Autoimmune Diseases in Pregnancy Studies

Rheumatoid Arthritis FAQs

Rheumatoid Arthritis FAQs
  1. What is rheumatoid arthritis?
  2. What should I know if I have rheumatoid arthritis and am planning on getting pregnant?
  3. Will rheumatoid arthritis get worse during pregnancy?
  4. Can rheumatoid arthritis lead to other problems during pregnancy?
  5. Are there things I can do to increase my chances of a healthy pregnancy?
  6. How will having rheumatoid arthritis affect my prenatal care and delivery?
  7. Can having rheumatoid arthritis cause birth defects?
  8. What types of medications are available to treat rheumatoid arthritis?
  9. Are any of the medications used to treat rheumatoid arthritis a risk to my baby?
  10. Can I breastfeed my baby if I am taking medications for rheumatoid arthritis?
  11. What if the baby’s father has rheumatoid arthritis?

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What is rheumatoid arthritis?

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Rheumatoid arthritis is a type of arthritis that is triggered by the immune system and can affect many parts of the body. The exact cause is unknown. Signs and symptoms include:

  • Joint pain and swelling
  • Redness and warmth
  • Stiffness that is most common early in the morning
  • Weight loss
  • Tiredness

Severe cases of rheumatoid arthritis can involve the skin, lungs, heart and eyes.

What should I know if I have rheumatoid arthritis and am planning on getting pregnant?

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Recent nationwide estimates suggest that 1,000 to 2,000 women with rheumatoid arthritis become pregnant every year. Since most people with rheumatoid arthritis take medications to control the inflammation and prevent or reduce damage to the joints, it is important to speak with your doctor or healthcare professional about the medications that you are taking and the treatment options available.

There has been some suggestion that having rheumatoid arthritis may decrease your chances of getting pregnant, but it is not clear whether this is due to the disease or the fact that women with rheumatoid arthritis wait longer before starting their families and may have smaller families.1

Because adverse pregnancy outcome may be related to high disease activity,2 you and your doctor or healthcare provider should discuss: (1) the best treatment options available that will keep rheumatoid arthritis disease activity low, (2) what medications are associated with the lowest risk to your baby, and (3) an effective method of birth control so that pregnancy can be delayed until the rheumatoid arthritis is under control.

Will rheumatoid arthritis get worse during pregnancy?

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Early studies have reported that up to 75% of women will have some improvement in rheumatoid arthritis symptoms during pregnancy.3 These improvements can start as early as the first trimester. It cannot be predicted whether rheumatoid arthritis symptoms will improve, stay the same or get worse during pregnancy, although women with low disease activity will generally stay stable during pregnancy while those with high disease activity have less of a chance of improvement.3

Can rheumatoid arthritis lead to other problems during pregnancy?

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There are not many studies on the outcomes of pregnancy in women with rheumatoid arthritis, though it may be linked to higher rates of c-sections and premature delivery.4 Two studies found that infants of women with rheumatoid arthritis had birthweights that were lower than those of healthy women – although they were still in the normal range.5,6 Infant birthweights of mothers with high disease activity were even lower.

Are there things I can do to increase my chances of a healthy pregnancy?

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When you have rheumatoid arthritis, it is important to discuss several aspects of the disease with your healthcare provider before you become pregnant. This is also the time to make sure that there is good communication between your obstetrician/gynecologist and the doctor who is treating you for rheumatoid arthritis. Important points to discuss with your doctors are:

  • How active your symptoms are.
    • According to the American College of Rheumatology, you can improve your chances of avoiding complications during your pregnancy if your symptoms are well-controlled 3-6 months before trying to get pregnant.
  • What medications you are taking.
    • Pregnancy outcome is better in women whose disease is not active. So as long as you are taking medications that are not harmful to your baby, if your disease is moderate to severe it may be recommended that you continue on these medications in order to avoid flare-ups during pregnancy or after your baby is born.
    • Discuss with your doctor when you should discontinue medication that is known to be harmful. Sometimes, these medications must be discontinued far in advance of pregnancy.
    • If your symptoms are mild, discuss with your doctor the possibility of discontinuing medications altogether before you try to become pregnant.
  • The results of your laboratory tests and physical examination.
    • Blood tests that show that you have certain antibodies – molecules that are produced by your immune system – may require you to receive additional treatment (such as aspirin) and additional monitoring of your baby with ultrasounds during pregnancy.7 It is useful to know ahead of time if you have these antibodies.
    • It is important to know if you have any other disorders such as high blood pressure, kidney disease, diabetes, or thyroid disease, so that they can be properly addressed and treated when appropriate, before pregnancy occurs.
  • Taking folic acid as a supplement because it has been shown to reduce the occurrence of certain birth defects.

How will having rheumatoid arthritis affect my prenatal care and delivery?

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The extra prenatal care that you receive will depend on how active your symptoms are. More than likely, you will be under the care of an obstetrician who specializes in high-risk pregnancies and who will also consult with the healthcare provider who is treating you for rheumatoid arthritis. Management decisions during your prenatal care will be based on your symptoms and tests results. You may:

  • Have specialized ultrasounds to follow the baby’s growth and to test for the baby’s well being.
  • Be given special medications that are safe to use during pregnancy if you have high blood pressure, diabetes, or special antibodies in your blood.
  • Be monitored carefully for flare-ups after you deliver your baby because a significant number of women will have a relapse of symptoms within the first 6 months.8

Can having rheumatoid arthritis cause birth defects?

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No, having rheumatoid arthritis alone does not increase the chances of birth defects.

What types of medications are available to treat rheumatoid arthritis?

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There are many different types of medications used to treat rheumatoid arthritis. These include nonsteroidal anti-inflammatory drugs (NSAIDS), steroids such as prednisone, antimalarial medications such as hydrochloroquine and chloriquine, sulfasalazine, and a group of drugs called biologics such as adalimumab (Humira®), etanercept (Enbrel®), certolizumab pegol (Cimzia®), and tofacitinib citrate (Xeljanz®) among others.

There are different levels of risk to the baby associated with taking these medications, and some are not recommended for use during pregnancy. You should discuss the risks of any medications that you are taking with your doctor or healthcare provider and, if needed, switch to medications that have fewer associated risks 3-6 months before trying to get pregnant. MotherToBaby offers free Fact Sheets on many of the medications used to treat rheumatoid arthritis.

Are any of the medications used to treat rheumatoid arthritis a risk to my baby?

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  • While nonsteroidal anti-inflammatory drugs (NSAIDs) can be safely used at certain times during pregnancy, there are some exceptions. NSAIDs should be avoided after 30 weeks of pregnancy because they can cause early closure of an important blood vessel in the baby’s heart. In addition, since they may interfere with implantation, they should probably not be taken around the time that you are trying to become pregnant. For more details on NSAIDS during pregnancy, see our Fact Sheet.
  • While steroids such as prednisone and prednisolone can be safely used throughout pregnancy, certain risks have been identified when they are taken for prolonged periods of time. One such possible risk is early rupture of membranes (which often leads to premature birth). In addition, prolonged use of steroids can cause an increase in your blood pressure and blood sugar levels during pregnancy. Newer studies have found that, when taken during the first three months of pregnancy, there is only a very small risk (smaller than previously thought) of the baby developing cleft palate or oral cleft. For more information on steroids during pregnancy, see our Fact Sheet.
  • Methotrexate should not be used during pregnancy because it has been associated with a specific pattern of birth defects. For more information, see our Methotrexate Fact Sheet.
  • Based on a limited number of studies, it is not clear whether leflunomide causes birth defects. Therefore, it is probably best be avoided its use during pregnancy until larger studies are performed. For more information, see our Leflunomide Fact Sheet.
  • Hydrochloriquine and sulfasalazine are considered safe to use during pregnancy and have not been associated with birth defects.9
  • Biologic response modifiers are a group of drugs used to treat rheumatoid arthritis that affect the immune system to decrease inflammation. Examples of currently used biologic agents for treating rheumatoid arthritis are adalimumab (Humira®), etanercept (Enbrel®), certolizumab pegol (Cimzia®), and tofacitinib citrate (Xeljanz®).

A few studies have looked at the safety of some of these medications during pregnancy in women with rheumatoid arthritis as well as other autoimmune diseases. Overall, no increase in birth defects has been found in babies exposed to etanercept (Enbrel®) or adalimumab (Humira®).10-12 In addition, a study performed by our group at MotherToBaby did not find any clear pattern of birth defects in babies of women who were treated with Enbrel® or Humira®.12 However, more studies are needed with larger numbers of women in order to confirm these findings. There are currently no published pregnancy studies evaluating certolizumab pegol (Cimzia®) or tofacitinib citrate (Xeljanz®); we currently have ongoing studies on both of these medications.

There is very little transfer of these medications to the baby during the first three months of pregnancy. However, as the pregnancy progresses, the medication transfers more easily so that it can be detected in the baby’s blood at birth, even after the mother has stopped taking the medication for weeks before delivery. Certolizumab pegol (Cimzia®) appears to be the one exception in that it does not seem to cross the placenta into the baby’s circulation.14

There has been some concern that the medications that are transferred across the placenta may affect the baby’s immune system, possibly increasing the chances of developing infections after birth. As a result, some healthcare providers have recommended stopping the medication between 30-34 weeks of pregnancy and not giving the baby any vaccinations that contain a live virus until at least 6 months of age.13

Due to limited data on the safety of these medications during pregnancy, if you are pregnant or planning a future pregnancy you should talk with your physician before starting this regimen. For more information, please see our free Fact Sheets on adalimumab (Humira®), certolizumab pegol (Cimzia®), etanercept (Enbrel®), infliximab (Remicade®), and tocilizumab (Actemra®).

Help us help future moms with Rheumatoid Arthritis: MotherToBaby is currently conducting studies on the safety of medications used to treat rheumatoid arthritis during pregnancy. Learn more or Sign Up Now!

Can I breastfeed my baby if I am taking medications for rheumatoid arthritis?

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Several, but not all rheumatoid arthritis medications can be used while you are breastfeeding.15 It is important to discuss with your doctor or healthcare provider which medications are considered low risk and which ones should be avoided. To find out more about specific medications, you can view MotherToBaby’s free Fact Sheets.

Other sources of information on breastfeeding include LactMed, which is provided by the National Library of Medicine, and The Transfer of Drugs and Other Chemicals Into Human Milk.

What if the baby’s father has rheumatoid arthritis?

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There are very few studies looking at pregnancy outcomes when the father has rheumatoid arthritis and is being treated with medications. However, the limited information available has not found an increased risk of birth defects or miscarriages in pregnancies whose father’s had been taking medications for rheumatoid arthritis.11,16,17 These medications included steroids, sulfasalazine, azathioprine, hydroxychloroquine, methotrexate, leflunomide, etanercept (Enbrel®), and adalimumab (Humira®).

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Disclaimer: The information presented should not take the place of medical care and advice from your healthcare provider. It is important that you discuss any questions you have about the use of medications during pregnancy and breastfeeding with your healthcare provider.

Last updated: September 30, 2014

References
  1. Katz PP. Childbearing decisions and family size among women with rheumatoid arthritis. Arthritis and rheumatism. Apr 15 2006;55(2):217-223.
  2. de Man YA, Dolhain RJ, Hazes JM. Disease activity or remission of rheumatoid arthritis before, during and following pregnancy. Current opinion in rheumatology. May 2014;26(3):329-333.
  3. de Man YA, Dolhain RJ, van de Geijn FE, Willemsen SP, Hazes JM. Disease activity of rheumatoid arthritis during pregnancy: results from a nationwide prospective study. Arthritis and rheumatism. Sep 15 2008;59(9):1241-1248.
  4. Reed SD, Vollan TA, Svec MA. Pregnancy outcomes in women with rheumatoid arthritis in Washington State. Maternal and child health journal. Jul 2006;10(4):361-366.
  5. Bowden AP, Barrett JH, Fallow W, Silman AJ. Women with inflammatory polyarthritis have babies of lower birth weight. The Journal of rheumatology. Feb 2001;28(2):355-359.
  6. de Man YA, Hazes JM, van der Heide H, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. Arthritis and rheumatism. Nov 2009;60(11):3196-3206.
  7. Cavazzana I, Franceschini F, Quinzanini M, et al. Anti-Ro/SSA antibodies in rheumatoid arthritis: clinical and immunologic associations. Clinical and experimental rheumatology. Jan-Feb 2006;24(1):59-64.
  8. Forger F, Vallbracht I, Helmke K, Villiger PM, Ostensen M. Pregnancy mediated improvement of rheumatoid arthritis. Swiss medical weekly. 2012;142:w13644.
  9. Bermas BL. Non-steroidal anti inflammatory drugs, glucocorticoids and disease modifying anti-rheumatic drugs for the management of rheumatoid arthritis before and during pregnancy. Current opinion in rheumatology. May 2014;26(3):334-340.
  10. Diav-Citrin O, Otcheretianski-Volodarsky A, Shechtman S, Ornoy A. Pregnancy outcome following gestational exposure to TNF-alpha-inhibitors: a prospective, comparative, observational study. Reprod Toxicol. Jan 2014;43:78-84.
  11. Viktil KK, Engeland A, Furu K. Outcomes after anti-rheumatic drug use before and during pregnancy: a cohort study among 150,000 pregnant women and expectant fathers. Scandinavian journal of rheumatology. May 2012;41(3):196-201.
  12. Chambers CD, Johnson DL. Emerging data on the use of anti-tumor necrosis factor-alpha medications in pregnancy. Birth defects research. Part A, Clinical and molecular teratology. Aug 2012;94(8):607-611.
  13. Williams M, Chakravarty EF. Rheumatoid arthritis and pregnancy: impediments to optimal management of both biologic use before, during and after pregnancy. Current opinion in rheumatology. May 2014;26(3):341-346.
  14. Mahadevan U, Wolf DC, Dubinsky M, et al. Placental transfer of anti-tumor necrosis factor agents in pregnant patients with inflammatory bowel disease. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. Mar 2013;11(3):286-292; quiz e224.
  15. Sammaritano LR, Bermas BL. Rheumatoid arthritis medications and lactation. Current opinion in rheumatology. May 2014;26(3):354-360.
  16. Weber-Schoendorfer C, Hoeltzenbein M, Wacker E, Meister R, Schaefer C. No evidence for an increased risk of adverse pregnancy outcome after paternal low-dose methotrexate: an observational cohort study. Rheumatology (Oxford). Apr 2014;53(4):757-763.
  17. De Santis M, Straface G, Cavaliere A, Carducci B, Caruso A. Paternal and maternal exposure to leflunomide: pregnancy and neonatal outcome. Annals of the rheumatic diseases. Jul 2005;64(7):1096-1097.