Rheumatoid Arthritis and Pregnancy

What to expect during your pregnancy.

By Mary Anne Dunkin

If you have RA and decide you want to start a family, you probably won’t have any more trouble getting pregnant than other women. As many as one in five couples have difficulty conceiving, regardless of any known medical condition. Although some studies show that women with RA have fewer children than otherwise healthy women, that may represent a choice to limit family size rather than a reduced ability to conceive or carry a baby to term. A 2006 study by researchers at the University of California, San Francisco, found that women with diagnosed with RA before the birth of their first child had the fewest pregnancies and children.

Before you try to conceive, it’s important that you speak with your doctor about the medications you're taking.  Some can affect an unborn child from the very earliest days of pregnancy and because the effects of certain drugs can remain in the body for a period of time after you stop taking them, ideally, you should work with your doctor to taper off harmful medications – and perhaps switch to less risky medications (See “Arthritis Medications in Pregnancy: What’s Safe, What’s Not.”) – for at least a few months before you try conceive.

Before you get pregnant is also the best time to speak to your doctor about prenatal vitamins and supplements of folic acid, which can help reduce the risk of certain birth defects.

First Trimester

If you unexpectedly find yourself pregnant and haven’t spoken with your doctor about medications – now is the time. Some drugs, such as leflunomide (Arava) and methotrexate can cause birth defects. If you’re taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or ketoprofen, your doctor may let you continue to using them – at least for a while. The greatest risk of these drugs comes later in pregnancy, when they may interfere with labor, affect amniotic fluid production or cause excessive bleeding during delivery. If you need medications to keep your disease under control, your doctor may put you on a corticosteroid, such as predisone, that reduces arthritis inflammation but crosses through the placenta only minimally.

One of the first symptoms of pregnancy for any woman is fatigue. For women who already experience fatigue with rheumatoid arthritis, fatigue may worsen. Otherwise, pregnancy should have little effect on arthritis during this trimester; nor should arthritis have any effect on pregnancy. If you have relatively mild disease during the first trimester, there’s good news: your disease is likely to remain mild through pregnancy, according to a 2008 study conducted by researchers in the Netherlands and reported in Arthritis & Rheumatism. If your disease is active during the first trimester, there’s a good chance it will improve a little later in your pregnancy.

Second Trimester

Approximately 70 percent of women with RA experience an improvement in symptoms beginning in the second trimester and lasting through about the first six weeks after delivery, says J. Bruce Smith, MD, assistant compliance officer for research at Thomas Jefferson University in Philadelphia and a rheumatologist whose research has focused largely on autoimmune disease and pregnancy. Fatigue may improve as well.

There are a number of theories why disease symptoms improve, including increased levels of anti-inflammatory cytokines and hormonal changes that occur during pregnancy. Researchers are continuing to study the phenomenon.

Exactly why some women with improve while others don’t is unknown, but a new study out of the Netherlands shows that women who are negative for rheumatoid factor and a type of autoantibody called anti-CCP are more likely to improve during pregnancy. Research also suggests that the father’s genetic contribution may play a role. The more genetically dissimilar a baby is to its mother, the better – at least as far as the mother’s disease goes.
 

Third Trimester

If your disease was mild to start with or improved during the second trimester, it will likely stay mild through the third trimester. However, fatigue may become worse as you grow heavier and closer to delivery.

Labor and Delivery

Having rheumatoid arthritis may slightly increase your risk of a premature baby, but does not increase your risk of having a baby with low birth weight, according to a 2006 study by researchers at the University of Washington, Seattle.

Women with RA are also more likely to have their babies delivered by Cesarean section. “Any form of arthritis that involves the hips may make vaginal delivery difficult,” says Michael Lockshin, MD, professor of medicine and Ob/Gyn at Weill Cornell Medical College and director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York “The biggest problem is that you have to be able to spread your legs fairly wide. A baby is a pretty big package to get through there.” For that reason, women with arthritis – even if their disease is inactive and their pregnancy uncomplicated – may be more likely to deliver by C-section.

Infection is a possibility after any delivery. If you are taking medications that suppress your immune system, however, infection is more likely. Most infections can be cleared up fairly easily and quickly with available antibiotics.

Postpartum

If you’ve enjoyed milder disease during your pregnancy, be prepared for your disease to worsen again – at least for a while – after you deliver. Many women with RA experience flares of their disease in the weeks following pregnancy. You may be having to deal with a disease flare at the same time you are trying to recuperate from childbirth and adjust to parenthood.

After you deliver, it is important to discuss medication choices with your doctor again, particularly if you plan to breast feed. Certain medications may interfere with breast feeding – either because they suppress milk production or pass through the breast milk and are unsafe for the baby.