Rheumatoid arthritis does not appear to have any adverse effects on pregnancy outcome. Some medications used to treat RA have not been thoroughly studied in pregnant women, however, and should be used with caution in this population. How a woman with RA is treated during her pregnancy is a complicated decision that should be made cooperatively by the patient, her obstetrician, and her rheumatologist. Treatment decisions require careful consideration of the risks and benefits to the mother and fetus.
During pregnancy, the joint symptoms of women with RA improve in approximately 75% of cases. Most women who improve experience initial relief in the first trimester, but RA almost invariably recurs within three to four months after delivery. A minority of pregnant patients have a significant worsening of their symptoms that requires changes in the dosages of their current medications or the addition of new medications.
Rheumatoid arthritis therapy during pregnancy is complicated because many of the drugs used to treat RA have not been adequately tested in medical studies of pregnant women. Therefore, they may be dangerous to the unborn child.
Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (Rheumatrex), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava), cyclosporine (Sandimmune, Neoral), gold salts (Solganal), azathioprine (Imuran), and D-penicillamine (Cuprimine, Depen) should be stopped in women who are trying to conceive and in pregnant and lactating women. Some of these medications are more harmful than others during pregnancy; that is, evidence of the risks of these agents to the fetus either exists or cannot be ruled out. Methotrexate should be stopped in both men and women who are planning to conceive a baby because evidence suggests that it may cause birth defects (also called teratogenicity). Women who are planning to become pregnant should stop methotrexate for at least one complete ovulatory cycle before attempting conception. Men taking this drug should stop it six months prior to fathering a child.
Prednisone is an option for the treatment of pregnant women with RA. Although the use of this medication in pregnant women has been not investigated in controlled medical studies, no evidence exists that low-dose prednisone (less than 20 mg daily) used in the first two trimesters poses any risks to the fetus. If this medication is necessary, joint symptoms are best managed with the lowest possible dose of prednisone. Potential complications of prednisone use during pregnancy include worsening of maternal gestational diabetes, hypertension, and intrauterine growth retardation.
Similarly, nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in the first two trimesters of pregnancy. They should be avoided in the third trimester because of their potential negative effects on the pregnancy:
- Effects on the baby's heart (premature closure of the ductus arteriosus)
- Prolonged labor
- Excessive bleeding after child birth (peripartum hemorrhage)
Although both NSAIDs and prednisone are excreted in breast milk, the American Academy of Pediatrics considers them safe for breastfeeding mothers. If NSAIDs are used, drugs with a short duration of action (a short “half-life”) are preferable. Ideally, these drugs should be taken immediately after breastfeeding.
The safety of using tumor necrosis factor (TNF) inhibitors during pregnancy has not been well studied. While several case reports indicate that women have gone through normal pregnancies and delivered healthy children while on one of these drugs, the U.S. Food and Drug Administration (FDA) does not recommend the use of TNF inhibitors in pregnant women.
Men and women with RA who are considering conceiving a child should discuss their treatment options with their rheumatologists well in advance of the planned pregnancy. Women should include their obstetricians in these discussions and should inform them of any change in their medications during their pregnancy. Much useful information on medications and pregnancy can be found at the Organization of Teratology Information Specialists website (www.otispregnancy.org).