From healthcentral.com
From conception to postpartum, get the inside line on what happens when you’re pregnant with RA
From that positive pregnancy test to holding your newborn, having a baby can be a thrilling experience. But if you have a chronic condition like rheumatoid arthritis (RA), pregnancy can also be a challenge. Research shows that getting pregnant when you have RA might take longer than someone who doesn’t have the condition. And you have a higher chance for issues during pregnancy and childbirth, including an increased risk of caesarean delivery, preeclampsia, preterm birth, stillbirth, NICU admissions, and babies with a lower weight at birth, as one recent study reported. After the baby is born, if you’re breastfeeding you’ll need to pay close attention to what treatment you take for RA while also monitoring your condition for flares.
These are all common concerns of rheumatoid arthritis patients, says Ashima Makol, M.D., a rheumatologist at the Mayo Clinic in Rochester, MN, who has published on the topic. “I think one of the important things to understand is that rheumatoid arthritis is a chronic inflammatory autoimmune disease. It affects women two times more often than men, often in their childbearing years. So that means that it’s very important that women, but also men, understand pregnancy planning,” she says. “Because RA is not going anywhere, and more often than not, it requires medications to manage it.”
If you have RA and you’re considering having a baby, these are some of the things you should know, from planning a pregnancy to postpartum with the condition.
Planning a Pregnancy With Rheumatoid Arthritis
Ideally, women want their rheumatoid arthritis symptoms to be as stable as possible before becoming pregnant, says Stuart D. Kaplan, M.D., a rheumatologist and chief of rheumatology at Mount Sinai South Nassau in Oceanside, NY. Per the American College of Rheumatology (ACR), “women should not consider getting pregnant until their rheumatic disease is under control.”
Your doctor an monitor your RA progression through routine exams, bloodwork, and imaging tests to determine if the treatment that you’re on for rheumatoid arthritis is helping reduce inflammation and quiet your condition.
Can RA Cause Problems Conceiving?
One of the best ways to improve your odds for a successful pregnancy is something called a preconception consult with a health care professional. The ACR guidelines strongly suggest RA patients have preconception counselling. It can help you get a better picture of what you need to do to optimize your pregnancy success with RA—whether it’s changing medications, taking a little more time to get your condition under control, or other enhancing other related lifestyle factors.
The best doctor for this visit (and beyond) is known as a maternal foetal specialist (MFM). You might need this specialist while trying to conceive and throughout your RA pregnancy, to ensure that you and baby stay safe and healthy. During the visit, your MFM may suggest an extra ultrasound, more labs, and discuss current RA medications and symptoms, says Layan Alrahmani, M.D., a maternal fetal specialist who is board-certified in obstetrics and gynaecology and an assistant professor at Loyola University in Chicago. She is also chair of the Society for Maternal-Foetal Medicine communications committee.
Having this consult can be helpful because it’s unknown whether rheumatoid arthritis is related to infertility. Studies have found that people with rheumatoid arthritis use infertility treatment options more often than those without RA, Dr. Makol says. “But does that mean they have a high risk of infertility? It’s not completely clear,” she adds. Still, finding out more about pregnancy planning early on in the process might assist women with rheumatoid arthritis in knowing how long to try getting pregnant the old-fashioned way before seeking additional fertility help.
Risks of Premature Birth With Rheumatoid Arthritis
The reason that rheumatoid arthritis stability going into pregnancy is so important? Those with more active RA can have more pregnancy complications than those whose condition is more controlled, research finds.
In fact, women with poorly controlled rheumatoid arthritis have a higher chance of preterm delivery (delivering a baby before 37 weeks of pregnancy) and babies with low birth weight or smaller size than is typical. Both of these complications can raise the risk for health issues with your baby.
Risks of Preeclampsia With RA
Experiencing rheumatoid arthritis flares or active inflammation during pregnancy can also increase your risk of preeclampsia, a condition marked by high blood pressure and signs of liver and kidney damage that needs immediate treatment. C-sections can be more frequent in those with moderate to high disease activity at time of delivery, too—a surgery that comes with risks including infection, blood loss, and blood clots.
Meanwhile, research has shown that having RA well-controlled for three to six months before becoming pregnant might help reduce pregnancy complications. “Your best chance of having a successful pregnancy with rheumatoid arthritis is that your rheumatoid arthritis is stable and not active for six months prior to getting pregnant,” Dr. Kaplan says.
RA Medication and Pregnancy
Some 90% of pregnant women take at least one medication, but despite this, there is little research available on the effects of medication during pregnancy. Because of this, there’s not always clear evidence that a RA med is totally safe in pregnancy, and patients and their doctors have to “weigh the risks versus benefits” of treating RA symptoms or not during these nine months, Dr. Kaplan points out.
Leading rheumatoid arthritis societies, like the ACR, have guidelines for what medications should not be taken during pregnancy with rheumatoid arthritis. These are helpful recommendations for your doctor to follow, Dr. Makol says.
The RA meds you should not take while trying to get pregnant, during pregnancy, or while lactating are:
Acetaminophen: There’s some controversy over the use of this over-the-counter medication for reducing pain in pregnancy—so use the lowest dose for the shortest time if you need to use it, the Arthritis Foundation reports.
Corticosteroids: These include prednisone and prednisolone, and they’re a tricky category—some low doses appear to be safe, according to the ACR guidelines, but higher doses need to be lowered to 20 mg or less when possible because they’re associated with risks in pregnancy. Prednisone at a strength of less than 20 mg daily is likely safe while breastfeeding, the Arthritis Foundation says.
Janus kinase (JAK) inhibitors: These include Olumiant (baricitinib), Xeljanz (tofacitinib), and Rinvoq (upadacitinib). Targeted synthetic DMARDs are effective in RA treatment but are associated with an increased risk of birth defects in animal studies, so they aren’t recommended in pregnancy, the Arthritis Foundation reports.
Leflunomide: This disease‐modifying antirheumatic drug (DMARD) can effectively reduce RA symptoms and progression. But studies in animals have also found that it can increase risk of birth defects. It can take a long time to totally leave the body—possibly up to two years—so your doctor will likely need to give you a medication called cholestyramine to remove the drug fully from your system before conception. If you become pregnant without planning to while on this medication, cholestyramine is still recommended ASAP. It’s also not safe to take while breastfeeding.
Methotrexate: This DMARD is the most common treatment for RA, with excellent results. But those results come at significant risk: It’s “teratogenic,” which means it can cause birth defects, Dr. Makol says. It may also be abortive and shouldn’t be used by either women or men within three months of trying to conceive; it should also not be taken by women during pregnancy or postpartum if you’re breastfeeding. “Basically, methotrexate and pregnancy do not mix,” Dr. Kaplan says. If you’ve been taking methotrexate for RA and become pregnant without planning to, discuss next steps with your doctor for your specific situation.
NSAIDs: Prior to conception, these OTC meds, including ibuprofen, aspirin, and naproxen, might be stopped for women in order to not interfere with ovulation, according to the Arthritis Foundation. They also shouldn’t be used in the third trimester of pregnancy—and for other times, used only with caution. COX-2 inhibitor Celebrex (celecoxib) should be avoided in pregnancy. But men with RA can safely use NSAIDS, including celecoxib.
So where does that leave you? These are the medications that are considered safe/possibly safe with rheumatoid arthritis for conception, pregnancy, and postpartum:
Biologics: Biologics are tricky—there’s not a lot of info about their safety during pregnancy, so if you're a woman, consult your doctor about whether it’s OK for you to use them or not. For men, biologics typically used in RA treatment, including Rituxan (rituximab), Benlysta (belimumab), Kineret (anakinra), and Stelara (ustekinumab), are safe to use if your partner is trying to conceive, the Arthritis Foundation reports.
Hydroxychloroquine: An antimalarial agent, at the doses it’s used for RA patients, it appears to be safe, our experts say. It’s also likely safe if you’re breastfeeding.
Sulfasalazine: This dihydrofolate reductase inhibitor is considered safe during pregnancy for women, but might have issues for men with RA looking to conceive, so discuss with your doctor. Current medical guidelines support continuing its use throughout pregnancy, along with folic acid supplementation. It’s also likely safe to use if you’re breastfeeding.
Tumour necrosis factor (TNF) inhibitors: These include Enbrel (etanercept), Remicade (infliximab), Humira (adalimumab), Cimzia (certolizumab pegol), and Simponi (golimumab). These meds are considered relatively safe early in pregnancy but should be stopped (if possible) in the third trimester because higher amounts of medication passed through the placenta could suppress a newborn’s immune system, according to the Arthritis Foundation. (One drug of this class—certolizumab— is considered safe throughout pregnancy and during breastfeeding.)
How Does Pregnancy Impact RA Symptoms?
So you’ve seen those two lines on the pregnancy test: You’re pregnant. What’s the next thing you should know about RA and pregnancy? “Pregnancy is an immunosuppressed state,” Dr. Alrahmani explains. “The likely reason is so the body does not reject the foetus—basically, the baby is like a foreign body. So immunity goes down so as not to cause rejection, per se. This is a good thing for autoimmune diseases, like RA, because the majority are quiescent during pregnancy.”
In fact, in about 50% women with rheumatoid arthritis, the condition goes into remission during pregnancy, Dr. Makol and colleague reported in their journal article on the topic. About 20% to 40% achieve remission by the third trimester. But almost 20% will experience worse or moderate-to-high disease activity during pregnancy that might need adjusted medication, they report. The remaining women might have RA symptoms about the same as when they’re not pregnant, our experts say.
Whether your RA goes into remission, stays the same, or gets worse ties back to pre-pregnancy symptom control. The more controlled your RA is when you get pregnant, the easier time you might have during pregnancy, Dr. Kaplan notes. “If you start off quiet, you have a better chance of staying that way,” he says.
But it’s not always easy to know whose RA will go into remission and who will experience symptoms from the condition while pregnant—your situation might differ.
“No two RA patients are going to be the same,” Dr. Makol says. For those whose RA calms during pregnancy, meds might be safely lowered, she says. But for those whose RA doesn’t go into remission? “Pregnancy is already a big stress on the body,” she says. “On top of that, you have chronic disease, as well as potentially risky medications.” Safety is important to monitor, she says, but so is the need for effective medications to keep RA pain in check.
Managing Rheumatoid Arthritis After Pregnancy
Congrats: You’ve had your baby. You’re officially in the stage of post-pregnancy called postpartum. And you have RA. What should you know about the two?
You very well might have a postpartum rheumatoid arthritis flare—research finds a postpartum flare rate from 40% to a staggering 90% in women with RA. “It probably has to do with the change in the hormones. It may also be due to physical stress of going through labor and delivering a newborn, because we know that physical and emotional stress can ramp up in rheumatoid diseases like RA,” Dr. Kaplan says.
Many patients will flare about six weeks after having a baby, he points out. This can be especially apparent in women whose rheumatoid arthritis went into remission during pregnancy, then comes rushing back after the immunosuppressed state of pregnancy (to protect the baby) ends with delivery, he says. “The good news is? We’ve got so many medications that can work. There’s almost always something you can do,” he adds.
So make sure to have a postpartum appointment with your rheumatologist set up in advance to discuss your treatment needs.
Other things to keep in mind after having the baby: Since rheumatoid arthritis can cause issues with using your hands from swelling and pain, you might need accommodations to breastfeed your baby. That could include using a nursing pillow to prop the baby up instead of holding the newborn to do so, Dr. Kaplan points out. Or asking a family member to assist you in assembling and de-assembling your breast pump parts, if you’re pumping exclusively or often.
All in all, being pregnant with rheumatoid arthritis is not without risks, but many couples experience a healthy, safe, and successful pregnancy—with the help of proper planning, the right medicine, and an all-important health care team by their side. And while we don’t know a lot about rheumatoid arthritis medication’s impact on a woman’s ability to produce breastmilk or breastfeed, seeking out the assistance of a lactation consult is always a good idea if you need help with the process of nursing, Dr. Alrahmani says.
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