No matter their health, many women worry when they ponder the idea of having a baby: Can I easily conceive? Will I deliver a healthy, full-term baby? Women with rheumatoid arthritis (RA) who want to start a family have these same concerns, but they have others, too, which is understandable since RA can affect both your baby’s health and your own, according to a study published in Current Rheumatology Reports.
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 pregnancy, says Megan Clowse, MD, director of the Duke Autoimmunity in Pregnancy Clinic and associate professor of medicine at the Duke University School of Medicine in Durham, North Carolina.
The good news: More is known about how to help women successfully plan a family and carry a healthy baby to term, Dr. Clowse says.
Choose Effective Birth Control Methods When You Have RA
When you live with 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, since this better reduces your chances of pregnancy complications, according to Mother To Baby, a website created by experts on birth-defect risks.
It’s necessary to use 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 annual meeting of the American Academy of Rheumatology, 33 percent used birth control methods considered to be ineffective. And some 28 percent of reproductive-age women taking the drug methotrexate (Trexall), known to cause birth defects in babies, were using ineffective contraception.
If you are not planning to get pregnant for at least a year, two of the most effective forms of birth control are an implant (Nexplanon) under the skin of your upper arm or an intrauterine device 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 have unexpected unprotected sex, the morning-after pill is also safe for women with RA, notes the Arthritis Foundation.
Your Chances of Conceiving May Not Be Lower
For some women with RA, it will take longer to get pregnant, and they might experience 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, including medication, insemination, or in vitro fertilization, per the Mayo Clinic. The latest guidelines on managing reproductive health from the American College of Rheumatology strongly recommend proceeding with assisted reproductive technology in women with uncomplicated RA who are taking pregnancy-compatible medications and whose disease is stable.
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, according to research.
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.
Consult Your Rheumatologist and Other Physicians When Trying to Conceive
“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 doctors still give women incorrect advice and discourage pregnancy when they shouldn’t, Clowse says.
If you’re 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 Medical Center 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 your rheumatologist about your pregnancy when starting a treatment plan, she says. Some cases of RA should be under control for 6 to 12 months prior to conception for the best outcomes for both mother and baby. In women with stable, well-controlled RA, some medications should be discontinued three months prior to conception, while other medications may need to be started several months before conception to ensure the best outcome, Ludmer adds.
A similar discussion should be had by men with RA who plan to be a father, Ludmer notes, because some drugs can also affect sperm. Though she adds that this is less important unless there is difficulty conceiving.
Fortunately, most disease-modifying anti-rheumatic drugs 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.
Many 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 is a long list of drugs that have been documented not to harm an unborn baby, according to an article published in The Journal of Rheumatology.
Drugs that are not safe include meds that are known to be incompatible with pregnancy, such as methotrexate, leflunomide (Arava), and cyclophosphamide (Cytoxan); certain biologics, such as abatacept (Orencia) and tocilizumab (Actemra); and drugs for which their prenatal safety is unclear, like tofacitinib (Xeljanz), apremilast (Otezla), and baricitinib (Olumiant), according to the Arthritis Foundation. 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 effects on an unborn baby.
RELATED: 8 Common Rheumatoid Arthritis Medication Mistakes
RA Flare-Ups May Still Happen During Pregnancy
Up to 40 percent of women will go into remission during pregnancy, according to Mayo Clinic rheumatologists in an article published in Open Access Rheumatology. But 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 etanercept (Enbrel) and infliximab (Remicade), can be continued during pregnancy, especially during the first trimester.
Experts disagree about whether women should stop taking certain TNFi drugs after the first trimester. The Arthritis Foundation recommends discontinuing their use in the third trimester. They should be stopped until after delivery, so the medicine is not transferred to the baby, and restarted soon after.
Women With RA Face an Increased Risk of Certain Complications
Women with RA are less likely than those with other autoimmune conditions like lupus to have difficulty carrying their baby to term. It’s important to be aware, though, that there is a small but increased risk of preterm birth and preeclampsia in women with RA, and low infant birth weight, according to a meta-analysis and review of research published in January 2023 in the Journal of Clinical Rheumatology.
Mental health is also a concern. A study published in April 2023 in BMC Medicine found that RA was associated with increased risk of new-onset postpartum psychiatric disorders, including postpartum depression, in women who didn’t have a history of psychiatric disorders. (RA wasn’t found to increase risk in women who already had a history of mental health disorders.)
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 CreakyJoints.
You’ll want to talk to your doctor about your concerns. But a good general rule is if they feel different from your usual symptoms, they’re likely to be the aches and pains of a regular pregnancy.
