27 A Toolkit for Health Care Professionals Recurrent Pericarditis Safety of medications during pregnancy follows the formal recommendations in the 2020 American College of Rheumatology reproductive health guideline.87 In general, first-line therapies with NSAIDs and the recommendations will vary based on the trimester, such that should only be used in first or second trimester. Colchicine, although once considered a teratogen, has accumulating data for safety from diseases that require colchicine (such as Familial Mediterranean Fever), resulting in societal guidelines that no longer discourage colchicine use during pregnancy and breastfeeding.87 Glucocorticoids remain second-line, and both the dose and form require consideration during pregnancy. In general doses, less than 20mg/day and ideally <10mg/day are advised. For refractory disease, IL-1 inhibitors may be conditionally considered although literature remains limited.88 Other disease-modifying antirheumatic drugs (DMARDs) have less data, but importantly agents such as methotrexate and mycophenolate mofetil (MMF), which may be used in refractory pericarditis, are contraindicated during pregnancy and should be discontinued prior to conception. Azathioprine however is safe in pregnancy. Figure 1: Challenges of pericarditis in pregnancy. TTE may be limited in later pregnancy, particularly subcostal view ESR and CRP rise throughout pregnancy at a variable extent Cardiac troponin may be elevated in gestational hypertension and preeclampsia Dyspnea is a common symptom in later pregnancy Heart rate increases throughout pregnancy, tachycardia is not uncommon by the 3rd trimester ECG changes, including inverted T-waves, are common in later pregnancy Small pericardial effusions can be seen in up to 15% of pregnant patients by 3rd trimester Limited utility of CMR given avoidance of gadolinium contrast CV IMAGING LABS SYMPTOMS HEMODYNAMICS ECG CHALLENGES OF PERICARDITIS DIAGNOSIS DURING PREGNANCY Reprinted with permission: Pryor, K et al. Pericarditis Management in Individuals Contemplating Pregnancy, Currently Pregnant, or Breastfeeding. Curr Cardiol Rep 25, 1103–1111 (2023).
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