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Pregnancy with Rheumatoid Arthritis

Pregnant Woman ReadingIn the past, women with rheumatoid arthritis were discouraged from getting pregnant. But now the picture is different. With the help of their doctors, along with careful disease management, most women with rheumatoid arthritis can have a successful pregnancy.

A successful pregnancy, however, does not necessarily mean everything goes according to plan. According to the American College of Rheumatology, "Doctors and patients must be ready to deal with possible complications for both mother and child."

Rheumatoid arthritis and similar diseases often affect women when they reach their childbearing years. Women with rheumatoid arthritis needn't be discouraged from getting pregnant, but they should be prepared.

It is especially important that patients get their rheumatoid arthritis under control before getting pregnant. Through working closely with their doctors, women with rheumatoid arthritis can have a pregnancy similar to that of otherwise healthy women.

This article offers tips to women with rheumatoid arthritis who are pregnant or are planning on becoming pregnant.

How can pregnancy affect rheumatoid arthritis?

Somewhat surprisingly, women with rheumatoid arthritis have reported improved symptoms during pregnancy, which often leads to a reduced need for medications.

After delivery, however, the painful symptoms of rheumatoid arthritis may flare up once again.

"According to one review, approximately 70 percent of patients with rheumatoid arthritis experienced substantial improvements in disease activity during pregnancy," says Sanmaan Basraon, MD, MPH, of the Department of Obstetrics and Gynecology of the University of Texas Medical Branch in Galveston, Texas.

"Most of these patients no longer required medications," Dr. Basraon continues. "But more than 90 percent of women relapsed within six to eight months [after childbirth]. Thirty percent of patients experienced no change or worsening of symptoms during pregnancy."

In other words, most of the women in that study experienced improvement to their arthritis during pregnancy. However, symptoms soon returned in the vast majority of these women.

How can rheumatoid arthritis affect pregnancy?

According to Dr. Basraon, "Rheumatoid arthritis appears to have no adverse effects on pregnancy. Studies show no increase in spontaneous abortion (miscarriage) or stillbirths in patients with rheumatoid arthritis."

Still, Dr. Basraon suggests ultrasound monitoring of fetal growth throughout a pregnancy.

How can the medications used to treat rheumatoid arthritis affect a pregnancy?

While rheumatoid arthritis itself does not seem to affect pregnancy, some of the medications used to treat the disease may not be advised during this time.

Some medications carry a warning that says not to use them during pregnancy. In many cases, there is limited research on the use of arthritis medications in pregnant women. But there are still some concerns about the medications commonly used to treat rheumatoid arthritis.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are typically the first medications used to treat rheumatoid arthritis. NSAIDs include aspirin, naproxen (marketed as Aleve) and ibuprofen among others.

Generally, NSAIDs do not appear to lead to abnormalities. Some studies suggest an increased risk of miscarriages and gastroschisis – a birth defect in which a newborn's intestines stick out of a hole in the abdominal wall.

While not all studies confirm these findings, there is evidence of links between NSAIDs and certain complications.

"Aspirin in high doses was once the mainstay of treatment. But at these high doses of 3.6 to 4 g/day, it can be associated with tinnitus (noise or ringing in the ears) and deafness, thus requiring drug level monitoring," says Dr. Basraon.

"Additionally, aspirin…is associated with increased blood loss during delivery and postpartum hemorrhage (heavy bleeding after delivery).

"Other non-steroidal agents like indomethacin, ibuprofen and ketoprofen have a similar safety profile as aspirin and use after 32 weeks of pregnancy is not advisable."

Dr. Basraon also says that indomethacin has been linked to the early closure of a blood vessel in the baby's heart called the ductus arteriosus.

"In summary, avoid use [of NSAIDs] in the third trimester and use with caution before the 24th week. If used, consider NSAIDs with short half-life, at low doses and intermittently," Dr. Basraon recommends.

Corticosteroids

Corticosteroids such as prednisone (Deltasone) and methylprednisolone (Medrol) are another type of medication used to treat rheumatoid arthritis.

Studies have linked mothers' use of steroid medications in the first trimester to oral clefts, or birth defects in which the tissues of the mouth or lip do not form properly.

According to Dr. Basraon, "The general recommendation is to use the lowest dose possible. Corticosteroids may increase the maternal risk of hypertension (high blood pressure), edema (swelling caused by fluid in your body's tissues), diabetes during pregnancy, osteoporosis, premature rupture of membranes and small-for-gestational-age babies."

However, Dr. Basraon also points out that because of their quick action, steroid medications can be useful to control acute arthritis flare-ups during pregnancy.

"Glucocorticoids can be used instead of non-steroidal agents in the third trimester. Stress doses of steroids should be used during labor and delivery if the mother received steroids – even low doses – for more than two to three weeks during pregnancy, and the [newborn] should be monitored for evidence of adrenal insufficiency and infection," says Dr. Basraon.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

There are a number of DMARDs used to treat rheumatoid arthritis, and the degree to which they affect pregnancies varies.

Examples of conventional DMARDs include:

  • Aralen (chloroquine)
  • Plaquenil (hydroxychloroquine)
  • Azulfidine (sulfasalazine)
  • Azasan (azathioprine)
  • Rheumatrex (methotrexate)

According to Dr. Basaraon, there seems to be no increased risks associated with using chloroquine or hydroxychlorquine during pregnancy; that is, if they are taken at doses commonly used for rheumatoid arthritis. As such, these two medications are considered safe to use in pregnancy and breastfeeding.

Dr. Basaraon notes that hydroxychloroquine is preferred over chloroquine because there is more evidence about its use during pregnancy.

The picture seems similar for sulfasalazine: according to the available evidence, there appears to be no increased risk of use during pregnancy. However, sulfasalazine may affect folic acid levels, so pregnant women taking the medication may need folic acid supplementation.

Both azathioprine and methotrexate have been associated with certain birth complications. Methotrexate specifically may lead to toxic effects on the embryo, miscarriage and malformations of the fetus.

"If a patient contemplates pregnancy and is on methotrexate, the recommendation is to discontinue use three months prior to conception, as its active metabolites (substances produced during digestion or other bodily chemical processes) remain in tissue for several months," says Dr. Basraon.

Tumor Necrosis Factor (TNF) Inhibitors

Common anti-TNF medications used by rheumatoid arthritis patients include:

  • Enbrel (etanercept)
  • Remicade (infliximab)
  • Humira (adalimumab)
  • Rituxan (rituximab)
  • Actemra (tocilizumab)

Etanercept, infliximab and adalimumab are considered category B – meaning studies on animals have shown no increased risks but data on humans remain lacking.

Dr. Basraon says that there have been individual reports showing positive outcomes in pregnant women using anti-TNF medications, with rates of miscarriage and birth defects similar to that of the general population.

There have been reports of neonatal lymphopenia (low levels of certain white blood cells) in babies exposed to rituximab in the second or third trimester of pregnancy. However, the condition seems reversible within a few months after birth.

"Use [of rituximab] should be discontinued 12 months prior to conception," Dr. Basraon recommends.

How can rheumatoid arthritis medications affect delivery?

With the help of trained healthcare professionals, women with rheumatoid arthritis can reduce the risk of arthritis-related complications during pregnancy. However, the joint pain and involvement of rheumatoid arthritis may get in the way during delivery.

According to Dr. Basraon, "A multidisciplinary team including specialists in maternal fetal medicine, rheumatologists and obstetric anesthesiologists should be involved in the management of pregnancy in patients with rheumatoid arthritis.

"In patients with severe articular involvement (joint involvement), especially if patients have epidural or spinal anesthesia (medical numbing of an area of the body), forcing joint motion in the hip, knee or neck during labor…can cause fractures or joint injury without the patient feeling pain."

How can women prepare for the potential risks of pregnancy with rheumatoid arthritis?

Any woman who is pregnant or planning on getting pregnant should work with a pregnancy specialist. And women with rheumatoid arthritis need extra special care.

Even well before getting pregnant, women with rheumatoid arthritis should be aware of the impact their medications may have on their babies and themselves. They must plan for their pregnancies far ahead so they have time to quit potentially harmful medications.

"Appropriate family planning with pre-pregnancy counseling is necessary, given the [risk of birth defects] associated with some rheumatoid arthritis treatments," says Dr. Basraon. "Counseling regarding effective contraception and the length of time drugs should be discontinued before safely attempting conception is required."

Dr. Basraon continues, "In the event of unplanned conception while on rheumatoid arthritis drug therapies considered high risk, immediate discontinuation of the medications and referral to a high-risk obstetrician for monitoring and review of options is recommended. These patients may need a reminder about the importance of using contraception during therapy with DMARDs."

Talk to your doctor if you have rheumatoid arthritis and are planning on getting pregnant. Open communication with your doctor and other healthcare specialists can help you on the road to a successful pregnancy.

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