26 Special Topics Pericarditis and pregnancy Pericarditis can affect women of reproductive age. Although incidence is not clearly characterized, data suggest it is similar to age-matched controls.85,86 The most common finding of pericardial disease in pregnancy is a pericardial effusion, which is often asymptomatic and not associated with pericarditis. Most cases of pericarditis are idiopathic in nature, and although similar to the non-pregnant patient, pericarditis may be secondary to autoimmune, autoinflammatory or viral infections. The diagnostic approach to pericarditis in pregnancy is similar to non-pregnant patients, with some caveats. Pleuritic chest pain is the most common symptom, and patients may experience symptoms such as dyspnea when supine that may be disregarded as a normal symptom of pregnancy. Diagnostics include the classic physical exam findings, as well as ECG, laboratory data and imaging. ECG changes should be interpreted cautiously and in the clinical context, as healthy pregnant patients can have T-wave changes in second and third trimesters. Additionally, inflammatory markers (hsCRP and ESR) may rise in normal pregnancy. Imaging is an important diagnostic tool with echocardiogram as the first-line imaging modality. In later pregnancy, subcostal views may be limited. Up to 15% of healthy pregnant patients may have a pericardial effusion, in acute pericarditis pericardial effusion has been noted in up to 60%-80% of patients. Advanced imaging is less commonly used, given concerns with gadolinium contrast during pregnancy. Figure 1 highlights the challenges associated with pericarditis during pregnancy. Management The management of pericarditis requires a thoughtful approach with multidisciplinary collaboration between OB-GYN, cardiology and rheumatology. Treatment recommendations can change depending on the trimester, which are detailed in Table 6. It is recommended as a general guidance that patients with prior pericarditis or recurrent pericarditis achieve disease control at least 6 months prior to conception. Table 6: Considerations for pharmacologic management of pericarditis before, during and after pregnancy. Preconception/ periconception 1st and 2nd trimesters 3rd trimester Breastfeeding NSAIDs Avoid if feasible, may affect ovulation Use (ibuprofen preferred) Avoid (except low dose aspirin) Use Colchicine Use Use Use Use Corticosteroids Use Use (prednisone or prednisolone preferred, dose <20mg/day) Use (non-fluorinated preferred, dose equivalent of <20mg/day prednisone) Use (non-fluorinated preferred, dose equivalent of <20mg/day prednisone) IL-1Ra Selective use* Selective use* Selective use* Use (limited data but presumed safe) Azathioprine Use Use Use Use IVIG Use Use Use Use Methotrexate Avoid; discontinue 1-3 months prior Avoid Avoid Avoid Mycophenolate mofetil Avoid; discontinue 6 weeks prior Avoid Avoid Consider alternative but reasonable with counseling Reprinted with permission: Pryor, K et al. Pericarditis Management in Individuals Contemplating Pregnancy, Currently Pregnant, or Breastfeeding. Curr Cardiol Rep 25, 1103–1111 (2023). *There should be shared decision making with the patient by a multidisciplinary care team (e.g., obstetrics, rheumatology, cardiology) of IL-1 inhibition use in pregnancy recognizing that there are no formal society guidelines that recommend the use of IL-1 inhibition in pregnancy.
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