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Delay pregnancy until scleroderma stabilizes. (Diffuse Disease).

NEW ORLEANS -- Women with diffuse scleroderma, including those with a previous renal crisis, should delay pregnancy until their disease has stabilized, Dr. Virginia Steen said at the Third International Conference on Sex Hormones, Pregnancy, and the Rheumatic Diseases.

Before 1985, doctors told most women with scleroderma not to get pregnant, because pregnancy outcomes were poor for both them and their babies. Now women with milder or stable disease can have good pregnancy outcomes without high rates of miscarriages and preterm births, said Dr. Steen, professor of medicine at Georgetown University, Washington, D.C.

Dr. Steen noted a prospective trial at the University of Pittsburgh in which 26 women had limited scleroderma and 41 pregnancies and 33 women with diffuse scleroderma had 50 pregnancies from 1987 to 1996. Only women with late diffuse disease had a significant increase in the frequency of miscarriage, compared with the other women,

Prematurity occurred in 29% of the pregnancies as a whole. However, 60% of the pregnancies in women with early diffuse disease were marked by premature delivery a significantly greater percentage than that seen in women with other manifestations of the disease. Only one of the premature infants died (Obstet. Gynecol. 94[1]:15-20, 1999).

The severity of scleroderma symptoms during pregnancy did not change significantly afterward, and "some patients actually felt they improved," she said at the conference, sponsored by the University of Connecticut and the University of Utah.

Some women with Raynaud's phenomenon reported feeling better during--but worse after--pregnancy A small number of patients with diffuse disease had worse skin disease symptoms when they stopped medication such as methotrexate during pregnancy.

Two women with early diffuse disease had a renal crisis during pregnancy; early diffuse disease is a major risk factor for renal crisis, Dr. Steen said. One woman elected to have an abortion; the other had a preterm infant who eventually did well.

Renal crisis is a severe kidney problem in scleroderma that requires ACE inhibitors as lifesaving medications. However, the use of ACE inhibitors in pregnancy can be associated with severe kidney problems in the baby particularly in the third trimester.

In her experience since 1982, Dr. Steen has seen 12 pregnancies among 10 women who became pregnant after having a renal crisis. Only four of them had a prior dialysis, and the creatinine levels of all the women had returned to almost normal.

Five women continued using ACE inhibitors (some also with calcium channel blockers): Five of their six pregnancies had no significant problems; one was ectopic.

In six pregnancies among another five women, two women never took any ACE inhibitors, resulting in increased blood pressure and creatinine levels and one stillborn and two healthy infants. The other three women developed high blood pressure and high creatinine levels when they stopped taking ACE inhibitors at the time of pregnancy and required additional medication. These two women took ACE inhibitors sporadically during the remainder of their pregnancies. They had one healthy premature baby and two very small babies. One of the mothers had an increased creatinine level and required dialysis for a short time. Again, none of the babies had any evidence of ACE inhibitor fetopathy.

Dr. Steen suggested it is best to use ACE inhibitors only at the lowest doses if needed.

She also noted a separate retrospective case-control study of 214 women with scleroderma, 167 women with rheumatoid arthritis, and 105 neighborhood control patients. The women were first evaluated in 1972 or later and then interviewed in 1986.

There were no differences between groups in the percentage of patients who had successful pregnancies or who had tried to get pregnant for at least 1 year and were unsuccessful, she said.

Miscarriages occurred at a similar rate of 12%-16% in each group. The frequency of both premature infants and small-for-term infants was significantly higher in the scleroderma group than in the control group.

Neonatal deaths, which occurred in small numbers, were similar among the groups (Arthritis Rheum. 42[4]:763-68, 1999).
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Author:Evans, Jeff
Publication:OB GYN News
Date:Feb 1, 2003
Words:663
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