Pregnancy with rheumatoid arthritis
Introduction
Introduction to pregnancy with rheumatoid arthritis Rheumatoid arthritis (RA), referred to as Fengfengguan, is a chronic autoimmune disease characterized by progressive joint disease. The cause is unknown, but it is generally considered to be an autoimmune reaction caused by infection. It is characterized by symmetrical polyarthritis, which is most common in the hands, wrists, elbows, knees, ankles and foot joints, but other joints in the body can also be affected, in addition to joints, rheumatoid subcutaneous nodules, arteritis, neurological diseases Anterior systemic manifestations such as keratitis, pericarditis, swollen lymph nodes, and splenomegaly are also common. basic knowledge The proportion of illness: 0.17% (the above is the probability of pregnant women) Susceptible population: pregnant women Mode of infection: non-infectious Complications: pericarditis, myocarditis, constrictive pericarditis, osteoporosis
Cause
Pregnancy with rheumatoid arthritis
(1) Causes of the disease
Genetic factor
A study of the comorbidity rate of the same disease in the family of rheumatoid arthritis and the incidence of rheumatoid arthritis was found to be 27% in monozygotic twins and to have rheumatoid arthritis in twins. At 13%, the data of these two groups were much higher than the prevalence of rheumatoid arthritis in the general population, suggesting a close relationship between genetic factors and rheumatoid arthritis.
2. Endocrine factors
The incidence of rheumatoid arthritis in menopausal women is significantly higher than that of men of the same age and older women. The levels of androgen and its metabolites are significantly lower in patients with rheumatoid arthritis. Some people think that the balance between estrogen and androgen is imbalanced and may be involved in rheumatoid joints. The onset of inflammation and the inflammatory process.
3. Infection
Epstein-Barr virus and rheumatoid arthritis studies have shown that the serum EBV antibody positive rate and mean serum titer in patients with rheumatoid arthritis are significantly increased.
4. Parvovirus
Studies on the relationship between parvovinus B19 and rheumatoid arthritis have shown that B19 may play a role in the pathogenesis of rheumatoid arthritis.
(two) pathogenesis
1. The etiology of rheumatoid arthritis is still unclear, characterized by proliferative and aggressive synovitis, which is repeated throughout the life of progressive patients. The hypothesis that rheumatoid arthritis has been proposed is that RA is a chronic immune mediator. The disease is caused by the reaction of T cells to unknown antigens. When T cells are activated, they release lymphokines (such as IFN-) and then activate mononuclear macrophages (M) to release various mononuclear factors (II- 1 and TNF-) and other inflammatory mediators, such as GMC-CSF and growth factors, followed by activation of fibroblasts, stimulate endothelial cell (EC) proliferation, form new blood vessels; activated osteoclasts erode bone, RA synovial membrane Inflammation is a highly complex and comprehensive course of disease.
2. The basic pathology of rheumatoid arthritis is synovitis, inflammation (exudation, infiltration), synovial cell hyperplasia and granulation tissue (vasospasm) formation, hyperplastic granule vasospasm covering the cartilage surface, and Invasion of subchondral bone, on the one hand, cartilage can not affect its metabolism due to contact with synovial fluid, and vasospasm releases certain hydrolase to erode the collagen matrix of articular cartilage, bone, ligament and tendon, leading to joint cavity destruction and fusion. , fibrous tonic, dislocation and even ossification.
3. The effect of pregnancy on rheumatoid arthritis 2/3 patients have spontaneous remission tendency during pregnancy, symptoms and signs improve, most patients with joint swelling and pain and morning rigidity are relieved, according to a group of cases by Neely (1977) Analysis: 62% of 56 pregnant women were relieved and the remaining 38% did not improve, and some even worsened, and 4 cases showed symptoms and signs for the first time in pregnancy. Some people followed up and observed postpartum conditions, even though the condition was already during pregnancy. There are obvious improvement, but because the basis of the disease has not been permanently improved, the majority of the disease is exacerbated within 1 to 6 months after delivery. In the early years, it was thought that the conditional remission during pregnancy was caused by a significant increase in cortisol secretion during pregnancy. Some patients have increased cortisol secretion during pregnancy, but the condition has not been alleviated or even worsened. Some of them do not support the above theory in the first episode of pregnancy. Some people think that the fetus is activated in the mother's body as a suppressor of cell transplantation. The soluble factor produced by the suppressor cells participates in the maternal autoimmune activity through the placenta, inhibits autoimmune diseases, and inhibits cell function due to the fetus. Can be temporary, the baby disappeared after delivery, resulting in increased postpartum condition, Unger (1983) found that the pregnancy-related pregnancy-related 2-glycoprotein levels in the blood of pregnant women averaged 1250mg / L, significantly higher than the pregnant women with no change or even worse ( 470mg/L), this glycoprotein has been shown to have immunosuppressive activity. Popel (1983) found that the concentration of immune complex (antigen-antibody complex) decreased during pregnancy, but pregnancy did not increase rheumatoid factor.
4. The effect of rheumatoid arthritis on pregnancy The rheumatoid factor IgM antibody cannot pass through the placental barrier. Therefore, RA does not increase the spontaneous abortion rate of the pregnancy and the perinatal mortality. The newborn also has no direct disease, and the umbilical cord Rheumatoid factor could not be found.
In patients with severe RA and vasculitic lesions, the placental blood supply may be affected and prone to fetal growth restriction.
If the affected joint has serious lesions, joint activity is affected, especially those with severe hip deformity may hinder vaginal delivery.
Prevention
Pregnancy with rheumatoid arthritis prevention
1. Prevent upper respiratory tract infections, pay attention to living hygiene, and often participate in physical exercise to enhance the body's disease resistance.
2, usually, whether sitting, standing, lying, you must maintain the correct posture, which can prevent fatigue, eliminate fatigue, restore the patient's physical and mental endurance, reduce the pressure and pain of the inflamed joints.
3, if you find that the body has a partial cold phenomenon, you should always add friction, or use cotton to rub the wine. Cold-proof insulation, the wall is free from moisture.
Complication
Pregnancy complicated with rheumatoid arthritis complications Complications pericarditis myocarditis constrictive pericarditis osteoporosis
The disease invades the heart and causes pericarditis, myocarditis, heart valve inflammation, about 1/3 of the corpse cases have pericardial adhesions, but the clinical is almost asymptomatic, individual cases may have constrictive pericarditis symptoms, and a few cases have lymph nodes in the active period of the disease Swelling, splenomegaly, and some intermittent edema of the lower extremities, osteoporosis and so on.
Symptom
Pregnancy with rheumatoid arthritis symptoms Common symptoms Subcutaneous nodular joints Ankylosing joint swelling Kidney damage Fatigue Loss of appetite Hand and foot numb thrombocytosis Rheumatoid nodules Low fever
Initial symptoms
The onset can be hidden or sudden, 3/4 is insidious onset, the patient has fatigue, burnout, physical decline, loss of appetite, low fever, numbness of hands and feet, Raynaud's phenomenon, etc., acute cases may have fever, sometimes For high fever, initial symptoms can precede joint symptoms for weeks or months.
2. Joint performance
Early one or two joints are stiff and painful during activity, but the joints have no abnormal appearance, and gradually become swollen. In acute cases, multiple joints can be swollen at the same time, spontaneous pain, and migratory. Later, they can develop into more symmetry. Arthritis, manifested as red, swollen, hot, painful and dysfunctional. Joint involvement often starts from the distal joints of the extremities, and later involves other joints. The proximal interphalangeal joints are most common, often with a fusiform enlargement, followed by The metacarpophalangeal (toe), wrist, knee, elbow, ankle, shoulder and hip joints (Fig. 1), sometimes the synovial joints such as the mandibular joint or the laryngeal ring joint can also be affected, and the large joints often appear. In the joint cavity effusion, a small number of patients may also have a few joint lesions, sometimes monoarthritis or tenosynovitis, morning joint stiffness, noon reduction, joint stiffness can be used as an indicator of disease activity.
The development of late lesions turned chronic, and the exudative changes of the synovial membrane also developed into proliferative, granulomatous lesions. From the outside, the thickened spongy synovium can be touched, and the range of motion of the joint becomes smaller, initially due to the flexor muscle group. Reflex sputum, mainly reversible changes, later due to synovial granuloma eroding bone, cartilage, can cause joint surface displacement and dislocation, coupled with ligament and joint capsule and other surrounding tissue destruction and scar formation, thus making the joint Irreversible deformation occurs, and the small joints are characterized by characteristic deformation. The most common is that the finger is semi-dislocated to the lateral side at the metacarpophalangeal joint to form a characteristic ulnar offset deformity. In addition, the proximal interphalangeal joint may be flexed and the back side is buttonholed ( Button hole) deformity, or proximal joint hyperextension, distal interphalangeal joint flexion is swan neck deformity (Figure 2), and hallux toe abduction due to subluxation of the big toe and metatarsophalangeal joint.
Proliferative synovitis covers the surface of articular cartilage. Granuloma can cause destruction of cartilage or subchondral bone and bone resorption, and is replaced by fibrous scar tissue, which causes fibrous bone fusion of the joint, resulting in joint stiffness and skin around the joint. Atrophy, pigmentation can be seen, and muscles can also shrink.
3. Skin
20% to 30% of patients may have rheumatoid nodules (subcutaneous nodules), mostly in the subcutaneous and periosteum, often located in the compression and friction parts, occurring in the olecranon sac or the extensor side of the upper end of the forearm Can also be seen in the wrist, ankle, long-term bedridden can occur in the head, trunk and dorsal side of the spine, nodules are removable or periosteal fixation, no tenderness or mild tenderness, round or oval, The texture is tough as rubber, ranging from a few millimeters to several centimeters in diameter, often lasting for weeks to years, sometimes ulceration occurs in the nodules, and necrotic material is discharged from it. Typical nodules are not only found under the skin, but also in the synovial membrane. Tissues around the joints, lungs, pleura, heart, intestines and other internal organs, generally with nodular cases, rheumatoid factor titers are also high, indicating that the disease is active and the prognosis is poor, nodules close to the periosteum can cause bone destruction .
The skin can also be seen with erythema, purple spots, pigmentation and pigmentation. Some patients can also cause sweating disorders due to neurological disorders, increased skin fragility and easy bruising. It is common in chronic patients, and hormone therapy is more obvious.
4. Respiratory system
(1) pleurisy: usually asymptomatic, more pleural adhesions found during X-ray examination or autopsy. Rheumatoid pleural exudate is characterized by lack of cellular components, low complement and sugar content, sometimes bloody, and dry Sexual pleurisy.
(2) Nodular lung disease: a small number of patients may have nodular lesions in the lungs, more common in men with strong rheumatoid factor positive, nodule size of 0.5 ~ 5cm, single or multiple round shadow, more Located at the edge of the lung, if the lesion develops, the nodule can merge into a cavity, sometimes causing pneumothorax or chronic bronchopleural fistula.
(3) diffuse pulmonary interstitial fibrosis: rheumatoid arthritis can be associated with pulmonary fibrosis, mild asymptomatic, a small number of patients with heavy activity can cause difficulty breathing, cough and sickle-toe.
5. Eye performance
15% to 20% of patients may have superficial scleritis, usually in the anterior part of the sclera close to the limbus, a more acute bulging dark purple lesion with a diameter of several millimeters. The surrounding deep blood vessels are obviously congested, and scleral atrophy may occur after scleritis. A small number of painless nodular lesions can cause eyeball perforation after collapse, and some also have iritis, choroiditis, and dry keratoconjunctivitis.
6. nerve
Muscle system peripheral nerve damage is heavy at the distal end of the finger (toe), usually in gloves, sock-like distribution, sometimes numbness of the fingers (toes), feeling sensation, loss of vibration sensation, more common in rheumatoid factor positive with subcutaneous nodules, course Elderly patients aged 10 to 15 years.
The mononeuritis multiplex can be seen in 10% of patients with ulnar nerves, radial nerves, median nerves and posterior tibial nerves.
7. Urinary system
Some patients may have kidney damage, anti-rheumatic drugs may cause renal damage or amyloidosis, mainly proteinuria.
8. Digestive system
Most of the drug-induced digestive tract mucosal lesions, mucosal erosion, ulceration, anorexia, upper abdominal fullness, burning pain, hunger pain, nausea, diarrhea, blood in the stool.
9. Blood system
Anemia is a common manifestation of this disease, the degree of which is mostly mild, its nature can be positive cells positive pigmentation, but also small cell hypochromic anemia, related to the degree of disease activity, active patients with thrombocytopenia, seen in 80% In the above patients, the number of platelets returned to normal after the disease was controlled, and eosinophils were elevated in 20% of cases, often indicating a serious condition, and a few cases showed cryoglobulinemia.
10. The incidence of malignant rheumatoid arthritis (MRA) is low
It accounts for less than 1% of rheumatoid arthritis and is a special type of rheumatoid arthritis. It is pathologically characterized by vasculitis. It is clinically more than a toroid, and there are small brown lesions (hemorrhagic foci) on the margin or fingertip. Because arteritis can cause infarcted lesions, Raynaud's phenomenon, further development can cause fingertip necrosis, shedding, severe cases can occur with nodular polyarteritis, systemic necrotizing arteritis, manifested as fever, white blood cells High, superficial scleritis, complex mononeuritis and mesenteric artery infarction and other serious extra-articular symptoms. This type of patient usually has severe clinical symptoms and long course of disease. Most of them use hormones and have rheumatoid nodules. The rheumatoid factor has high titer, serum complement is reduced, and the prognosis is poor. In recent years, immune complex deposition has been demonstrated in the vasculitis site, and a large amount of low molecular weight 7SIgM-RF and IgG-RF are present in the serum.
Examine
Pregnancy with rheumatoid arthritis
1. Serum and cytology examination
(1) Autoantibodies:
The first class of rheumatoid factor (RF), RF (r) positive rate is 60% to 70%.
2 The anti-nuclear factor (APF) has a positive rate of 48.6% to 86%.
3 The positive rate of anti-keratin antibody is 60% to 73%, which can be seen in patients with early rheumatoid arthritis.
4 anti-SA antibody, 42.7% of patients with rheumatoid arthritis, the joint rate of rheumatoid arthritis patients, the positive rate of the antibody was 68.4%, the specificity of its diagnosis was 78% to 97%.
(2) rheumatoid anihritis associated nuclean artigen (RANA): an acidic nuclear protein, 40% of patients with rheumatoid arthritis have a RANA antibody titer of 1:128.
(3) Type III collagen antibody: Antibodies may play a role in triggering the occurrence and pathological changes of rheumatoid arthritis, which may be useful for the diagnosis of rheumatoid arthritis and for the study of the pathogenesis and treatment of rheumatoid arthritis. .
(4) Other autoantibodies, complement and immune complexes: The level of complement in patients with rheumatoid arthritis fluctuates with changes in the condition, and there is no total complement in patients with extra-articular lesions and inactive rheumatoid arthritis, and C3 and C4 levels are normal. Even slightly higher.
2. Acute phase reactant index
(1) C-reactive protein: C-reactive protein is related to the disease activity index, morning stiffness time, grip strength, joint pain and swelling index. When the disease is relieved, C-reactive protein decreases, and vice versa.
(2) ESR increases: ESR increases when the condition worsens.
(3) Others: 2 microglobulin, transferrin, ceruloplasmin, 1-antitrypsin and anti-chymotrypsin increased, and studies have shown that 1-acid glycoprotein and amyloid A in rheumatoid joints Patients with inflammation are significantly elevated and are closely related to the level of C-reactive protein.
(4) Hematological changes:
1 red blood cells: most patients with rheumatoid arthritis are associated with mild anemia.
2 white blood cells: there may be a slight increase in white blood cells and eosinophilicity during the active phase.
3 platelets: When the disease is active, about 70% of the patients' platelets continue to rise more than 300 × 109 / L, and only after the disease is relieved, the platelets can be reduced to normal.
3. Synovial fluid examination
Rheumatoid arthritis synovial fluid micro-turbidity, viscosity is reduced, leukocytes in synovial fluid are elevated, generally 5000 ~ 50000 / l, neutrophils > 50%, albumin > 40g / L, hyaluronidase <1g /L, macroscopic cells, polymorphonuclear cells and their remnant nucleus (Reiter cells) can be seen under the microscope.
1. Joint X-ray film is most common with both wrists and ankles, so the clinical X-ray examination routinely chooses both hands (including wrists) or both hands and the bipeds. The American College of Rheumatology divides the X-ray performance into 4 period:
Stage I: normal or osteoporosis at the joint end.
Stage II: Osteoporosis at the joint end, occasional subcapsular destruction of the articular cartilage or changes in bone erosion.
Stage III: obvious subcapsular destruction of the articular cartilage, narrow joint space, subluxation of the joint and other deformities.
Stage IV: In addition to changes in stage II and III, there is fibrosis or bony rigidity.
2. CT and magnetic resonance imaging (MRI) generally do not use these two examinations, but can be used for lesions that are difficult to display in flat films. CT can help to detect early bone and joint erosion, femoral head dislocation, etc., rheumatoid arthritis cervical vertebrae The involvement of the circumferential joint lesions is relatively common. CT examinations can show changes such as odontoid erosion, spinal compression, joint dislocation, etc. MRI shows that the joints have hyaline cartilage, tendons, ligaments, synovial cysts and spinal cord compression. good effect.
Diagnosis
Diagnosis and diagnosis of pregnancy complicated with rheumatoid arthritis
diagnosis
As the diagnostic criteria for RA are:
1. Morning joint stiffness is at least 1 h, duration 6 weeks.
2.3 or more joints were swollen for a duration of 6 weeks.
3. Symmetrical joint swelling, duration 6 weeks.
4. The carpometacarpal joint, the metacarpophalangeal joint and the interphalangeal joint are swollen for a duration of 6 weeks.
5. Subcutaneous nodules appear under the skin that are susceptible to compression or susceptible to rubbing.
6. X-ray examination has typical rheumatoid arthritis changes (including bone decalcification around the joints, degenerative changes).
7. Rheumatoid factor (currently clinically limited to detection of IgM-RF) titer > 1:32.
Where 4 or more of the above criteria can be diagnosed with rheumatoid arthritis, it should be noted that these criteria are not only for diagnosis, but to facilitate the classification of a large number of patients in order to summarize epidemiological investigations, drug trials and Study the natural process of rheumatoid arthritis, so some patients, especially those in the early stages of the disease, do not meet this set of artificial standards, and do not rule out the possibility of rheumatoid arthritis.
Differential diagnosis
There are no specific clinical and laboratory indicators for rheumatoid arthritis. Although RF and X-ray signs have important diagnostic significance, they are not unique to rheumatoid arthritis and need to be differentiated from other diseases in clinical practice.
Connective tissue disease
If symmetrical polyarthritis is the first symptom of systemic lupus erythematosus (SLE), scleroderma, mixed connective tissue disease (MCTD) and other connective tissue diseases, and RF-positive, early difficult to distinguish from rheumatoid arthritis SLE occurs mostly in young women. The joint symptoms are often not heavy. Generally, there is no cartilage and bone destruction. The systemic symptoms are heavy. There are often facial erythema and visceral damage. Most of them have kidney damage, proteinuria, serum anti-dsDNA antibody, SM antibody. Lupus cell positive is conducive to the diagnosis of SLE, scleroderma occurs in women aged 20 to 50 years, often accompanied by Raynaud's phenomenon, may have difficulty in opening mouth, mask face and other special performance, MCTD clinically has some clinical manifestations of major rheumatism And it has the characteristics of high titer anti-RNP antibody positive.
2. Seronegative spondyloarthropathy (SpA)
(1) Ankylosing spondylitis: its characteristics are
More than 1 male patient.
2 good hair age is 15 to 30 years old.
3 family history, 90% to 95% of patients with HLA-B27 positive.
4RF negative.
5 mainly invades the ankle and spine.
6 tendon, ligament attachment inflammation is a characteristic change of the disease.
The typical ankle arthritis and spine of the 7X line are bamboo-like changes.
(2) Wright syndrome: aseptic urethritis, conjunctivitis and arthritis triad are the basic characteristics of this disease. Most patients have a history of sexually transmitted urethritis or bacterial sputum 2 to 4 weeks before onset, and their arthritis has Multiple, asymmetry, knee, ankle, and toe and other lower extremity joints are characterized by multiple involvement of this disease in men aged 20 to 40 years, and HLA-B27 is often positive.
(3) psoriatic arthritis: this disease is accompanied by psoriasis skin manifestations, joint lesions involving the distal finger joints of the fingers, interphalangeal joints, asymmetry, some patients may have ankle arthritis and The spine is involved.
3. Osteoarthritis
More often after middle age, the prevalence increases with age, mainly involving the distal interphalangeal joints and hips, knee and other weight-bearing joints, increased pain during activities, rheumatoid factor is generally negative, joint X-ray examination can be seen at the joint edge Lip-like hyperplasia.
4. Rheumatoid arthritis
More common in young people, 1 to 2 weeks before onset of fever, sore throat, after the knee, elbow, shoulder, hip and other large joints of migratory swelling, serum anti-streptolysin "O" and anti-streptokinase positive, Generally no morning stiffness, no joint deformity, some patients have myocarditis and heart valve disease.
5. Gouty arthritis
Rheumatoid arthritis with single joint or arthritis must be differentiated from gouty arthritis. Most of the gouts are male patients, and most of them are acute onset. The site of arthritis is the first metatarsophalangeal joint, and the inflammation is local red, swollen and hot. Pain is obvious, pain is often severe and can not be touched, blood uric acid is elevated, chronic patients have tophis near the affected joints or subcutaneous tissues such as the ear wheel, ulna olecranon, toe and other parts, such as the use of optical microscopy to examine the contents of the tophi Sodium urate needle crystals.
