If you have rheumatoid arthritis (RA) and are thinking about starting a family, you probably have lots of questions and concerns. Will your RA affect your chances of getting pregnant? Are your medications safe during pregnancy? What if you decide to stop taking them? Will your RA flare?
These are all questions that need to be discussed with your rheumatologist, preferably in advance of becoming pregnant, says Shreyasee Amin, MD, a rheumatologist at the Mayo Clinic in Rochester, Minn.
RA, an autoimmune disease in which the body engages in friendly fire against its own joints, primarily strikes women of childbearing age. The good news is that unlike other autoimmune diseases, RA does not seem to affect a woman’s fertility or ability to have a healthy pregnancy. Your symptoms may even get better during pregnancy, but they may flare about three months after delivery (right around the time that the sleep deprivation from having a newborn kicks in).
“Unless you have other RA complications such as lung or hip involvement, the RA should not affect your ability to become pregnant, carry the baby to term, and deliver naturally,” Amin says. That said, a little medication counseling goes a long way toward achieving these goals, she says.
Take Stock of Your Medications
“Women with RA need to work with their obstetrician and rheumatologist to make sure they are on safe medications prior to conceiving, and if they are not, they need to change or discontinue their medications based on their disease activity and preferences,” she says.
Some RA medications that pregnant women should not take include methotrexate and Arava (leflunomide). Women must be off these drugs for a period of time before even becoming pregnant. Discuss the safety of other medicines such as azathioprine (Imuran), hydroxychloroquine (Plaquenil), prednisone, and sulfasalazine, and with your doctor. The jury is out on some of the newer biologic agents such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade), Amin says.
What if you don’t feel comfortable taking medication while you are pregnant? “Some women do wish to discontinue their medication altogether, and I discuss the risk of a potential flare with them, but I also explain that there is a chance that their disease may improve while pregnant,” says Amin. Doctor's don't really know exactly why RA tends to go into remission during pregnancy, but it's common.
That’s not to say you will feel great for your entire pregnancy. But if your back aches or your ankles swell, don’t assume the worst, Amin says. “These symptoms may just be part of a normal pregnancy.”
First, Do No Harm
Bonnie Soos, a 32-year-old schoolteacher in Adina, Ohio, was diagnosed with RA 11 years ago. She has spent the better half of the last two years trying to get pregnant.
“I had to get off methotrexate and be off of it for three months before I could start trying,” Soos says. She also had knee surgery around this time. “As soon as I went off methotrexate, I started to flare and could not function,” she recalls. “I couldn’t get dressed or lift my arms. I dreaded getting out of bed in the morning.”
Unfortunately, this can be a fairly common scenario, explains Amin. And it’s definitely one that gets a woman out of the mood to try and get pregnant. “Who wants to try and conceive while in so much pain?” Soos asks.
She took prednisone for a while, and was recently switched to another medication that's safe to take while trying to conceive. “I have been feeling wonderful ever since,” she says.
For some women, waiting until their RA is under control before trying to get pregnant may be a smart choice, says Emilio B. Gonzalez, MD, chief of rheumatology at University of Texas Medical Branch in Galveston, Texas. “I sit down and tell them that many treatments for RA are not compatible with pregnancy and if they are really suffering, perhaps the priority is to get the RA under control and then start planning their family at a later date,” he says. “If you have RA, it doesn’t mean you should not get pregnant, but it can be a challenge to manage the RA before and after pregnancy.”
If your RA is under good control before pregnancy, there is a good chance it will stay that way.
Managing RA Flares During Pregnancy
For women who choose to stay off any medication during their pregnancy, “We monitor the pregnancy to see if they have flares, [and] we can use medications that are safe to manage these flares,” Amin says.
While prednisone is safe during pregnancy, it may increase an expectant mom's risk of high blood sugar and high blood pressure, so you'll need to monitor levels closely. High blood pressure in pregnancy is a risk factor for preeclampsia, which can be a life-threatening condition. High blood sugar may mean gestational diabetes. Steroids also increase risk of bone loss.
None of this means that a women with RA is necessarily considered high-risk, she says. “The pregnancy can be followed by a regular obstetrician," Amin says. "However, if the obstetrician is uncomfortable with medications, a woman may wish to be followed by a high-risk obstetrician."
Many pregnant women with RA work closely with both their obstetrician and their rheumatologist to manage their pregnancy. “If the obstetrician isn’t sure if it’s a flare or not a flare, they can consult with the rheumatologist,” says Manju Monga, MD, the Berel Held Professor and the division director of maternal-fetal medicine at the University of Texas.
Some issues may arise, but they can usually be dealt with in advance, she says. For example, the use of an epidural during delivery may pose a problem for women whose RA affects their spine, Monga says. “This is rare, but it is a good idea to consult with an anesthesiologist in the event that they need a general anesthesia instead of a spinal,” she says.
All in all, the prognosis is good, Monga says. “In general, patients with RA do really well with pregnancy,” she says.