Rheumatoid Arthritis & Pregnancy
This guide aims to cover some of the common concerns that women with rheumatoid arthritis (RA) may have over various pregnancy issues from conception, controlling disease during pregnancy through to the birth and breastfeeding. It is important to remember that while RA may affect your pregnancy and its outcome, pregnancy itself will also affect your RA. In the past there were concerns that RA might affect the ability to conceive, but if the disease is well controlled, most women with RA can have an enjoyable and successful pregnancy.
As with any normal pregnancy, planning ahead is important and you should discuss your plans as early as possible with your rheumatologist. Following a healthy lifestyle will increase your chances of conceiving and reduce potential problems during pregnancy. The risk of foetal loss or genetic abnormalities for women with RA is not significantly greater than for any other pregnant women. All women who are pregnant or planning a baby should take folic acid supplements (0.4mg/day) to decrease the risk of spina bifida and this can be especially important if you have been treated with drugs such as methotrexate.
Some of the drugs used to treat RA can be maintained while trying to conceive but several should be avoided as they are known to affect fertility. Also some drugs may have to be stopped for a while before trying to conceive to ensure they are eliminated from the body, such as leflunomide which can remain in the body for up to 2 years. A number of drugs (for example methotrexate or sulfasalazine) may also reduce sperm count so it is also important for men with RA to consult their GP/rheumatologist before trying for a baby. Guidance for doctors about the use of arthritis drugs during pregnancy have been updated in 2016 by the British Society for Rheumatology and the advice below is in keeping with these guidelines.
RA during pregnancy
Many women, up to 75%, find that the pain and swelling associated with RA is much improved during pregnancy, usually in the second trimester (14-27 weeks) and this is probably due to the normal hormonal changes in pregnancy. This temporary remission normally continues throughout the course of the pregnancy. During the later stages of pregnancy, swelling, backaches and tiredness are common for many women regardless of their RA status. It is important that these normal pregnancy symptoms are not mistaken for RA problems but equally discussed with your doctor and/or midwife if you have any concerns.
Use of drugs in pregnancy
Most drugs are labelled ‘not for use in pregnancy’ as many are not tested in pregnant women so it is difficult to guarantee safety especially with the newer drugs where the number of pregnancies studied is still low. In addition any animal studies that may have been carried out may not be applicable to humans. Although you may be concerned about the possible harmful effects of taking RA drugs while pregnant, it is important to remember that uncontrolled arthritis during pregnancy can also have adverse effects on your baby such as low birth weight.
As arthritis will vary between individuals it is always advisable to speak to your GP/rheumatologist about your situation and always to consult him/her before you stop any drugs. Some of the concerns about the common drugs used to treat RA are listed below.
Non Steroidal Anti-inflammatory Drugs (NSAIDs) (e.g. ibuprofen, naproxen)
Many women and men take NSAIDs for relief of pain and stiffness associated with RA. These drugs are considered safe to take while trying to conceive but the general advice is for women to avoid these drugs during the first trimester of pregnancy, as there is some evidence they may be associated with miscarriage. They are safe to take in the second trimester but should be avoided after week 32 as they may interfere with the way your baby transitions from a mother’s blood supply to their own in preparation for birth. They are safe to take while breastfeeding and many women find them beneficial to treat any pain after childbirth (i.e. following caesarean section). Men do not need to avoid NSAIDs at any time while their partners are trying to conceive.
Selective Cox-2 Inhibitors (e.g. celecoxib, etoricoxib)
Some women and men will be prescribed Cox-2 inhibitors instead of NSAIDs. There is no good quality data about their safety during conception, pregnancy or breastfeeding. Therefore, it is advised that both men and women avoid these medications while trying to conceive and women continue to avoid during pregnancy and while breastfeeding.
Corticosteroids (e.g. prednisolone)
Low to moderate doses of these can be safely used during pregnancy and are commonly used in normal pregnant women to mature the lungs of babies who may be born prematurely. However they have also been linked to premature rupture of membranes, increased risk of hypertension and increased risk of developing gestational diabetes (where blood sugar levels are too high). If you have been using steroids for a long time it is important to not stop them when you discover you are pregnant and instead consult with your GP/rheumatologist. It may be necessary to receive a ‘stress dose’ when the baby is born to reduce the flare-up of RA activity.
This drug is commonly used to prevent malaria and there are no known increased risks of abnormalities in babies and it is not thought to affect your fertility.
This drug has been used to control RA successfully in pregnancy although it has been linked to temporary infertility in men. Women should take folic acid alongside sulfasalazine while trying to conceive and throughout pregnancy. Men may consider stopping sulfasalazine if their partners are struggling to conceive as it may reduce their fertility, but it is not recommended that all men stop this treatment unless there seems to be a problem with conception.
This drug is best avoided during conception, pregnancy and breastfeeding because of harmful effects on eggs and sperm. It is associated with an increased risk of birth defects such as spina bifida and is also linked to an increased risk of miscarriage. It is advisable to stop taking this drug for at least three months before trying to conceive. Your folate levels may be reduced if you have been on this drug so taking folic acid supplements is important. Men should discuss whether to stop MTX prior to trying to conceive with their rheumatologist.
There are now many different biologic drugs available to treat arthritis including the anti-TNF drugs (etanercept, infliximab, adalimumab, certolizumab pegol and golimumab) as well as other biologic drugs such as tocilizumab, abatacept and rituximab. A recent study has shown that women who became pregnant while on anti-TNF agents did not suffer any increased risk to themselves or their baby, although most of these women stopped their medication once they realised they were pregnant. The most recent British guidelines state that women can continue most anti-TNF drugs until the end of pregnancy week 16. They should be avoided later in pregnancy (after the second trimester) as they do cross into the baby during the later parts of pregnancy. If you do receive anti-TNF drugs later in pregnancy, ensure your baby’s GP, paediatrician and health visitor are aware of this as it could affect some of the vaccines your child may need to receive.
The information on the effects of some of the other biologic drugs on pregnancy and fertility are largely unknown. It has been shown that, similar to patients with RA, babies who are exposed to Rituximab in the womb may also be born with low blood cell counts and it is currently recommended that women wait at least 6 months following their last dose of rituximab before trying to conceive.
Delivery and After
For many women with RA, labour is much the same as for any other normal pregnant woman. However there may be problems if your arthritis affects the hips or mobility and it is important to discuss any concerns with your midwife/consultant before the birth. There is some evidence that suggests that women with RA have a slightly increased risk of having a premature baby, are at an increased risk of having a caesarean section and may face a longer stay in hospital.
Many women find that their RA returns or flares up six to twelve weeks after delivery (because of hormone excesses in pregnancy returning to normal). Coping with a newborn baby can be tiring for all mothers and this may be more so for women with RA because of the additional worries of RA flaring up. It is important to have sufficient support and help during this period, from those around you as well as your GP/rheumatologist. Many women with RA will be anxious that their RA will be passed to their child; fortunately for most women the risk of their child developing RA is low.
There is no reason why you won’t be able to breast-feed your baby and even if it is only for a few weeks it is a healthy start to life. However as some drugs can pass through into the breast milk it is important to discuss which drugs are best to take with your GP/rheumatologist. It is also important to remember that in the long-term it may be better for you to take drugs to control your RA than not take them in order to breast-feed. More specific information on drugs while breast-feeding is available elsewhere on this website.
As arthritis will vary between individuals the most important thing is to plan ahead and discuss the pros and cons of drugs for your own situation with your GP/rheumatologist in order to achieve a happy and healthy pregnancy. However, if you do find that you have unexpectedly become pregnant while taking drugs for your arthritis, don’t panic and contact your GP/rheumatologist as soon as possible.
Professor Kimme Hyrich, MD PhD FRCPC, Arthritis Research UK Centre for Epidemiology, University of Manchester
Original article: 23/09/2004
Next review due: 04/05/2019