If you have rheumatoid arthritis and are planning to start a family, you may be wondering how RA will affect you and your baby during pregnancy.
Since about 1.5 million people in the U.S. have this chronic inflammatory condition and it affects women nearly three times as frequently as men, according to the Arthritis Foundation, you’re certainly not alone in facing pregnancy with RA.
Getting Pregnant with RA
There’s good news when it comes to getting pregnant with RA: Although the condition tends to strike women at a higher rate during their childbearing years, those with RA typically don’t have any more trouble conceiving than those without the disease, according to the Arthritis Foundation.
Generally, about 1 in 5 couples have difficulty getting pregnant, regardless of any medical conditions, and these numbers hold true for couples in which the woman suffers from RA.
More good news: The risks of pregnancy loss and genetic abnormalities are not any greater during an RA pregnancy, according to the National Rheumatoid Arthritis Society.
If you are planning to get pregnant, you should speak with your rheumatologist and obstetrician as early as possible to make sure your lifestyle and medications are compatible with a healthy pregnancy.
Having this chronic condition well under control from the start and having a healthy lifestyle in place will help to minimize any pregnancy and postnatal complications.
Most doctors recommend that RA be under control, without rheumatic flares, for at least three to six months before a woman attempts to get pregnant.
There are other methods beyond medication that can be employed to manage the pain and other symptoms that often accompany RA, according to Everyday Health.
These tactics include weight management, which can help you to better manage joint pain; regular massages and exercise to help reduce muscle and joint pain; and orthoses, such as padded insoles for your shoes, that can help support and protect your joints.
Other popular methods include acupuncture and transcutaneous electrical nerve stimulation (TENS), which uses low-voltage electric currents to relieve pain.
Keep in mind that other factors in conjunction with RA may increase your chances of having a high-risk pregnancy.
According to the American College of Rheumatology, factors that may cause a pregnancy to be high-risk include having had a previous pregnancy with complications; underlying kidney, heart, or lung disease, including pulmonary hypertension; a history of blood clots; the presence of SSA and SSB antibodies; the use of in vitro fertilization to become pregnant; pregnancy with multiples; and the age of the mother being over 40.
RA Medications During Pregnancy
If you’re taking medication to control your rheumatoid arthritis, you may be concerned about its effects on your unborn baby.
Some types of RA drugs can harm your child during pregnancy, and some should be avoided for several months before you conceive, according to the Mayo Clinic. Still, there are other options available that carry a much lower risk.
Since there is limited information about their safety during pregnancy, doctors typically recommend avoiding biologic response modifiers, which include anakinra (Kineret), rituximab (Rituxin), abatacept (Orencia), tocilizumab (Actemra), and tofacitinib (Xeljanz).
The same goes for selective Cox-2 inhibitors, such as celecoxib and etoricoxib. There is not enough research available to give a clear answer on how these drugs affect pregnancy outcomes, both for the mother and her baby.
Even before you try to conceive, doctors also recommend stopping the use of leflunomide (Arava), as it can cause abnormal development or even death of the fetus.
Leflunomide is especially troublesome as it can remain in a woman’s body for several months after she has stopped the medication, so those who take this medication need to plan pregnancy well in advance.
According to a study done by the University of California and Rady Children’s Hospital in San Diego, though, women who underwent a cholestyramine elimination procedure meant to flush the leflunomide out of their system had a decreased risk of adverse pregnancy outcomes.
Methotrexate (Trexall), although commonly used to treat RA, is also not advised during pregnancy, according to the Mayo Clinic. This drug can cause miscarriage early in pregnancy as well as birth defects later on.
If you are taking one of these potentially harmful medications, talk to your doctor about switching to a different medication that is considered safe or less of a risk during pregnancy, such as a tumor necrosis factor (TNF) inhibitor or nonsteroid anti-inflammatory drug (NSAID).
Low to moderate doses of corticosteroids such as prednisolone can also safely be used during pregnancy, and it is important to continue the use of steroids during pregnancy if you have been taking them for a long time beforehand, according to the National Rheumatoid Arthritis Society.
Hydroxychloroquine and sulfasalazine have also been used successfully to control RA during pregnancy, although it’s suggested that women take folic acid alongside sulfasalazine while they are trying to get pregnant and throughout pregnancy.
For most women with RA, drug therapy for the condition is still possible during conception and gestation, and many doctors even recommend continuing medication throughout pregnancy, as the consequences of a rheumatic disease flare may be of greater concern than the effects of medication.
Work together with your rheumatologist and obstetrician to decide the best course of treatment for your personal situation.
RA Symptoms During Pregnancy
Up to 75 percent of women with RA report that symptoms of the condition such as pain and swelling are greatly reduced during pregnancy, and especially during the second trimester, according to the National Rheumatoid Arthritis Society.
The normal hormonal changes that accompany pregnancy are responsible for this remission of sorts, and the reduction of symptoms often carries through to the end of the woman’s pregnancy and even several weeks after she gives birth.
Interestingly, according to the Arthritis Foundation, the father’s genetic contribution may play a role in the amount of RA symptoms the mother experiences during pregnancy.
If the fetus is more genetically similar to its father, for example, the mother’s RA symptoms are often that much more improved.
On the other hand, some women may experience increased symptoms similar to their RA symptoms during the first and third trimesters.
However, these are often not caused by RA; rather, they are symptoms of pregnancy that mimic RA symptoms, such as fatigue, swelling, and backaches (especially during the third trimester, as the woman grows heavier).
Labor and Delivery
According to research by the Mayo Clinic, women with RA are somewhat more likely to give birth prematurely, and they also have a slightly increased risk of giving birth via Cesarean section.
Cesarean sections were especially more common among women who had moderate-to-high disease activity during pregnancy versus low disease activity.
The reason behind this may be that arthritis activity, especially in the hips, makes delivery difficult.
Some studies associate RA with low birth weight among babies, although this hasn’t been shown across the board.
Low birth weight does seem to be more common among women who have high disease activity in the third trimester of their pregnancy.
Women with RA who take medications that suppress the immune system are at increased risk for infection after delivery.
However, if the infection does occur, it is fairly easy to manage with the administration of antibiotics.
Postpartum and Breastfeeding
If your RA symptoms were reduced during pregnancy, you may unfortunately, experience a revival of these symptoms six to 12 weeks after you give birth, as your hormones return to normal, according to the Arthritis Foundation.
In a 2008 study, 39 percent of postpartum women with RA experienced at least one moderate rheumatic flare.
Taking care of a newborn baby while recovering from childbirth can be exhausting for any new mother, but women with RA may find this especially difficult if they experience a rheumatic flare simultaneously.
Keep this in mind as you plan your postpartum experience, as you may want to have extra help and support on hand, if possible.
You should also work closely with both your rheumatologist and obstetrician during the postpartum period to manage any flares and adjust your medication.
“We stress the fact that there are many challenges [after childbirth], including having to pick up a baby and to change diapers, and things like that.
So you need to come into that situation with eyes wide open,” says rheumatologist W. Hayes Wilson, M.D., in a video by CNN that spotlights one woman who has dealt with RA through four successful pregnancies.
“I think most women accept that there may be challenges, but they’re very willing to go ahead and accept those challenges in order to have a baby.”
It is especially important to discuss medication options with your doctor if you plan to breastfeed your child.
Leflunomide, methotrexate, and selective Cox-2 inhibitors should continue to be avoided during breastfeeding, as they can be transferred to your child through your breast milk and cause harm, according to the Arthritis Foundation.
Some drugs that are not safe during pregnancy, such as warfarin, are considered safe during breastfeeding, according to the American College of Rheumatology.
In fact, doctors recommend that women with a history of blood clots re-start the use of warfarin as soon as possible after the child is born, to lower their risk of developing blood clots following delivery.
As the symptoms and severity of RA will vary from individual to individual, it’s important to plan ahead and discuss both the benefits and potentially harmful side effects of drugs that may be relevant to your personal situation.