Bonnie L Bermas, MD
RN Maini, BA, MB BChir, FRCP, FMedSci, FRS
Paul L Romain, MD
INTRODUCTION — Rheumatoid arthritis (RA) affects one 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 being prepared for pregnancy, using birth control unless pregnancy is desired, and being monitored frequently during pregnancy.
In many women with RA, disease activity improves substantially during pregnancy. However, some women’s RA flares or remains active during pregnancy. It is often necessary to change or modify treatment of RA during pregnancy to control flares and/or to minimize the risks of some RA treatments to the developing fetus.
A number of other topics about rheumatoid arthritis are available separately. (See “Patient information: Rheumatoid arthritis symptoms and diagnosis” and “Patient information: Rheumatoid arthritis treatment” and “Patient information: Disease modifying antirheumatic drugs (DMARDs)”.)
CHANGES IN RHEUMATOID ARTHRITIS DURING PREGNANCY — Many changes normally occur during pregnancy, which allow a fetus to grow and develop. Some of these changes contribute to the improvement of RA symptoms during pregnancy.
Disease activity during pregnancy — Approximately 70 to 80 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 for a number of weeks or months into the postpartum period. The severity of a woman’s RA before pregnancy cannot predict if she will improve 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 RA should discuss their desire to become pregnant with a rheumatology and 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 non-prescription medications for rheumatoid arthritis, 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; it is best to allow one to three full menstrual cycles to pass before attempting pregnancy. Men who take methotrexate should stop it for at least three months. 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 who may become pregnant are advised to 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 consider 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 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 has not been studied well, so the 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.
For some patients, the benefits of the drug in controlling disease and 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 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 information: Deciding to breastfeed”.)
Medications and breastfeeding — Many of the same restrictions on medication use during pregnancy apply also to breastfeeding mothers :
- 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 TNF inhibitors, such as etanercept, infliximab, or adalimumab, during breastfeeding. 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 (file://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT).
Several topic reviews about breastfeeding are available separately. (See “Patient information: Deciding to breastfeed” and “Patient information: Common breastfeeding problems” and “Patient information: Breast pumps” and “Patient information: Maternal health and nutrition during breastfeeding”.)
Birth control and rheumatoid arthritis — Within a few weeks after delivering an infant, 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 information: Birth control; which method is right for me?”.)
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 every four months 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:
Patient information: Rheumatoid arthritis symptoms and diagnosis
Patient information: Rheumatoid arthritis treatment
Patient information: Disease modifying antirheumatic drugs (DMARDs)
Patient information: Deciding to breastfeed
Patient information: Common breastfeeding problems
Patient information: Breast pumps
Patient information: Maternal health and nutrition during breastfeeding
Patient information: Birth control; which method is right for me?
Professional Level Information:
Rheumatoid arthritis and pregnancy
Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation
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.