Doctor, I wish to be a mother

by Dr. Vaijayanti Lagu - Joshi

The great Mother Nature has blessed woman with unique gift of Motherhood. It is a wonderful journey of a woman becoming a mother - full of anxieties, pleasures, dreams and of course fear, worries and agonies, too. We, rheumatologists, come across many young ladies who suffer from chronic arthritis and are eager to become mothers. A lot of uncertainties and queries make such pregnancies very stressful. We doctors label them as high risk, precious pregnancies.

In the productive age group of 20-30 years, these young ladies suffer from rheumatoid arthritis mostly, followed by some collagen vascular diseases like systemic lupus erythematosis (SLE), scleroderma or overlap diseases. Although there is no contraindication to pregnancy on the background of disease, pregnancy in this state demands special attention and care. Ideally a team of expert rheumatologists, obstetricians, physiotherapists, nutritionists and family members need to work in co-ordination. As a rheumatologist, I attempt to clear a few common queries and doubts of these young ladies.

"Doctor, am I fit for pregnancy ?" the story begins with the utmost worry. Pregnancy is a very important decision, decided by emotional, social and economical factors, but the topmost factor is medical fitness. The young patients of arthritis can surely undergo pregnancy, provided their arthritis is well controlled. We always advise to plan the pregnancy in such situations. The patients need to undergo clinical examination, laboratory investigations and a critical look at on going arthritis medications. After a satisfactory control of disease for 3-6 months, and gynecologist's opinion, we doctors can give a "green signal" to the patients.

Once there is a decision for pregnancy a series of questions stands :

Will the child in utero suffer from arthritis like me ?

Not necessarily. Almost all rheumatic diseases are multifactorial. Apart from genes, there are many environmental factors like infections, stress that contribute to the disease. The children might be at high risk to develop the disease in later life, but presently there are no markers available to predict this. Normal development of child is possible with today's medical care. Only exception is neonatal lupus where due to transmission of few antibodies through placenta the new born baby shows rashes & congenital heart block in a few cases of mothers suffering from SLE.

Does arthritis worsen during pregnancy ?

Almost 2/3rd of our young rheumatoid arthritis patients show total remission of disease during pregnancy, however a few can show activity or worsening of disease. SLE patients with renal involvement might show flare up during pregnancy and need critical monitoring. But otherwise pregnancy itself being immunosuppressive condition arthritic conditions fare well during this period.

How does arthritis affect the course of pregnancy ?

If the rheumatic diseases, arthritis are under good control the usual course of pregnancy will not be affected, but some special problems may occur in uncontrolled disease, SLE like rise in blood pressure, leading to toxaemia of pregnancy, sometimes spontaneous abortions, preterm deliveries, still births or intrauterine growth retardation.

If arthritis is under control, is normal delivery possible ?

Yes ! only in some situations, caesarian or surgical interventions are needed.

How does pregnancy affect the arthritis / rheumatic diseases ?

During pregnancy, many physiological changes occur in the body. The weight gain, fluid retention leading to swelling over feet, postural changes of spine do affect the joint condition. There could be worsening of knee pains, low back aches, muscular cramps and stiffness of joints. Sometimes there could be worsening of breathlessness due to awkward positioning of diaphragm. These problems need to be tackled with the help of doctors and physiotherapists. Maintaining good postures, practicing relaxation exercises, strengthening exercises will help overcome the need for pain killers.

How will medicines affect the pregnancy and developing child ?

First 3 months of pregnancy are crucial for development of all organs of the child. Hence, most of the medications except a very few important medications are to be stopped. Few medications of arthritis, like methotrexate, cannot be continued during pregnancy. Few medications have some side effects on fetus but still their benefits are more than the risks and hence, are continued in pregnancy. However, the pregnant young lady must consult the doctors before taking any other medicines and use of anti-inflammatory drugs or painkillers must be to the minimum.

How frequently should the patient visit the doctor ?

It is very important to be under regular vigilance of both rheumatologist and obstetrician. During first 3 months of pregnancy, traveling and physical exertion are to be avoided. But later on, there should be monthly visits to the doctors and monitoring of parameters like weight, blood pressure, foetal growth, health of mother and a few routine blood and urine investigations are also advised. If patient catches any infection, develops fever or shows worsening of arthritis, the young lady should immediately report to the doctor.

What are the precautions regarding diet and exercises during pregnancy ?

The nutrition should be well balanced and complete. The regular diet must include milk, green leafy vegetables, fresh fruits and fibre rich items. There are no dietary restrictions from arthritis point of view. But food should be well cooked in hygienic conditions.

Exercises like walking, muscle strengthening and relaxation exercises along with "range of motion" exercises for joints are good to keep muscular skeletal system in a good state. However, the schedule needs to be as per the physiotherapist's /doctor's advice. Undue stress, exertion are to be strictly avoided.

How shall the young arthritis patients cope with stress of pregnancy ?

The pregnancy leads to changes in the body as well as the mind. Anxieties, mood swings, undue fears, tensions indirectly affect the pregnancy as well as the background disease. Again a team of doctors, physiotherapists, family members should encourage these young ladies to open up and freely discuss their anxieties and queries. They should practice meditation, stress relieving exercises and keep their minds also under control.

Ultimately, a good team approach and co-ordination between rheumatologists / obstetricians, physiotherapists, regular close monitoring and awareness by patient can ease out the stress and lead to a "fruitful pregnancy". There are no words to describe our satisfaction when we see our young arthritis patients becoming proud mothers of healthy children.