Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)
- Bonnie L Bermas, MD
Bonnie L Bermas, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editor
- 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
Rheumatoid arthritis (RA) affects 1 percent of the adults in the United States, with more women affected than men. Many women with RA are of childbearing age, which highlights the importance of careful family planning especially in patients who are taking medications or who have active disease.
In many women with RA, disease activity improves substantially during pregnancy. However, some women's RA flares up or stays active during pregnancy. Thus, it is often necessary to change or modify treatment of RA during pregnancy to control flares while minimizing the risks of RA treatments to the developing fetus.
A number of other topics about RA are available separately. (See "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)".)
CHANGES IN RHEUMATOID ARTHRITIS DURING PREGNANCY
Many changes to the immune system occur normally during pregnancy. These changes enable a fetus to grow and develop. Some of these changes contribute to the improvement of rheumatoid arthritis (RA) symptoms during pregnancy.
Disease activity during pregnancy — Approximately 50 to 60 percent of women with RA notice improvement of RA signs and symptoms during pregnancy. The decrease in disease activity generally starts in the first trimester and lasts through delivery. Unfortunately, we cannot predict which patients will get better during pregnancy.
It is sometimes difficult to distinguish between the common discomforts of pregnancy and the symptoms of RA. Pregnancy discomforts that are similar to those of RA include the following:
●Swelling of the hands, feet, or ankles
●Joint pain, especially in the low back
●Shortness of breath
●Numbness or pain in one or both hands (caused by carpal tunnel syndrome of pregnancy)
Pregnancy outcome — Most reports show that there is no increase in stillbirth or miscarriage in women who have RA. However, some medications, particularly high-dose steroids, may increase the risk of having a smaller than normal infant and may increase the risk of premature rupture of the membranes.
CARE BEFORE PREGNANCY
Women with rheumatoid arthritis (RA) should discuss their desire to become pregnant with an arthritis specialist (rheumatologist) and an obstetrical care provider before trying to become pregnant.
General recommendations that apply to all women who are considering pregnancy can be found separately. In addition:
●If a woman takes prescription or nonprescription medications for RA, these should be reviewed with a healthcare provider. Some medications are safe during pregnancy while others are not. In some cases, an alternate medication can be substituted for an unsafe drug.
●Women who take methotrexate should stop it at least one month before trying to conceive, although it is best to allow one to three full menstrual cycles to pass before attempting pregnancy. This waiting period is necessary to allow the effects of methotrexate on the body to pass so that it will be safe to become pregnant.
●Women who take leflunomide must stop it for at least two years before trying to conceive, unless a course of treatments to eliminate the drug from the body is used. Thus, women of childbearing potential should discuss use of this medication with their arthritis specialist.
Am I ready for pregnancy? — It is common for women with long-term medical problems to be worried about how their health will be affected by pregnancy and parenting. Women with RA often have an improvement in symptoms of pain and fatigue during pregnancy, but then may have a worsening of these problems after delivery. Thus, it is important to be prepared for the changes that a new child may bring, including interrupted sleep, fatigue, stress, and anxiety. Close communication with an obstetric and a rheumatologic care provider, and support from family and friends, can help to ease the additional challenges of being pregnant and raising a child.
RHEUMATOID ARTHRITIS TREATMENT DURING PREGNANCY
Some women with rheumatoid arthritis (RA) flare during pregnancy and require treatment. However, some medications used in the treatment of RA can be harmful to the fetus. The benefit of any medication must be balanced with the potential risk.
Care during pregnancy — During pregnancy, care of women with RA is usually shared between a rheumatologist and an obstetrical provider.
Medications during pregnancy — The safety of RA medications during pregnancy and their effects on the fetus are not always clearly known. For each patient, the decision about which drugs to use will depend upon their response to treatment, the activity of their disease, their overall medical status, and other individual factors.
Methotrexate and leflunomide should be avoided completely during pregnancy, due to a significant risk of fetal harm. If a woman takes one of these medications during pregnancy, she should speak to her clinician immediately (see 'Care before pregnancy' above). Other medications may be taken more safely during one part of the pregnancy but not another, such as aspirin and nonsteroidal antiinflammatory drugs (NSAIDs).
For some patients, the benefits of the drug in controlling disease and in maintaining function may outweigh the possible risks to the mother or to the fetus. The use of any medication for arthritis during pregnancy is thus a matter that a patient and her rheumatologist should discuss, so that potentially dangerous medications can be avoided and the individual risks and benefits of any other drug can be carefully weighed. (See "Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation".)
RHEUMATOID ARTHRITIS AFTER DELIVERY
Approximately 90 percent of women with rheumatoid arthritis (RA) experience a flare during the postpartum period, usually within the first three months and particularly after a woman's first pregnancy . Many experts recommend restarting RA medications in the first few weeks after delivery.
Breastfeeding and rheumatoid arthritis activity — It is not clear if breastfeeding increases the risk of an RA flare. The postpartum period is a common time for women with RA to have a flare of the disease, so it is difficult to know if breastfeeding further increases this risk. However, there are numerous benefits of breastfeeding for both women and their infants. For these reasons, women with RA who want to breastfeed are encouraged to do so. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)
Medications and breastfeeding — Many of the same restrictions on medication use during pregnancy apply also to breastfeeding mothers :
●Nonsteroidal antiinflammatory drugs (NSAIDs) can be used, but aspirin should be avoided.
●Prednisone can be taken in low doses.
●Methotrexate, azathioprine, and cyclosporine should be avoided during breastfeeding. There is insufficient information available regarding the safety of tumor necrosis factor (TNF) inhibitors such as etanercept, infliximab, or adalimumab during breastfeeding, although many experts agree that minimal amounts, if any, of these medications will be absorbed by the stomach of a nursing infant. The quality of information regarding medication safety in breastfeeding varies. A reliable source of up-to-date information is LactMed, which is available from the National Library of Medicine (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT).
Several topic reviews about breastfeeding are available separately. (See "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient education: Maternal health and nutrition during breastfeeding (Beyond the Basics)".)
Birth control and rheumatoid arthritis — After delivering an infant, before resuming sexual relations, it is important to start thinking about birth control. A number of birth control options are available, most of which are safe and effective for women with RA. In most cases, RA should not affect which birth control method a woman chooses.
A full discussion of birth control options is available separately. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient education: Rheumatoid arthritis treatment (Beyond the Basics)
Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Maternal health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Birth control; which method is right for me? (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
●The Arthritis Foundation
●American College of Rheumatology
- Silman A, Kay A, Brennan P. Timing of pregnancy in relation to the onset of rheumatoid arthritis. Arthritis Rheum 1992; 35:152.
- Guidelines for monitoring drug therapy in rheumatoid arthritis. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:723.
- Nørgård B, Pedersen L, Christensen LA, Sørensen HT. Therapeutic drug use in women with Crohn's disease and birth outcomes: a Danish nationwide cohort study. Am J Gastroenterol 2007; 102:1406.
- Østensen M, Förger F, Nelson JL, et al. Pregnancy in patients with rheumatic disease: anti-inflammatory cytokines increase in pregnancy and decrease post partum. Ann Rheum Dis 2005; 64:839.
- Straub RH, Buttgereit F, Cutolo M. Benefit of pregnancy in inflammatory arthritis. Ann Rheum Dis 2005; 64:801.
- Barrett JH, Brennan P, Fiddler M, Silman AJ. Does rheumatoid arthritis remit during pregnancy and relapse postpartum? Results from a nationwide study in the United Kingdom performed prospectively from late pregnancy. Arthritis Rheum 1999; 42:1219.
- Soscia PN, Zurier RB. Drug therapy of rheumatic diseases during pregnancy. Bull Rheum Dis 1992; 41:1.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.