“I've been married a little over a year, and I am afraid of getting pregnant, even though I want to someday,” a myRAteam member wrote.

Rheumatoid arthritis (RA) often affects women during their childbearing years, and many members on myRAteam have questions about starting a family. Although many women with rheumatoid arthritis have healthy pregnancies and babies, there are several important factors to consider before and during pregnancy. Understanding potential complications and medication changes women with RA may encounter can help ensure a healthy, successful pregnancy.

Pregnancy and RA Medications

Many RA medications, including disease-modifying antirheumatic drugs (DMARDs), are safe to use during pregnancy. Rheumatologists generally recommend using low doses for the shortest period to manage symptoms. However, not all DMARDs are safe during pregnancy. For example, methotrexate should be stopped at least three months before becoming pregnant and during the entire pregnancy due to the potential for miscarriage and birth defects. Although additional research is needed, biologic medications such as tumor necrosis factor (TNF) inhibitors are generally considered safe during pregnancy. The American College of Rheumatology recommends continuing TNF inhibitors if necessary to manage symptoms during pregnancy. To limit infection risk in babies, some rheumatologists recommend stopping biologic medications during the third trimester.

If you are pregnant or thinking about becoming pregnant, always discuss any medications you might be taking with your doctor.

First Trimester

People with RA should make a medical plan with their doctor and rheumatologist before becoming pregnant or as soon as they find out they are pregnant. According to the American College of Rheumatology, some pregnant people with RA may only need routine visits to their rheumatologist. For example, pregnant women with low risk for pregnancy complications can usually plan regular three-month visits to the rheumatologist. However, those with active disease are considered high-risk and should be monitored by both a rheumatologist and a high-risk obstetric team. These women should schedule doctor visits more frequently late in pregnancy, as often as weekly.

Ideally, RA should be well controlled for three to six months before becoming pregnant, as uncontrolled RA increases the risk of complications such as preterm birth and low birth weight. Regardless of RA activity, many people experience typical first-trimester pregnancy symptoms, such as fatigue, nausea, vomiting, and bloating.

In some cases, RA symptoms improve during pregnancy. “I'm currently 10 weeks pregnant with twins. I've noticed at one point, my RA felt like it was completely gone!” one myRAteam member wrote. In other cases, symptoms stay the same or worsen: “I am 17 weeks pregnant, and I was hoping that my pain and RA would get better. But it has not.”

For those who experience improvement, symptoms such as pain and fatigue may ease in the first trimester. Researchers believe this is due to hormone and immune system changes that occur during pregnancy. Those who experience relatively mild RA activity during the first trimester are likely to have mild disease throughout pregnancy.

Second Trimester

Women with low RA disease activity in the first trimester will likely continue experiencing mild disease in the second trimester. A study in the Journal of Rheumatology found that disease activity improved in 60 percent of women with RA during pregnancy. In many cases, this improvement in RA symptoms becomes evident in the second trimester.

However, typical pregnancy symptoms such as weight gain and a growing belly may cause pressure or pain on the hips, knees, and back. This increased pressure may exacerbate RA symptoms such as joint pain, swelling, and stiffness.

Women should discuss their symptoms and management strategies with their health care team. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are not recommended after 20 weeks of pregnancy. The U.S. Food and Drug Administration updated this guidance in October 2020.

Third Trimester

About half of pregnant women with RA have low disease activity throughout pregnancy, and up to 40 percent achieve remission by the third trimester. During the third trimester, many women experience swelling, backaches, and tiredness regardless of whether they have RA.

If RA affects a woman’s back or hips, she may notice more pain in those joints as the baby grows and places more stress on those joints. To help manage these third-trimester symptoms, pregnant women with RA may find relief from warm baths, hot packs, gentle swimming, yoga, and naps. Women should discuss these symptoms with an obstetrician or rheumatologist if concerns arise or symptoms worsen.

Birth

Pregnant individuals with RA should make a birth plan with their rheumatologist and obstetrician. For many women with RA, labor and delivery proceed in a normal way. Unless pelvic joint deformities are present, RA should not affect the ability to have a vaginal delivery. If RA has had an impact on a woman’s hips or mobility, delivery plan adjustments may be needed.

Cesarean delivery (C-sections) are not more common overall in women with RA. However, high disease activity during pregnancy increases the risk for preterm, low birthweight babies and the need for a Cesarean delivery.

Talk to your doctor about pain management options. An epidural may not be an option for individuals whose spines are affected by RA.

Postpartum

Although many women with RA experience low disease activity during pregnancy, flare-ups are common after delivery (postpartum). Some studies show that more than 46 percent of women experience RA flares postpartum. Researchers believe hormonal and immune system changes in the months after delivery are responsible for these flares.

Caring for a newborn baby is tiring for all new parents and can be especially challenging for those with RA due to flares, fatigue, and joint pain. People with RA should ensure they have a secure support system to help them during the postpartum period.

To ease RA pain, a rheumatologist or lactation consultant can suggest ways to hold the baby that relieve the pressure on the neck, shoulders, wrists, and fingers. There are also strategies you can use to reduce discomfort during diaper changes, bathing, and feeding.

If you plan to breastfeed, your doctor can help recommend low-risk medication. Although many medications are safe, certain drugs should not be taken while breastfeeding because of their potential effects on the baby.

Talk With Others Who Understand

By joining myRAteam — the social network for people with rheumatoid arthritis and their loved ones — you can connect with more than 152,000 other members who understand life with RA. Every day, members come together to ask questions, give advice, and share their stories.

Are you pregnant or planning to become pregnant while managing your RA? Share your experience in the comments below, or share your story on myRAteam.