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Managing Arthritis During Pregnancy
Pregnancy and childbirth have a significant impact on rheumatoid arthritis (RA). The good news is that pregnancy frequently leads to a reduction in symptoms (in about 75 percent of women). Unfortunately, most women can expect a symptom flare-up, usually within the first three months following the birth. For about a quarter of women, the disease stays active or flares up during pregnancy. In general, studies show that women with RA can have a very favorable pregnancy and outcome; RA does not harm the baby except for an increased risk of low birth weight and prematurity in women with very active disease.
A Note on Medication
Perhaps the biggest challenge in relation to pregnancy and RA is managing medication. Numerous rheumatoid arthritis medications are not safe during pregnancy or breastfeeding, leaving only a limited number of options available.
Pregnancy often leads to an improvement in symptoms, and sometimes even remission, which often means drugs can be reduced or withdrawn. However, many women often still require some medication during pregnancy. In addition, particularly critical periods for managing RA are the preconception period (when drugs that could potentially harm the baby must be withdrawn) and during breastfeeding (when symptoms flare up again but limited drugs are safe for the breastfed baby).
Certain drugs must be withdrawn prior to pregnancy due to known risks of miscarriage and birth defects. In particular, the FDA advises that methotrexate be withdrawn three to six months prior to conception, and leflunomide two years before conception.
Please note that if you do become pregnant while taking these medications, an adverse outcome is not guaranteed.
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Don’t panic. Some women taking methotrexate during pregnancy have had normal births.
However, you should talk to your rheumatologist as soon as possible. Other drugs are only safe at lower doses or during particular trimesters. Also, many drugs have not been sufficiently tested during pregnancy to guarantee their safety. In general cortisone (prednisolone) is safe at lower doses, although no drug can be guaranteed completely safe. Even cortisone causes a very slightly increased risk of cleft palate in the first trimester and of premature labor in the last.
You must talk to your rheumatologist and obstetrical provider about the risks and benefits of using particular drugs to control your disease. You must also consider that untreated rheumatoid arthritis can negatively impact the baby, as well as your own longer-term health.
Prior to Conceiving
It is a good idea to speak to your rheumatologist and obstetrical healthcare provider before you plan to conceive. The aim will be to get your arthritis symptoms under control prior to conception. This will give you the ability to withdraw certain drugs and/or to change to ones that are safer during pregnancy.
During this period, you should also consider your symptoms and how you will cope with the demands of pregnancy. Consider exercises (if your doctor permits) to strengthen your leg and arm muscles for the physical demands of pregnancy, such as weight gain, changes in balance, instability in the hips, and increased laxity of ligaments and tendons. You should also consider how you will manage carrying a newborn baby and what support or adaptions to your home you might need after the birth.
During early pregnancy, you should take a good prenatal vitamin. Women on certain medications, such as cortisone, may also need additional calcium and vitamin D, so talk to your rheumatologist. Fish oils are beneficial for arthritis, but you should check that they guarantee low levels of mercury.
A healthy rheumatoid arthritis diet is essential. You want to aim to gain the recommended 20 to 30 pounds of weight during the pregnancy, but not too much so you don’t increase the pressure on your joints more than necessary. Pregnancy can make you very hungry, so keep lots of nutritious snacks on hand.
Consider trying non-drug based therapies to help with arthritis. This might include using splints, cold packs, or taking paraffin baths. Regular gentle exercise is beneficial, as long as your doctor agrees. It not only helps with weight control, but also helps keep the joints flexible. Safe exercises to consider are swimming and walking.
During pregnancy, you will need to have regular medical checkups with your rheumatologist and obstetrical healthcare provider, especially if you have active arthritic disease or if you are taking medications. Cortisone, for example, increases the risk of gestational diabetes as well as high blood pressure and you will need to be closely monitored for both.
During the later stages of pregnancy, it can be difficult to distinguish the normal symptoms of pregnancy from those of RA. Back pain, swelling and fatigue are all normal parts of pregnancy. Numbness or pain in the hands is also not uncommon, due to water retention causing carpal tunnel syndrome.
These symptoms should not be mistaken for an arthritis flare-up. You should keep in regular contact with your healthcare team to let them know how you are doing. Regular dental checkups are also advised, since people with RA are at increased risk of gum disease and gum disease can trigger preterm labor.
After the Birth
Most women with RA can deliver normally, even if they have had a hip replacement. Delivery is usually no different for a woman with RA compared to any other. After the birth, be prepared for a flare-up, which usually occurs within the first three months. This is often enough time to breastfeed the baby during the early period.
Some drugs, such as cortisone and hydroxychloroquine, are safe while breastfeeding. However, if these are not enough to control symptoms, then weaning maybe necessary in order to start other medications. Whatever occurs, the aim is a healthy mother and baby. Most women with RA deliver normal, healthy babies without significant impact on their disease.