"Pregnancy in Rheumatic Diseases" at the American College of Rheumatology Annual Meeting
Almost five years ago, I talked with my rheumatologist about altering my treatment plan so that my husband and I could try to start a family. Though my rheumatologist was very supportive of my goals, I struggled to find any other resources on how to manage pregnancy, breastfeeding, and motherhood with RA. I was desperate for this information, but it seemed like resources were few and far between – and I have to admit the ones I did find were not very uplifting. I’m not sure I ever felt more alone.
Two babies later, the topic of motherhood with RA has become very near and dear to my heart. I’ve done my best to share my own story, in part by chronicling my second pregnancy on this site, so that other women on this journey will not feel so alone. But there’s only so much information I can provide to other women as a fellow patient. What most women with RA who want to become pregnant really need is advice and support from their rheumatologists.
For this reason, I was very excited to attend a session entitled Pregnancy in Rheumatic Diseases at the most recent annual meeting of the American College of Rheumatology. I was heartened to see that the lecture hall was packed with doctors and other rheumatology health care professionals. In fact, the session on pregnancy had the best attendance of all the “quality of life” topics I attended while at the annual meeting. Dr. Lisa R. Sammaritano, of the Hospital for Special Surgery and Weill Cornell Medical College, delivered the lecture to the assembled healthcare professionals.
Dr. Sammaritano encouraged rheumatologists to counsel the patient and their partner regarding the risks of pregnancy with a particular rheumatic disease, as well as discussing recommendations for a safe pregnancy. She emphasized the importance of assessing the unique risks individually for each patient, and then presented a general approach for assessing pregnancy risk. Although the approach she presented was meant to help rheumatologists evaluate and help their own patients, I think it is also a useful way for women with RA to evaluate themselves before deciding to start a family.
The first step is to assess disease severity. In cases of severe damage (such as cardiac, pulmonary, neurologic, or renal) Dr. Sammaritano conceded that it might not be safe to consider pregnancy. In these cases, she recommended discussing options for IVF with a gestational carrier (surrogacy) or adoption as a path to motherhood. If there is no severe damage from the disease, the next step is to assess current disease activity, as active disease at conception can affect both mother and baby. So if a patient’s disease has been active recently, it is best to defer pregnancy while treating to control the disease.
Once the disease has been inactive or controlled for about six months, then it’s time to do a medication assessment. Medications that are not compatible with pregnancy will need to be discontinued or changed to another low-risk medication before it is safe to become pregnant. Dr. Sammaritano pointed out that discontinuing medications does increase the risk of flares, so she reminded doctors to monitor and support their patients through this process.
When she reached the section of the lecture specifically discussing rheumatoid arthritis and pregnancy, Dr. Sammaritano said that it is true that many RA patients feel better during their pregnancies. However, she emphasized that the number of women who do feel better is less than previously thought. The initial report from about 30 years ago suggested that 70-75% of RA patients achieve some degree of remission while pregnant, but a 2008 prospective study has dropped this number to 48%. Though this drop in number may seem discouraging, I personally think that setting appropriate expectations for patients in this area is very important. I fully expected to feel much better while pregnant – but to my surprise flared badly during my second pregnancy. So hopefully rheumatologists will use these new statistics to help their patients be better prepared for disease activity, which can actually occur at any time during pregnancy.
As far as treating disease activity during pregnancy, each patient must be evaluated by her own doctors on an individual basis. In general, despite a slightly increased risk of preterm delivery, Dr. Sammaritano suggested that low dose prednisone should be preferred to NSAIDs, especially during the third trimester. Methotrexate should be discontinued at least three months before conception. And although this is still an evolving area, she confirmed that current research suggests it is likely safe to continue TNF-inhibitors until the detection of pregnancy and probably even during pregnancy if necessary. She did note that if TNF-inhibitors are used during pregnancy, it’s important the OBs and pediatricians be aware that infants should not receive any live vaccines for at least six months after birth.
Overall, Dr. Sammaritano encouraged rheumatologists to help their patients plan for pregnancy, including the need for effective and safe contraception until the disease is controlled and certain medications have been discontinued. She also emphasized the importance of having a plan in place for dealing with the likely occurrence of a post-partum flare. But, by understanding the risks and working as a team with their doctors, most patients with rheumatic diseases can have successful pregnancy outcomes.
This activity is not sanctioned by, nor part of, the American College of Rheumatology.