfortunately, there is a higher rate of infertility in women who are genetically predisposed to developing rheumatoid arthritis. However, if a patient is able to become pregnant, lots of studies have shown that the inflammation in rheumatoid Arthritis patients remits through the course of the pregnancy. Some patients have less joint swelling and pain during pregnancy while others have no signs of swelling during pregnancy. The pathophysiology behind this odd response to pregnancy is the changing levels of sex hormones. Estrogen and progesterone are immunosuppressive and are higher during pregnancy, thus alleviating the lymphocyte response to the disease. Oral contraceptives can also help with the severity of rheumatoid Arthritis by controlling the estrogen and progesterone levels in the female.

Conversely, nursing is damaging to the rheumatoid Arthritis patient. The rapid drop in progesterone and the loss of the high levels of estrogen cause an inflammatory relapse post partum. Patient symptoms and the number of inflamed joints significantly increases post partum. On top of these normal hormone changes after pregnancy, the nursing mother also has the effects of the hormone, prolactin. Prolactin is immunostimulatory and can actually induce autoimmune arthritis. Therefore, in genetically at risk patients, breastfeeding can induce rheumatoid arthritis, especially after the first pregnancy. The hormone prolactin is secreted at a level of 30 times that of a typical woman, thus potentially producing a worse prognosis for the patient. Rheumatoid arthritis is known for the early morning symptoms, which corresponds to the peak of prolactin concentration.

On a positive note, there is no correlation with developing rheumatoid arthritis on subsequent pregnancies. If breastfeeding does not incite rheumatoid arthritis after the first pregnancy, it typically will not incite the disease on the second or third pregnancies either. This is because the greatest risk is with the first exposure to the elevated prolactin concentrations. However, this study did not include women who breastfed the second child without breastfeeding the first child. The downside is that if rheumatoid arthritis is provoked with breastfeeding for the patient after the first child, it will be provoked with each additional child. Thus, the damage to the joints from breastfeeding would be worse the longer the patient breastfeeds and the more children the woman breastfeeds. Jorgenson et al. showed that breastfeeding greater than three children results in a 3.7 fold increase in disease severity. Laboratory tests will show an elevated serum C-reactive protein in these breastfeeding women.

Key Points:

Pregnancy alleviates symptoms and inflammation in many rheumatoid arthritis sufferers
Symptoms resume post partum due to the lower estrogen and progesterone levels
Breastfeeding can increase the onset and severity of rheumatoid arthritis suffering

Assignment: Discuss the risks and benefits of breastfeeding with your pregnant rheumatoid arthritis patients.

Overview of Rheumatoid Arthritis
Rheumatoid arthritis is a chronic inflammatory polyarthritis of synovial joints. Rheumatoid arthritis is an autoimmune disease; however, the true etiology of the autoimmunity is unknown. What is known is that genetics and environmental factors are involved. For example, the human leukocyte antigen (HLA) DR 1 and 4 are found frequently in rheumatoid arthritis patients with 80% of Caucasian patients expressing one of these two cell surface molecules. Environmental factors known to be associated with rheumatoid arthritis include silicate exposure, cigarette smoking, and excessive decaffeinated coffee consumption. Excessive coffee consumption is defined as greater than three cups per day. Eight to fifteen percent of patients report having an infectious illness prior to the rheumatoid arthritis symptoms. Environmental factors that decrease the risk of developing rheumatoid arthritis include tea consumption, oral contraceptive use that controls the sex hormones previously discussed, and high vitamin D intake. The typical age of onset is 40 to 60 years of age. This disease affects 1-3% of adults with women accounting for the majority. The disease is three times more prevalent in women than men. In the United States, 1.5 million women are affected and 600,000 men. Twenty to thirty percent of untreated patients will be unable to work within three years of the diagnosis.

The disease is characterized by periods of waxing and waning symptoms throughout the patient’s lifespan and there is no cure. Within months of the diagnosis, significant damage can occur. The inflammation leads to progressive joint damage that is permanent as well as being a cause of joint pain and stiffness. This disease has a high morbidity and an increased mortality compared with the general public. Morbidity can be accounted for by the limits to the patient’s activities of daily living, which could include anything from the inability to work down to difficulty with chewing. Remember the temporal-mandibular joint can be affected too.

The classic presentation for rheumatoid arthritis is bilateral and symmetrical pain and stiffness in multiple joints; however, one third of patients present with one joint or a few scattered joints being affected. The wrist is usually involved followed by the proximal interphalangeal and metacarpophalangeal joints.




Figure 2


Figure 2 shows a rheumatoid arthritis patient with wrist involvement. Unlike the seronegative inflammatory arthritides, the sacroiliac joints are typically not involved. Symptoms typically build over weeks to months and are preceded by loss of appetite, weakness and fatigue. One key symptom is the extreme weakness and prolonged morning stiffness.

The signs of a rheumatoid arthritis joint include a hot, painful joint with a boggy feel. Lymphadenopathy may be seen or muscle atrophy around the affected joints. Flexing the joint is palliative. Constitutional symptoms may also coincide with the acute flares.

Key points:
Rheumatoid arthritis is an autoimmune disease causing chronic synovitis
Increased mortality and high morbidity is associated with the disease
The joint damage is permanent
Classic signs and symptoms help to make the diagnosis; however, many patients do not present with these classic scenarios

References:

Hampl JS, Papa DJ. Breastfeeding – related onset, flare, and relapse of rheumatoid arthritis. Nutrition Reviews. Washington: Aug 2001. Vol. 59, Iss. 8; pg. 264, 5 pgs
Hampl JS, Papa DJ. Breastfeeding – related onset, flare, and relapse of rheumatoid arthritis. Nutrition Reviews. Washington: Aug 2001. Vol. 59, Iss. 8; pg. 264, 5 pgs
Rindfleisch JA, Muller D. Diagnosis and Management of Rheumatoid Arthritis. American Family Physician. Kansas City: Sep 15, 2005. Vol. 72, Iss. 6; pg. 1037, 11pgs


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