Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness. For individuals of reproductive age, RA and its treatments introduce unique considerations when planning a family. While RA can complicate the journey to parenthood, the majority of people with this condition successfully conceive and experience healthy pregnancies. Understanding the relationship between RA, fertility, and maternal health is foundational to optimizing reproductive outcomes.
The Link Between RA and Conception
Active rheumatoid arthritis can sometimes lead to a delay in conception, often termed subfertility. The primary mechanism behind this delay is systemic inflammation, driven by elevated levels of inflammatory signaling molecules such as cytokines. These molecules interfere with the hormonal balance required for regular ovulation and successful implantation.
Specific treatments for RA can also impact the ability to get pregnant; for example, nonsteroidal anti-inflammatory drugs (NSAIDs) may hinder ovulation by affecting prostaglandin production. Physical symptoms of RA, including pain and fatigue, can also reduce sexual activity, lowering the probability of conception. Studies indicate that though conception may take longer for some individuals with RA, most will eventually become pregnant.
Essential Pre-Conception Planning and Medication Review
Achieving low disease activity or remission is recommended for at least three to six months before attempting conception to improve pregnancy outcomes. This proactive “treat-to-target” approach reduces the inflammatory environment that can negatively affect both conception and the developing fetus. Planning should begin with coordinated care involving the rheumatologist, obstetrician, and sometimes a maternal-fetal medicine specialist.
The core of pre-conception planning is a thorough review and adjustment of all medications, as several RA drugs are unsafe during pregnancy. Methotrexate (MTX) is a teratogen and must be stopped at least three months before attempting conception due to its risk of causing birth defects. Male partners taking MTX should also discontinue it for a minimum of three months before trying to conceive.
Leflunomide, another DMARD, possesses a prolonged half-life and requires a specific washout procedure to clear it from the body before conception. This washout involves taking a medication like cholestyramine, followed by a waiting period. Medications generally considered safe to continue during conception and throughout pregnancy include hydroxychloroquine and sulfasalazine.
Low-dose corticosteroids (typically less than 7.5 mg of prednisone per day) can be utilized to maintain disease control during this preparation phase. Certain biologic agents, such as some TNF inhibitors, may be continued up until conception or into the first trimester, but this requires specialist collaboration. Stopping biologic DMARDs prematurely increases the risk of disease flares and adverse pregnancy outcomes. Stopping NSAIDs is also advised when actively trying to conceive, as they may interfere with implantation.
Managing RA Disease Activity During Pregnancy
Once pregnancy is established, the disease course of RA often changes. Approximately 50% to 60% of women experience an improvement in symptoms, sometimes achieving remission, particularly in the second and third trimesters. This improvement is related to the hormonal and immunological shifts that occur during gestation. However, this positive effect is not universal, and 20% to 40% of pregnant women with RA may continue to have moderate to high disease activity.
Active RA during pregnancy is associated with specific risks to both the mother and the fetus, underscoring the importance of maintaining low disease activity. High disease activity increases the risk of complications such as preeclampsia, preterm delivery, low birth weight, or being small for gestational age. These risks are minimized when the disease is well-controlled.
A high likelihood of a disease flare exists in the postpartum period, with rates reported as high as 40% to over 70% in the months following delivery. This postpartum flare is linked to the immune system reverting to its pre-pregnancy state. For managing flares during pregnancy, treatments are carefully selected, including low-dose prednisone, hydroxychloroquine, and sulfasalazine. Certain TNF inhibitors may also be continued through pregnancy, though they are often stopped in the third trimester to limit fetal exposure.