Rheumatoid arthritis (RA) is three times more common in women than in men, and although the peak time of onset is not until the mid-thirties, it is reported to complicate approximately 1 in 1000 pregnancies. It is a non-specific autoimmune disease. A proportion of patients are seropositive for rheumatoid factor, an anti-IgG antibody.
RA tends to run a course of remissions and relapses. Pregnancy usually has a beneficial effect on disease progress, though relapses during the puerperium are common (but may be delayed by lactation). New-onset rheumatoid arthritis is also more common in the postpartum period.
Problems and special considerations
The pregnant woman with RA poses several concerns for the anaesthetist.
Effects of the disease on the joints
RA tends to affect primarily the small joints of the hands and wrists, and although this can be disabling for the patient, it is not usually a problem for the anaesthetist. In more severe cases there may be involvement of the hips, knees and lumbar spine, which may make positioning for regional analgesia or anaesthesia difficult. In very severe cases there may be kyphosis of the thoracic spine and fixed deformity of the ribs, causing restrictive lung disease.
RA affects the cervical spine in up to 45% of cases, and it is important to remember that the cervical spine may be unstable and prone to subluxation. The temporomandibular joint (TMJ) may also be affected, and tracheal intubation may be difficult or impossible. Cricoarytenoid arthritis may be present, causing glottic constriction.
Systemic effects of the disease
These are widespread. Both pericardial and pleural effusions may occur (often asymptomatically). Systemic granulomas can form in the lungs, myocardium, heart valves, aortic root and coronary arteries. Deposits in the cardiac conducting system may occur. A vasculitic process may rarely cause coronary or pulmonary arteritis.
Syndromes associated with RA include Felty’s and Sjogren’s, in both of which peripheral neuropathies may occur.
Long-term medication
The general principle of drug management during pregnancy is to reduce medication to a minimum and to restrict it to those drugs with the best safety record.
Women with symptomatic RA are usually maintained on high-dose aspirin, nonsteroidal anti-inflammatory drugs and corticosteroids. Although these are all relatively contraindicated during pregnancy, it may be impossible to stop them. Serial ultrasound examination of the fetal heart helps to give early warning of closure of the fetal ductus arteriosus or of developing fetal pulmonary hypertension.
Gold, penicillamine and most immunosuppressive drugs are avoided during pregnancy where possible. The degree of risk from the newer immunomodulatory preparations (e.g. tumour necrosis factor inhibitors/antibodies) is unclear.
Management options
The mother with RA may have several anaesthetic risk factors and should be identified as early as possible during pregnancy and referred for anaesthetic assessment. History taking should include a drug history, and questioning about any previous anaesthetics, especially if these involved tracheal intubation. A history of hoarseness or stridor may suggest cricoarytenoid arthritis; nasendoscopy can be performed if further investigation is necessary. A full airway assessment is mandatory, including jaw protrusion (TMJ involvement) and neck movement (cervical spine involvement). Where appropriate, cervical spine x-rays should be taken in extension and flexion - for example, if neck symptoms are present, or the disease has been present for a long duration. A detailed cardiorespiratory history is essential. Pulmonary function tests may be considered, and electrocardiography should be performed to exclude conduction defects. If there is suspicion of a rheumatoid cardiomyopathy, echocardiography should be requested. The extent of any peripheral neuropathy must be documented.
The mother should be advised to accept early epidural analgesia. If this is precluded by coagulopathy or absolute maternal refusal, patient-controlled opioid analgesia may be offered. If caesarean section is necessary, a graduated epidural top-up or combined spinal-epidural is often recommended in preference to single-shot spinal anaesthesia, in order to reduce the risk of an unexpectedly high motor or sensory block compromising the airway, and to provide greater haemodynamic stability in the event of undiagnosed cardiac problems. There is some anecdotal evidence to suggest that neuraxial anaesthesia may result in a more extensive spread of block than expected in patients with RA.
If there are known cervical spine problems and general anaesthesia is essential, the anaesthetist must have access to fibreoptic equipment and awake intubation. Indirect video laryngoscopy may be useful to avoid excessive cervical spine movement, even if the airway is not predicted to be difficult. Even if there is severe fetal distress, general anaesthesia should not be induced without additional aids for difficult intubation (and the presence of an anaesthetist who is familiar with their use). Careful attention is required to positioning throughout labour and delivery, particularly in the presence of regional analgesia/anaes- thesia or during general anaesthesia, to avoid forcing joints beyond their normal range.
Key points
• Rheumatoid arthritis is a multisystem autoimmune disease.
• Pregnancy tends to be associated with remission of the disease.
• The anaesthetist should expect difficulty with tracheal intubation.
• Cardiac and respiratory manifestations of the disease may be present.
• Peripheral neuropathy may infrequently occur.
• The mainstay of drug treatment is non-steroidal anti-inflammatory drugs, which the mother may need to continue throughout pregnancy.
Further reading
Elliott AB, Chakravarty EF. Management of rheumatic diseases during pregnancy. Postgrad Med 2010; 122:213-21.
Marker-Hermann E, Fischer-Betz R. Rheumatic diseases and pregnancy. Curr Opin Obstet Gynecol 2010; 22: 458-65.
Samanta R, Shoukrey K, Griffiths R. Rheumatoid arthritis and anaesthesia. Anaesthesia 2011; 66: 1146-59.
Smolen JS, Aletaha D, Mclnnes IB. Rheumatoid arthritis. Lancet 2016; 388: 2023-38.