Rheumatoid Arthritis And Pregnancy: Expert Advice Before You Plan Pregnancy

Rheumatoid arthritis (RA) is a chronic autoimmune disease with prevalence being three times higher in women than men. It is a systemic autoimmune disease characterised by inflammatory synovitis affecting multiple joints. The inflammation due to RA leads to progressive joint destruction and severe disability. It also leads to increased mortality. However, if treated with Disease Modifying Anti-inflammatory drugs (DMARDS) remission can be achieved.

A woman has to undergo many phases in life including pregnancy. A woman with RA may have to follow some instructions during pregnancy. With advances in the management of RA the disease can be better controlled and a safer outcome of pregnancy is possible. However treating RA during pregnancy can be challenging as most of the disease modifying antirheumatic drugs (DMARDS) cannot be used safely considering their adverse effects on pregnancy. 

Now, lets look at some important pointers:  

1. RA and fertility

About one third of females with RA have trouble conceiving a child. They are more likely to have undergone treatment for fertility than women without RA. Data reveal that women with RA bear fewer children compared to women without RA.  Pregnancy can influence autoimmune rheumatic disease like RA. 

2. RA activity and pregnancy

Disease activity of RA often ameliorates during pregnancy; reverting in partial improvement in clinical symptoms and sometimes even complete remission but the improvement can be short lived and the disease usually relapses after delivery. The studies  have shown that pregnancy influenced the disease course more in patients who had moderate to high disease activity at time of conception. 

The disease often shows flare during post partum period. This trend is generally observed even during subsequent pregnancies. 

3. Management of RA and Pregnancy

Obtaining reproductive history is important in all women diagnosed with RA. Patient should be educated about risks and possibility of adverse outcomes associated with RA or due to medications. 

It is imperative to counsel them for contraception while on DMARDs and while doing so patient's background should be considered.

4. Male patient with RA on DMARDs

Patients on methotrexate should wait for at least 3 months after cessation of drug before attempting conception. The patient should preferably have low disease activity or be in remission. 

5. Post conception management

If the pregnancy is unplanned while the patient is on RA therapy, a possible risk of each medication on mother and foetus should be explained.

Immediate discontinuation of drug like methotrexate and leflunomide should be done. In case of women receiving leflunomide and conceiving unintentionally, the pregnancy should be terminated. If patient desires to continue the pregnancy, she should undergo washout procedure to facilitate drug excretion. 

Hydroxychloroquine and sulfasalazine can be continued during pregnancy.  

Recommendations –

The other DMARDS should be stopped for at least three months before planning for pregnancy and Leflunomide should be stopped for 2 years before pregnancy. Non-steroidal anti-inflammatory drugs should also be stopped during pregnancy.

Some key points to keep in mind - 

1. Pregnancy should be planned only when RA is stable or inactive 
2. The optimal therapeutic strategy should be chosen striking a balance between efficacy and adverse effects of medications
3. Detailed patient counselling should be done prior to planning pregnancy
4. Leflunomide should not be given to patient of childbearing age
5. A good control of RA disease activity during antenatal period is vital for positive maternal and foetal outcomes 

(Dr. Jyotsna Oak, Physician and Rheumatologist, Kokilaben Dhirubhai Ambani Hospital, Mumbai)

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