Pregnancy and rheumatoid arthritis 101

What can women with rheumatoid arthritis (RA) expect if they want to have a baby?

A majority of women with RA can have successful pregnancies and healthy babies, especially if their RA is well controlled. It is important for women with RA to plan ahead and have an appointment with their rheumatologist and high-risk obstetrician prior to conception. There are also certain medications that should be stopped prior to pregnancy and your RA should be controlled before contemplating pregnancy. It is also important for all women to start on folic acid supplementation before you get pregnant.

Does RA affect the ability to get pregnant or carry a child to term? Women with RA are able to conceive, however, some may have a more difficult time. Impaired fertility may be related to contributing factors from RA such as disease activity, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and prior treatment with methotrexate.

Large studies that compare women with and without RA have shown that women with RA are potentially at an increased risk for preterm delivery (prior to 37 weeks gestation) and high disease severity is associated with higher risk of preterm delivery. Women with RA have also been shown to be at an increased risk of delivering an infant who is small-for-gestational age.

Will they have to stop taking certain medications during pregnancy? Before stopping any medication, it is important to consult with your rheumatologist and obstetrician to discuss an alternative treatment plan during conception and pregnancy. The benefit of keeping RA well controlled must always be weighed with the risk of any medication used and the treatment plan for a pregnant women is determined on an individual basis.

There are two medications, methotrexate (MTX) and leflunomide (LEF), to be avoided during pregnancy. Methotrexate is known to cause birth defects and induce miscarriage. It is advised to stop this medication three months prior to conception. Leflunomide is known to cause birth defects in animal studies and experts advise this medication to be stopped prior to pregnancy and ensure levels are undetectable prior to conception.

With RA treatment, medications can have specific effects depending on the timing of their use in pregnancy. This table shows the medications that are safe and those to be avoided in each trimester.

Will their condition actually get better while pregnant? There is a common misconception that a majority of women have improvement in symptoms and disease in pregnancy; only about 30 to 50 percent of women experience improvement during pregnancy. Therefore, once a woman with RA conceives successfully, it is important to continue safe and appropriate medications for RA during pregnancy and in the postpartum period.

What can be expected during each trimester? As a women progresses through pregnancy, maternal weight gain and hormonally-based changes in joints and body position can be expected. During the third trimester there can be an added strain on joints, specifically on large, weight bearing joints. RA mostly affects joints in the hands, wrists and feet, but can also affect elbows, knees, shoulders and ankles. The increased stress on joints from pregnancy can contribute to joint symptoms in women with RA.

Does RA raise the risk for C-section? Studies have shown women with RA have a slightly higher rate of delivering via cesarean section for their first pregnancy. Nevertheless, the preferred mode of delivery is vaginal and a cesarean section should only be performed for obstetrical reasons.

What can be expected after delivery? Women with RA usually recover well from delivery and are able to breast feed successfully. In terms of medications to avoid during breast feeding and lactation, aspirin, cyclosporine, cyclophosphamide, methotrexate and chlorambucil should be avoided. NSAIDs, prednisone in low doses, hydroxychloroquine, sulfasalazine are all safe in nursing mothers. TNF inhibitors can be continued or initiated during nursing as these biologic agents are large molecules and only reach the breast milk in low concentrations; however, it is important to share this information with your pediatrician as certain live vaccines should be avoided while breastfeeding on this class of medication.

Do some women experience post-partum flares? After delivery, there is an increased risk of flare in disease activity in RA. The rate of women who have flares in the postpartum period ranges from 60 to 90 percent. This flare usually occurs within the first three months postpartum. After delivery, and even during lactation, continuation of appropriate medication is vital to prevent a flare of RA disease activity.