What is the recommended management for pericarditis in a pregnant woman at 28 weeks gestation?

Management of Pericarditis at 28 Weeks Gestation

At 28 weeks gestation, you must immediately discontinue all NSAIDs (except low-dose aspirin ≤100 mg/day) and transition to low-dose prednisone (2.5-10 mg/day) as the primary anti-inflammatory agent, with consideration of continuing or initiating colchicine despite traditional contraindications. 1

Critical Timing Considerations

You are at a pivotal gestational age where standard pericarditis management fundamentally changes:

• All NSAIDs (ibuprofen, indomethacin, naproxen) must be stopped immediately at 28 weeks due to risk of premature ductus arteriosus constriction and fetal renal impairment 1, 2
• Low-dose aspirin (≤100 mg/day) is the only NSAID that may continue beyond 20 weeks, though its anti-inflammatory efficacy for pericarditis is limited 1
• The traditional "third trimester" designation is misleading—the critical cutoff is gestational week 20-28, not the calendar third trimester 1, 2

Recommended Treatment Algorithm at 28 Weeks

First-Line Therapy

Prednisone 2.5-10 mg/day should be initiated or continued as your primary anti-inflammatory agent:

• Use the lowest effective dose that controls symptoms 1
• Safe throughout pregnancy and breastfeeding 1, 3
• Must supplement with calcium and vitamin D to prevent maternal bone loss 1
• Taper extremely cautiously during pregnancy—do not rush dose reductions 1

Adjunctive Therapy: The Colchicine Controversy

The evidence on colchicine use at 28 weeks is evolving and contradictory:

• Traditional ESC 2015 guidelines state colchicine is contraindicated during pregnancy 1
• However, newer evidence (2021-2023) supports colchicine use throughout pregnancy to prevent recurrences, particularly when disease control is critical 4, 5, 3
• No adverse fetal outcomes have been documented in women with Familial Mediterranean Fever treated with colchicine throughout pregnancy 1
• If pericarditis is recurrent or difficult to control, strongly consider continuing or initiating colchicine after informed discussion with the patient about limited but reassuring safety data 5, 3

Symptomatic Relief

• Paracetamol (acetaminophen) is safe throughout pregnancy for pain control 1
• H2-blockers or proton pump inhibitors are allowed for gastric protection if needed with corticosteroids 1, 6

Monitoring Requirements

Establish close surveillance with the following schedule:

• Weekly clinical assessment initially to evaluate treatment response 1
• Serial echocardiography to monitor for pericardial effusion progression or tamponade 1
• Monitor for signs of cardiac tamponade: hypotension, tachycardia, elevated jugular venous pressure, pulsus paradoxus 1
• Assess inflammatory markers (CRP, ESR) to guide therapy adjustments 1

High-Risk Features Requiring Hospitalization

Admit immediately if any of the following are present:

• Fever >38°C (100.4°F) 1
• Large pericardial effusion (diastolic echo-free space >20 mm) 1
• Any signs of cardiac tamponade 1
• Failure to respond to therapy within 7 days 1
• Subacute presentation suggesting possible tuberculous or neoplastic etiology 1

Delivery Planning

Normal vaginal delivery remains the preferred approach:

• Vaginal delivery is recommended as first choice in most cardiac patients, including those with pericarditis 1
• Cesarean delivery should only be performed for standard obstetric indications 1
• Epidural analgesia during labor is safe and helps reduce hemodynamic stress 1
• Antibiotic prophylaxis during delivery is not recommended for pericarditis 1

Critical Pitfalls to Avoid

Do not continue NSAIDs beyond 28 weeks under any circumstances (except aspirin ≤100 mg/day)—the fetal risks of ductus arteriosus constriction and oligohydramnios are severe and well-documented 1, 2

Do not use high-dose corticosteroids (>10 mg/day prednisone) unless absolutely necessary—this increases risk of gestational diabetes, hypertension, and fetal growth restriction 1, 3

Do not dismiss colchicine automatically—while older guidelines contraindicate it, emerging evidence supports its safety and efficacy in preventing recurrences during pregnancy 4, 5, 3

Do not attempt diagnostic pericardiocentesis unless there is hemodynamic compromise—the procedure carries risks in pregnancy and most cases can be managed medically 1

Multidisciplinary Team Approach

Coordinate care with the following specialists:

• Maternal-fetal medicine for high-risk obstetric management 5, 3, 7
• Cardiology for pericarditis-specific management 5, 3
• Consider rheumatology consultation if disease is refractory or recurrent 4

Post-Delivery Management

After delivery, treatment options expand significantly:

• Resume NSAIDs (ibuprofen, indomethacin, naproxen) if breastfeeding—all are compatible with lactation 1
• Continue prednisone during breastfeeding if needed 1
• Initiate or resume colchicine after breastfeeding discontinuation for long-term recurrence prevention 1
• Taper corticosteroids gradually to avoid disease flare 1