Planning a pregnancy with rheumatoid arthritis

This review discusses the importance of pregnancy planning and disease management during pregnancy in women with rheumatoid arthritis.

Though rheumatoid arthritis can affect both genders, it is more often diagnosed in women, particularly those in their 30s and 40s. Because many treatments for rheumatoid arthritis are not safe during pregnancy, it is vital that patients discuss contraception and pregnancy with their physicians. Good outcomes for both mother and infant are more likely if the patient understands how best to manage their disease, contraception and pregnancy. This review outlines the considerations for women with rheumatoid arthritis during their child-bearing years.

Patients with rheumatoid arthritis experience a series of flares and remissions; times when the joints are swollen and painful (a flare, or high disease activity) and times when the disease is not active (remission, or low disease activity). It would be ideal for rheumatoid arthritis patients to plan their pregnancies for times when disease activity is low. While many women see a decrease in disease activity during pregnancy, those patients with active disease at conception are more likely to have disease activity during pregnancy and the post-partum period.

Many women, though, do see an improvement in their symptoms. Rheumatoid factor and anti-citrullinated protein antibody are two antibodies (substances produced by the immune system to fight against invading organisms, or, in rheumatoid arthritis, against healthy joint tissue) often present in rheumatoid arthritis patients. One study found that 75% of patients who were negative for these antibodies saw improvement in symptoms during pregnancy, compared to only 39% of patients who had produced these antibodies. 

While some studies have found higher rates of negative outcomes, such as preeclampsia (high blood pressure), preterm birth, or small-for-gestational-age infants, other studies have not found these correlations, particularly in patients whose disease is well-controlled. Rheumatoid arthritis itself has not been associated with an increase in birth defects, however, it is important to monitor and possibly alter treatments prior to and during pregnancy, as many drugs, including methotrexate (Trexall) and tumor necrosis factor-inhibitors, can increase the rate of miscarriage and birth defects. It is recommended that patients who are treated with methotrexate use contraception.  While there are treatments compatible with pregnancy, rapid changes in treatment can lead to flares, therefore it is ideal to make slow changes prior to pregnancy.

A post-partum (post-childbirth) disease flare can be experienced by 50–70% of patients, generally within 6 months of delivery. The increase in disease activity often necessitates treatment being restarted.

This review suggested that a healthy pregnancy is possible for rheumatoid arthritis patients, however, consideration of disease activity and treatments should be taken before trying to conceive. 

Consult with your physician regarding contraception and treatment prior to pregnancy.