What is the management for joint swelling during pregnancy?

Management of Joint Swelling During Pregnancy

For joint swelling during pregnancy, intra-articular glucocorticoid injections should be considered as first-line treatment for local symptoms of inflammation, while continuing pregnancy-compatible medications such as hydroxychloroquine, azathioprine, sulfasalazine, and colchicine if needed for systemic disease control. 1

Initial Assessment

• Determine if joint swelling represents inflammatory arthritis by evaluating:

  • Number of affected joints
  • Morning stiffness duration (>30 minutes suggests inflammatory cause)
  • Presence of pain with swelling
  • Involvement of metacarpophalangeal or metatarsophalangeal joints

• Basic laboratory workup should include:

  • Complete blood count
  • Urinalysis
  • Liver function tests (transaminases)
  • Antinuclear antibodies
  • Erythrocyte sedimentation rate or C-reactive protein
  • Rheumatoid factor and anti-CCP antibodies if rheumatoid arthritis is suspected

Treatment Algorithm

Local Therapy

1. Intra-articular glucocorticoid injections
   • First-line treatment for localized joint swelling
   • Safe during all trimesters of pregnancy
   • Provides rapid symptom relief
   • Use aseptic technique with proper skin preparation 1
   • Consider local anesthetic to reduce procedural discomfort 1

Systemic Therapy for Underlying Rheumatic Disease

First-Line Medications (Safe Throughout Pregnancy)

• Hydroxychloroquine (strongly recommended) 1
• Sulfasalazine (strongly recommended) 1
• Azathioprine/6-mercaptopurine (strongly recommended) 1
• Colchicine (strongly recommended) 1

Second-Line Medications (Conditionally Recommended)

• Calcineurin inhibitors (tacrolimus, cyclosporine) 1
• TNF inhibitors:
  • Certolizumab (strongly recommended - minimal placental transfer) 1, 2
  • Infliximab, etanercept, adalimumab, golimumab (conditionally recommended) 1, 2
  • Consider discontinuing TNF inhibitors with IgG1 Fc construct in third trimester if disease is well-controlled 2

Corticosteroids

• Low-dose prednisone (≤10 mg daily) can be continued if needed 1
• Higher doses should be tapered to <20 mg daily, adding pregnancy-compatible steroid-sparing agents if necessary 1

Medications to Avoid During Pregnancy

• Methotrexate, mycophenolate mofetil, cyclophosphamide, leflunomide (strongly contraindicated) 1, 3
• NSAIDs should be avoided in third trimester due to risk of premature closure of ductus arteriosus 1
• Rituximab, belimumab, anakinra, abatacept, tocilizumab, secukinumab, ustekinumab should be discontinued when pregnancy is confirmed 1

Special Considerations

Disease-Specific Responses to Pregnancy

• Rheumatoid arthritis often improves during pregnancy
• Psoriatic arthritis improves in approximately 80% of pregnancies
• Ankylosing spondylitis typically remains active or worsens in 80% of cases 4
• Be prepared for potential postpartum flares, which occur in 50-90% of cases depending on the underlying disease 4

Sacroiliac Joint Pain

• Common during pregnancy and may require specific management
• Osteopathic manipulative treatment may be beneficial 5

Monitoring

• Regular assessment of disease activity throughout pregnancy
• Monitor for medication side effects
• Adjust treatment based on disease activity and pregnancy stage
• Coordinate care with obstetrician and maternal-fetal medicine specialist

Postpartum Considerations

• Anticipate possible disease flare in postpartum period
• For breastfeeding mothers, continue hydroxychloroquine, TNF inhibitors, sulfasalazine, colchicine, azathioprine, and prednisone <20 mg daily 1
• For prednisone ≥20 mg daily, discard breast milk obtained within 4 hours of medication administration 1

By following this structured approach to managing joint swelling during pregnancy, clinicians can effectively control inflammation while ensuring the safety of both mother and baby.