Rheumatoid arthritis and pregnancy
- Bonnie L Bermas, MD
Bonnie L Bermas, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Rheumatoid arthritis (RA) affects about 1 percent of adults, but the frequency varies depending upon the population studied. There is a female predominance in RA, and many female patients are of childbearing age . Thus, the management of RA during pregnancy is a common challenge. In many patients with RA, disease activity improves substantially in the gravid state. However, modification of treatment so as to minimize the potential for fetal toxicity while maintaining adequate disease control can be difficult in patients whose RA flares or remains active.
The influence of RA upon fertility and pregnancy, the influence of pregnancy upon the disease, and the management of RA during pregnancy and lactation will be reviewed here. The use of antiinflammatory and immunosuppressive drugs in patients with rheumatic diseases during pregnancy and lactation is discussed in detail separately. (See "Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation".)
EFFECT OF RA ON FERTILITY
Smaller family size has been observed in women with rheumatoid arthritis (RA). The reasons for this appear multifactorial, including patient choice, medication use during the usual period of family planning, and subfertility related to disease activity [2,3]. The relative importance of each potential factor has been difficult to determine [2-7]. As examples:
●In one structured telephone survey of 411 women with RA, 8 percent reported having been advised by medical professionals to limit family size, and 20 percent reported that having RA affected their decision to have children; concerns for carrying the child, caring for the child, and passing on RA to biologic offspring were cited as contributing reasons . In this same group, receiving the diagnosis of RA prior to the birth of the first child or receiving the diagnosis prior to age 18 were associated with fewer pregnancies and children; by contrast, women who were diagnosed with RA after age 30 did not report smaller family sizes compared with the reference population. Similarly, in a registry-based study from Norway, women with RA who did not have children prior to diagnosis were less likely to become pregnant than controls at the end of the observation period .
●In another survey involving 578 women with RA, patients were asked about the number of pregnancies, live births, miscarriages, and pregnancy terminations they had had . Over half (55 percent) of the patients had fewer pregnancies than intended; of these women, 42 percent cited infertility as a reason and the remainder limited the number of pregnancies because of arthritis-related concerns, which included the ability to care for children, the concern that the disease activity would be impacted, and concerns about passing on the susceptibility to RA to their offspring.
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- EFFECT OF RA ON FERTILITY
- Immunology of pregnancy
- EFFECTS OF PREGNANCY ON DISEASE ACTIVITY
- Disease activity during pregnancy
- Postpartum flare
- MANAGEMENT OF RA DURING PREGNANCY AND LACTATION
- Medication use during pregnancy
- - Moderate to high risk of fetal harm
- - Selective use allowed during pregnancy
- - Minimal fetal and maternal risk
- Treatment approach
- - Prior to pregnancy
- - Routine management during pregnancy
- - Persistent or flaring disease activity
- Medication use during breastfeeding
- PREGNANCY OUTCOME
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS