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Pregnancy and RA

Nicole Droz, MD

Rheumatologist & Associate Medical Director, Musculo.

Rheumatoid arthritis is an autoimmune condition that can cause swelling, pain and inflammation in the joints.  While rare, it can affect other organs in the body as well. RA is more common in women and is usually diagnosed during child bearing years.  The disease can present unique challenges from family planning to birth which will be outlined in the following sections. 

Family Planning:

It is very important to have an in depth discussion with your rheumatologist before becoming pregnant.  Many medications, such as methotrexate and leflunomide, cannot be taken during pregnancy and can cause severe birth defects.  Prior to conception, medications should be optimized and disease should be in remission.  Women who have controlled disease prior to conception tend to remain in remission throughout pregnancy and have healthier babies. Disease should be in remission for at least 3-6 months prior to getting pregnant.  The good news: with careful planning most women have successful pregnancies.

 

Fertility:

Women

Several studies have demonstrated that women with RA have fewer children than those without RA.  Women with RA, especially those with active disease, may have difficulty conceiving and have been shown to access fertility treatments more often than those without RA.  Infertility rates may be up to 2 times higher as compared to women without RA.1 Time to conception is also longer in people with RA and can be as high as 12 months or more.2,3

Many factors may be responsible for this delayed time to conception including active RA and medications (like NSAIDs or high doses of steroids).4

In any conversation about fertility, it is important to recognize other disease related symptoms which may interfere with sexual desire.  Pain, fatigue, mental health conditions and other factors can decrease sexual desire and rate of conception.5

Men

Certain medications used to treat RA may make it more difficult for a man to father a child. For example sulfasalazine can reduce sperm count.  Fortunately, this side effect is reversible when the medication is stopped.  If a man is having fertility problems while taking this medication, a discussion with the prescribing rheumatologist should occur.  Although birth defects have been reported in women taking certain medications for RA, there is no evidence to support birth defects in children of men taking medications for RA. 

 

Pregnancy:

A fetus is made from 50% paternal DNA and 50% maternal DNA.  A healthy, functioning immune system needs to identify any non-self proteins in order to fight off infections.  During the normal process of pregnancy, the immune system down-regulates to protect the fetus from maternal rejection.

The good news: because of this down-regulation of the immune system, many women tend to have improvement of their RA symptoms, even in the setting of reduction or modification of their RA specific medications.6

 

Disease changes during pregnancy:

In women with well-controlled RA, pregnancy outcomes are similar to those in the general population (normal birth weight, term deliveries, low risk of C-sections) highlighting the importance of optimal disease control and close follow up with rheumatologists throughout pregnancy.7

Pregnant women with active RA symptoms have been found to have a higher prevalence of maternal high blood pressure, preterm delivery and C-sections.8

 

Postpartum Challenges:

After delivery, mothers with RA are at risk for disease flares. Flares can occur in up to 50% of patients in the postpartum period.9  This may be triggered by hormonal changes and increases in pro-inflammatory molecules.

 

Medication considerations:

Several medications should be avoided during pregnancy or breastfeeding due to risk of birth defects or side effects to the infant.  Methotrexate and leflunomide should not be taken during pregnancy or while breastfeeding. Steroids should be tapered to the lowest possible dose.  Many biologics have not been adequately studied in pregnancy so close collaboration with your rheumatologist is vital for choosing the best medication regimen during pregnancy and the postpartum period.10

With careful prenatal care, moms-to-be with well-controlled RA are as likely to have a healthy pregnancy and baby as those without the condition. As the research shows, odds are also good that your symptoms will improve while you’re expecting. Ask your physician about any potential side effects of the medications you’re taking and any other questions you might have as your pregnancy progresses.

 

 

Please click here for references:

  1. Clowse ME, Chakravarty E, Costenbader KH, Chambers C, Michaud K. Effects of infertility, pregnancy loss, and patient concerns on family size of women with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care Res 2012; 64:668e74.
  2. Skomsvoll JF1, Ostensen M, Baste V, Irgens LM. Number of births, interpregnancy interval, and subsequent pregnancy rate after a diagnosis of inflammatory rheumatic disease in Norwegian women. J Rheumatol 2001 Oct;28(10):2310e4.
  3. Jawaheer D, Zhu JL, Nohr EA, Olsen J. Time to pregnancy among women with rheumatoid arthritis. Arthritis Rheum 2011; 63(6):1517e21.
  4. Littlejohn EA. Pregnancy and rheumatoid arthritis. Best Pract Res Clin Obstet Gynaecol. 2020;64:52-58. doi:10.1016/j.bpobgyn.2019.09.005
  5. Helland Y, Dagfinrud H, Kvien TK. Perceived influence of health status on sexual activity in RA patients: associations with demographic and disease related variables. Scand J Rheumatol 2009;37:194e9.
  6. Förger F, Villiger PM. Immunological adaptations in pregnancy that modulate rheumatoid arthritis disease activity [published correction appears in Nat Rev Rheumatol. 2020 Mar;16(3):184]. Nat Rev Rheumatol. 2020;16(2):113-122. doi:10.1038/s41584-019-0351-2
  7. De Man YA, Hazes JMW, Van Der Heide H, Willemsen SP, de Groot CJ, Steegers EA, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. Arthritis Rheum 2009;60:3196e206.
  8. Kishore S, Mittal V, Majithia V. Obstetric outcomes in women with rheumatoid arthritis: results from nationwide inpatient Sample database 2003-2011. Semin Arthritis Rheum 2019 Mar 23;(18):30633e4. pii: S0049-0172.
  9. Jethwa H, Lam S, Smith C, Giles Ian. Does rheumatoid arthritis really improve during pregnancy? A systematic review and metaanalysis. J Rheumatol March 2019;46(3):245e50.
  10. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and musculoskeletal diseases [published online February 23, 2020]. Arthritis Rheumatol. doi:10.1002/art.41191