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Pregnancy, Rheumatoid Arthritis, and Lupus

by Bonnie L. Bermas, MD

For most expectant mothers, pregnancy is a time of wonder and worry. The excitement that starts with a positive pregnancy test is coupled with concern for a healthy pregnancy and baby. This concern is multiplied in women with rheumatic conditions. They must also worry about whether pregnancy will cause their condition to flare up, what medicines are safe to take, and whether the condition itself will affect the developing fetus or their own long-term health. In this article, we will look at these issues in women with two particular rheumatic conditions: rheumatoid arthritis (RA) and systemic lupus erythematosus (lupus).

RA and lupus are autoimmune conditions. In autoimmune conditions the immune system — which is designed to protect the body from foreign substances that might harm it — malfunctions and mistakenly attacks the body’s own tissues. Treatments for both RA and lupus include medicines that reduce immune system activity, to a greater or lesser degree. Pregnancy has its own impact on the immune system. The system must make some adjustments so that the mother’s body won’t attack as foreign the genes in the fetus that come from the father. These adjustments make it possible for the fetus to grow safely. They have other effects, too, which can impact rheumatic conditions such as RA and lupus in different ways.

Keep in mind

It’s not always easy to tell whether changes in the way an expectant mother feels are a result of pregnancy or of RA or lupus. When a woman is pregnant, for example, she can become anemic, which leads to fatigue and lack of energy. But RA and lupus can cause anemia, too. Pregnancy also affects certain markers of inflammation. For example, doctors use a blood test to measure an inflammatory marker called the erythrocyte sedimentation rate (ESR), which is often high in people with RA or lupus. But it may also be high in a pregnant woman, so measuring ESR may not be a good way to evaluate how active her RA or lupus is. In addition, pregnancy can make blood clots more likely. But some women with lupus have proteins called antiphospholipid antibodies in their blood, and these proteins also increase the risk of clots.

Pregnancy can also cause musculoskeletal issues itself. For example, as the fetus grows, the pregnant woman’s ligaments relax to allow the pelvis to stretch. Most pregnant women put on weight, which is both healthy and expected, and this can cause posture to change. These changes can cause joint aches and back pain. Similarly, carpal tunnel syndrome (CTS), which causes pain and numbness in the wrists, is a common complication of pregnancy, especially during the second and third trimesters. But CTS is also associated with RA and lupus. It can be tricky to figure out whether these problems are caused by pregnancy or by the underlying rheumatic condition.

If you have RA

RA mainly affects the joints, making them stiff, painful, swollen and, sometimes, unstable and deformed. But it can also have effects beyond the joints, ranging from fatigue to problems of the heart or eyes. Between 1% and 2% of the world population have RA, and it is more common among women than men. It often appears when people are in their twenties or thirties, so it’s not surprising to find women with RA among those considering pregnancy.

When a woman with RA is considering having a baby, the first thing that she’ll probably want to know is whether her arthritis will flare up during pregnancy. It is hard enough for the typical woman to contemplate carrying around 20–30 extra pounds of weight during pregnancy. But the thought of carrying that weight on replacement joints or on joints that are intermittently swollen and sore can be daunting. Fortunately, 70% to 80% of women with RA who become pregnant will go into remission during pregnancy. (That is, their symptoms will go away.) For the remainder, RA may become milder and more readily managed. It is difficult to predict who will go into remission. Despite this uncertainty, I generally recommend that my patients stop taking their RA medicines when they become pregnant because of the high likelihood that they will go into remission and not require treatment. Ideally, before you get pregnant, you’ll have worked out a plan with your rheumatologist for what types of medicine you will take if you do have a flare during pregnancy. (See “Medicines” below for information on specific drugs.)

If you have RA you also have to consider the type of delivery you will have. Most women with RA can safely undergo labor and vaginal delivery. If your RA affects your pelvis and lower extremities extensively, however, a vaginal delivery might be difficult. Your doctor may advise a planned cesarean section.

Unfortunately, many women with RA find that their arthritis flares up after they give birth. Caring for a newborn, especially for the first time, is a difficult task. It’s even more challenging if you are battling an RA flare. That’s why it’s important to carefully plan how you will manage the period after the baby is born. Careful planning can ease the adjustment of this postpartum period. If you plan to breast-feed your baby, discuss this with your health-care team (rheumatologist, obstetrician, and pediatrician) ahead of time. Some RA medicines are compatible with breast-feeding. Try to decide which of them you will be willing to take if you have a flare after the baby is born. Arrange if you can for some extra help at home during this period of transition. If that is not possible, do your best to have some extra meals stashed in the freezer so you can pull them out if things get difficult. Planning is key and will go a long way to easing the stress of even the worst RA flare during this period.

Last Reviewed on September 3, 2010

Bonnie L. Bermas is Assistant Professor of Medicine at Harvard Medical School and Director of the Lupus Center at Brigham and Women’s Hospital in Boston.

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