Pregnancy, Birth and Arthritis
Many young people with arthritis worry about having the condition or being on medication because it may affect their ability to become pregnant or breastfeed. They may also worry about how their arthritis or medicines will affect their child. For people with arthritis, pregnancy often needs to be thought about and planned well in advance, which can be emotionally challenging for some people as it takes away spontaneity. However, like many things in life, planning ahead, especially around medication, is very important and will make it more likely that you will have a successful pregnancy and a healthy child.
Be prepared to keep an open mind and adjust your plans if things don’t go quite as expected. You may be lucky enough to have a completely uneventful pregnancy or you may have some ups and downs, but don’t feel guilty if you need to change your plans. Your physical and mental health and wellbeing is very important too.
Will I pass on arthritis to my child?
Many potential parents worry they will pass on their arthritis to their child, but whilst it is true that some types of arthritis do run in families, whether or not someone will develop arthritis is a combination of many complicated factors including genes, environment and lifestyle, and the overall risk of you passing on arthritis to your baby is very low.
Can I have a baby if my arthritis is active?
If your arthritis is active, you may not feel well enough or energetic enough to think about having a baby straight away. So most people, including both women and men, will want their arthritis to be under good control before embarking on what is always a major life event. Stay in touch with your rheumatology team who will be able to help if your arthritis is active.
Fertility and arthritis
There are certain conditions that rheumatologists see which can increase the risk of recurrent miscarriage, but most types of arthritis do not cause fertility problems. Fertility declines with age, and it can sometimes take people with arthritis a little longer to become pregnant, so if you are over 36 and know that you may have difficulty becoming pregnant or have been trying for a baby for some time without success, or if you have had 3 or more miscarriages, speak to your doctor. You may need to think about having some specialist advice and support to get pregnant. Fertility treatment is suitable and available for people with arthritis, so it is better to think ahead and act sooner rather than later to increase your chances of becoming pregnant.
Planning a pregnancy
Once you’ve got used to the idea of planning a pregnancy and are thinking ahead, you’ll want to know what to do with your medicines, whether to stop them or switch to something else, and what might happen to your arthritis if you do stop all your medicines. You’ll also need to think ahead about breastfeeding. Many medicines should not be used during this time as they can be transferred to the baby in breast milk.
Make sure you make a list of all your questions and take them to your next rheumatology appointment.
If you decide to stop all your medicines, your arthritis may get worse, or you may experience more pain. This might be something you can manage for a short while until you become pregnant, but if it takes you longer than you hoped to get pregnant or if your pain or inflammation gets really bad, you’ll need to have a plan with your rheumatology team about what to do. This could involve switching to a medicine that is safer during pregnancy, temporarily increasing your painkillers, or perhaps having steroid injections into your joints or muscles to give you some temporary relief. The most important things are, at the same time, to try to keep your arthritis under control and for you to have a safe pregnancy and a healthy child.
Medicines and pregnancy
Most drug labels carry warnings about avoiding medicines during pregnancy and breastfeeding but sometimes this is because the effects on pregnant women are unknown. For obvious reasons, trials of medicines are not done on pregnant women but research has been done on pregnant animals, and some pregnancies do happen accidentally to women taking medicines, so we know that some drugs are more dangerous during pregnancy than others, while some are considered safer. The British Society for Rheumatology produced guidelines about medicines used for arthritis during pregnancy and breastfeeding in 2016 and as research develops will update this information. A summary of their current advice is included here: https://academic.oup.com/rheumatology/article/55/9/1693/1744535# and https://academic.oup.com/rheumatology/article/55/9/1698/1744537.
Paracetamol and other painkillers
Paracetamol is safe during pregnancy and breast feeding. Codeine is also safe but if taken in high doses, especially if morphine-like drugs are used during labour, there is a risk of breathing problems (respiratory depression) in the new-born baby. Tramadol should be avoided in pregnancy as it can cause birth defects in animals, and morphine can also cause respiratory depression in the new-born.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Studies have shown that using NSAIDs such as ibuprofen and naproxen around the time of conception can lead to an increased risk of miscarriage during the first 8 weeks of pregnancy. This is thought to be because NSAIDs interfere with chemicals called prostaglandins which are important in embryo implantation. Many people with inflammatory arthritis depend on NSAIDs for pain relief, however, and guidelines therefore suggest using these medicines very cautiously in the first 3 months of pregnancy and stopping them completely after 32 weeks as they can cause problems in the baby at the time of delivery. NSAIDs are safe to use when trying to conceive, but many rheumatologists would advise stopping them as soon as you have a positive pregnancy test and for the first 3 months of pregnancy if possible.
Disease-modifying anti-rheumatic drugs (DMARDs)
Certain drugs, including cyclophosphamide, mycophenolate mofetil, methotrexate and leflunomide, should definitely not be taken if you are thinking of trying for a baby because they can cause birth defects and so must be stopped before conception.
Hydroxychloroquine is a mild DMARD and has not been connected with birth defects so can be continued through pregnancy.
It is recommended that women stop using methotrexate 3 months before planning a pregnancy because it can cause miscarriage and birth defects. Methotrexate can cause low levels of folic acid which can lead to birth deformities called neural tube defects (for example spina bifida), so women who have been taking methotrexate should take extra folic acid during pregnancy. It is important to use effective contraception between stopping methotrexate and trying for a baby. Methotrexate is also not safe when breastfeeding. It used to be thought that men should also stop methotrexate 3 months before conception, but current British Society for Rheumatology guidelines suggest that it can be taken by men when planning a pregnancy as there is no evidence that this causes harm.
For women taking leflunomide, it is recommended that pregnancy is avoided for 2 years after stopping the drug, because this medicine lasts for a very long time in the body. This period can be shortened if women undergo a procedure called “washout”, where a medicine called cholestyramine that can remove leflunomide form the body is taken several times a day for about 11 days, followed by a blood test to check that pregnancy is safe, However this can be a complicated process, so in general women planning pregnancy in the near future should not be started on leflunomide in the first place. Leflunomide is also not safe during breastfeeding. Current British Society for Rheumatology guidelines suggest that leflunomide can be taken by men when planning a pregnancy as there is no evidence that this causes harm.
Sulfasalazine is considered one of the safer drugs that can be continued through pregnancy, but it’s recommended to take additional folic acid throughout pregnancy to prevent neural tube defects.
Azathioprine is another safer drug that can be continued through pregnancy provided it is given at a fairly low dose.
Prednisolone and methylprednisolone are considered safe in pregnancy and breastfeeding, but the dose should be kept to the lowest dose that controls arthritis. More than 15mg daily of prednisolone for a long period can increase the risk of early (pre-term) labour. Occasional injections of steroids into painful joints or into muscles involve a very low dose of methylprednisolone, which would be considered safe in pregnancy and breastfeeding.
Cyclophosphamide and mycophenolate mofetil
Both of these medicines can cause birth defects and are not safe during pregnancy or breastfeeding. If you are taking one of these drugs you should switch to another medicine at least 3 months before trying to conceive and you should use effective contraception during this time.
Anti-TNF biologic drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab).
These drugs are mostly safe through pregnancy and are not known to cause significant birth defects, but the advice is to consider stopping infliximab at 16 weeks and etanercept, golimumab and adalimumab at the end of the second trimester because of the risk of transferring these drugs through the placenta to the baby. Certolizumab is a large molecule that can’t pass through the placenta so is safe throughout pregnancy. All anti-TNF biologic drugs are thought likely to be safe if breastfeeding, although research is very limited.
Rituximab is a very long-lasting medication that should be stopped 6 months before pregnancy and only continued during pregnancy if there is no other option, so discuss things with your rheumatology team if you are taking this medication.
Other biologic medications and JAK inhibitors, including abatacept, tocilizumab, ustekinumab, secukinumab and baricitinib.
These medicines are less commonly used than other biologic medicines for people with arthritis and have been available for less time than anti-TNF biologics which means that research on these drugs in pregnancy is even more limited. Baricitinib is not recommended if you are planning a pregnancy and the other medicines in this group should only be continued if there is no other option available for your arthritis.
Arthritis during pregnancy
It used to be said that for most women with inflammatory arthritis, pregnancy was a good time because arthritis would go into remission. We now know that is not quite true and may depend on the type of arthritis you have. Although for most women rheumatoid arthritis does improve in pregnancy, only about 1 in 3 women will find that their arthritis goes into remission and for about 1 in 5 women their arthritis will get worse. Some studies have shown that for women with ankylosing spondylitis or axial spondyloarthropathy, the overall disease activity stays the same or gets slightly worse during pregnancy. However in psoriatic arthritis, up to 80% of women may go into remission.
It can be difficult emotionally if you believe that your arthritis will go into remission during pregnancy and it doesn’t, so being aware that things might be difficult in advance can help you prepare, and of course knowing that this won’t go on for ever can also help. Pain relief and other treatments can help during pregnancy and self-management, including relaxation, exercise, looking after yourself and accepting offers of help, can all help too.
Arthritis and pregnancy complications
Most people with arthritis will have no major issues during pregnancy, but if you have lupus or Sjogren’s syndrome associated with something called Anti-Ro/SS-A or Anti-La/SS-B antibodies, your baby may be at risk of a condition called congenital heart block, which is a type of heart rhythm problem. The risk of this is only about 1-2% if you have these antibodies, but you will need to have close monitoring of your baby’s heart rate during pregnancy and should be managed by an experienced obstetrician.
Pregnancy is a time when ligaments become more lax or loose in preparation for childbirth. If you have painful hypermobile joints or hypermobile-EDS, you may find that certain pains get worse through pregnancy, or you may develop back or hip pain or symphysis pubis dysfunction (SPD). Physiotherapy can help a lot. Remember that exercise is usually safe in pregnancy and resistance exercise can continue with advice if you find it helpful. Your feet may ache more as your weight increases, but supportive shoes, trainers and insoles can all help.
Arthritis and childbirth
Childbirth can often be a frightening thought, even without arthritis, but the reality is that even if you’ve had major hip surgery, this should not affect your ability to give birth naturally. Even women who have had spinal fusion surgery for a condition called adolescent idiopathic scoliosis using spinal rods can give birth naturally, and most people who have had spinal fusion surgery will still be able to have an epidural if they want one. Having severe ankylosing spondylitis with spinal fusion may make this more challenging and you should discuss your birth options with your obstetrician at an early stage, as sometimes the worry about whether or not you will have an easy childbirth can be avoided if you know that you will need to have a planned Caesarean section. If you have particular joints that are stiff and painful, often giving birth in slightly different positions or with suitably placed pillows can make things easier. Ask your midwife for advice on the available options and make use of any offered pain relief.
Flares after childbirth
Many women with inflammatory arthritis find that as the pregnancy hormones drop after childbirth, they start to experience a flare of their arthritis. This typically occurs at around 6-12 weeks after the baby has been born. Although this is often unpredictable, studies have shown that the majority of women with ankylosing spondylitis and psoriatic arthritis will experience a flare. The best way of dealing with this is to be prepared and plan ahead. If you are breastfeeding your baby and plan to continue, then you probably won’t want to or should not restart some of your previous medicines. Instead you may opt for occasional methylprednisolone injections to see if this helps. It’s essential that if you’re experiencing severe or frequent flares, that you speak to your rheumatology team because not only are these painful and potentially disabling, but you risk long-term joint damage if you remain off your medicines.