A growing number of women with RA seem to be taking the plunge into motherhood, in part due to better treatments that can keep their disease under control during the nine months of pregnancy, says Megan Clowse, MD, director of the Duke Autoimmunity in Pregnancy Clinic and associate professor of medicine at Duke University in Durham, North Carolina. The good news: More is known about how to help women successfully plan their family and carry a healthy baby to term, Dr. Clowse says.
Women With RA Are Eager for Information About Pregnancy and Health
Before she conceived, Aimee Matsumoto, a public relations professional in Pasadena, California, who has RA, frequently fretted about what would happen. “I worried tremendously that my RA would affect my pregnancy, especially about flares and pain management,” she says. Fortunately, her disease stayed in check, and nine months ago she delivered a healthy baby girl named Sloane. “Women with RA who want to have a baby are eager for information,” Clowse says, especially about how they can safely balance their own health and that of their unborn child. For answers, many turn to their physicians. While a good number know the latest information about how to strike that balance, too many still give women incorrect advice and discourage pregnancy when they shouldn’t, Clowse says. Women are also turning to other women with the disease to get advice. A study of queries about pregnancy on three Reddit subgroups dealing with arthritis, published in August 2019 in ACR Open Rheumatology, found dozens of threads on topics like the impacts on pregnancy and how to manage symptoms after conceiving.
Choose Effective Birth Control Methods When You Live With RA
When you have RA, it is important that you don’t get pregnant until you are ready. That means having your disease under the best possible control for at least three to six months before you try to conceive, because this better reduces your chances of pregnancy complications, according to Mother to Baby, a website created by experts on birth-defect risks. This means choosing effective contraception, which is especially critical if you are on medication that is not compatible with a healthy pregnancy. This is something not every woman with RA is doing. In a survey of nearly 200 women by the arthritis community website CreakyJoints presented in 2017 at the American Academy of Rheumatology (AAR), some 28 percent of reproductive-age women were taking the drug Trexall (methotrexate), known to cause birth defects in babies; used birth control methods considered to be ineffective, such as male condoms or the rhythm method; or worse, were using no birth control at all.
Effective Birth Control Methods When You Have RA and Aren’t Planning a Pregnancy
If you are not planning to get pregnant for at least a year, the most effective forms of birth control are an implant (Nexplanon) under the skin of your upper arm, or an intrauterine device (IUD) inserted into your uterus, according to Planned Parenthood. “These methods are virtually foolproof for avoiding pregnancy, and are easily reversible when you are ready to conceive,” Clowse says. Other effective methods, when used properly, include oral contraceptives and vaginal rings. If you do have unexpected unprotected sex, the morning after pill is also safe for women with RA, notes Princeton University.
Your Chances of Conceiving May Not Be Lower
It can be true that some women with RA take longer to get pregnant, experiencing subfertility before they ultimately conceive. And, as with women without this autoimmune disease, some will need physician-assisted methods to get pregnant, notes the Centers for Disease Control and Prevention (CDC), including medication, insemination, or in vitro fertilization, per the Mayo Clinic. Longer conception times seem to be related to the severity of a woman’s condition, the medication she uses, or the fact that some women delay pregnancy until they are older and the disease is better controlled. Still, Clowse says, “Many women with RA will not have a problem conceiving.” More good news: Rates of miscarriage are thought to be no different for women with the disease than for those without, she says.
Work With Your Rheumatologist and Other Physicians
If you are thinking of beginning a family, you’ll want to find a rheumatologist who is knowledgeable about the concerns of younger women, and with whom you feel comfortable discussing your plans, says Lynn Ludmer, MD, medical director of rheumatology at Mercy Hospital in Baltimore. “Family planning is not just for the gynecologist. It should absolutely be part of your conversations with your rheumatologist also,” Dr. Ludmer says. It’s best to consult with your rheumatologist at least three months before you conceive, she says. That way your doctor can assess whether your disease is sufficiently controlled and, importantly, whether the medication you are taking is safe during pregnancy. A similar discussion should be had by men with RA who plan to be a father, Ludmer stresses, because some drug can also affect sperm. Fortunately, most disease modifying anti-rheumatic drugs (DMARDs) have been found to be safe for men to take when conceiving, according to a review published in April 2019 in the journal Seminars in Arthritis and Rheumatism. Throughout your pregnancy, keep your regular appointments with your rheumatologist, who will check the progress of your disease and help you plan to best manage your condition after you deliver.
Most RA Drugs Are Safe During Pregnancy
Fortunately, a large number of drugs used for RA today are fine to continue during pregnancy, Clowse says. “In the old model, doctors stopped all medications and crossed their fingers that you wouldn’t flare too badly,” she observes. Now there are a long list of drugs that have been documented not to harm an unborn baby, according to an article published in March 2109 in The Journal of Rheumatology. Drugs that are not safe should be tapered off under your doctor’s supervision. These include meds that are known to be incompatible with pregnancy, such as Trexall (methotrexate) and Arava (leflunomide), and those whose prenatal safety is unclear, like Xeljanz (tofacitinib) and COX-2 inhibitors. Your doctor can help you replace these drugs with others. To find out if the drugs you are on should be continued, the website Mother to Baby publishes an easily accessible list of all drugs with detailed, up-to-date information of their affects on an unborn baby.
RA Flare-Ups May Still Happen During Pregnancy
Doctors used to say that more than three-quarters of women go into remission during pregnancy. But unfortunately, newer research paints a less rosy picture. Only about 20 to 40 percent of women will do so, according to Mayo Clinic rheumatologists in an article published in March 2016 in Open Access Rheumatology. Nearly 20 percent report moderate to high disease activity during pregnancy, the article notes, another reason why good communication with your rheumatologist is so important. “I tell women that pregnancy might be good for RA, but TNF inhibitors are better,” Clowse says.
Fine to Stay on TNF Blockers — at Least at First
Popular biological drugs known as TNF inhibitors (TNFi) or TNF blockers, including Enbrel (etanercept) and Remicade (infliximab), can be continued during pregnancy, especially during the first trimester. This is good news for women on these drugs, because a study planned for presentation at the November 2019 annual meeting of the American College of Rheumatology found that women who discontinue their TNFi at conception face a high risk of flares during pregnancy. The same research also suggests that women who stay on the drug during pregnancy are often able to successfully lengthen their time between injections, so long as their disease remains controlled. Experts disagree about whether women should stop taking certain TNFi drugs after the first trimester, but Clowse believes most of these meds can be taken until around 32 weeks. After that they should be stopped until after delivery so the medicine is not transferred to the baby, and restarted soon after. Because newer biologics, such as Orencia (abatacept) and Actemra (tocilizumab), don’t have as long a track record in pregnant women, Clowse recommends that women wanting to get pregnant avoid them for now.
Women With RA Face a Small Risk of Preterm Birth
Women with RA are less likely than those with other autoimmune conditions like lupus to have difficulty carrying their baby to term. However, there is a small increased risk of preterm birth and preeclampsia in women with RA. Those with good control of their disease, with or without drugs, should not have this problem, Clowse says.
Improve Health Habits and Lifestyle Prior to Pregnancy
In their Patient’s Guide to Pregnancy and Family Planning With Rheumatic Diseases, CreakyJoints advises women and their partners to adopt healthy lifestyle habits before they conceive. If you or your partner smoke, you’ll want to break this habit. If you drink heavily, scaling back can increase your odds of conceiving and having a healthy baby. Eating healthy foods and trying to reach your best weight are also helpful for a future pregnancy.
Is This Symptom a Sign of Pregnancy or a Sign of a Flare?
It may seem odd that pregnant women sometimes say they can’t tell if their disease is flaring or if they are experiencing the symptoms of pregnancy. But that’s because some of the symptoms — like low back pain, fatigue, nausea, and swollen hands or feet — can be similar, according to the CreakyJoints patient guide. You’ll want to talk to your doctor about your concerns. But according to CreakyJoints, a good general rule is if they feel different from your usual symptoms, they are likely to be the aches and pains of a regular pregnancy.
