Pregnancy is branching away from my usual topics of blogs and reading but here is something else I get asked about with reasonable regularity. Remember that the inflammatory arthropathies commonly onset in the younger years of adult life, when people are working and wish to start having families.
Previously when asked about this my stock answer is “Rheumatoid Arthritis tends to get better during pregnancy and often flares after”. After some more in-depth research this still holds up as a statement but I am going to add a little more depth below (this is as much for my benefit as yours!).
I will look to follow up this blog with one looking at Spondyloarthropathy. Happy reading and I am especially keen to hear from anyone who finds this particular blog useful with it being outside of my usual wheelhouse!
PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE
Fertility and Conception
These are fundamentally linked in the “getting pregnant” part of pregnancy, I hope I don’t have to go too much further into this and we all know where its going…
This portion of the process is made complicated by a few factors in women with RA. Diagnosis is linked with longer “Time To Pregnancy” with a higher proportion of women taking longer than 12 months to conceive than matched controls. This is significantly worse with higher levels of disease activity compared to remission. Higher disease activity signifies higher levels of pain and worse function, it is also medicated more aggressively and many medications used to treat RA have a direct effect on fertility. This as a combination is not a surprising revelation that women with RA take longer to get pregnant.
Disease activity during pregnancy
Rheumatoid Arthritis symptoms tend to improve during pregnancy with 54-95% of women reporting decreased symptoms.
Disease activity post partum
Frustratingly just as there becomes a requirement to carry around and look after a new born, 62-90% of women will experience a flare in symptoms from their RA.
From reading the literature this is exceedingly difficult to calculate due to confounding factors and there is likely to be a difference between planned and unplanned pregnancies due to medication use during conception. My summation is that women with RA are somewhat more likely to have pre-term births and/or caesarean section than controls. There is a slightly higher risk of pre-eclampsia but miscarriage rate is likely to be comparable (again possibly this is an underestimation in unplanned pregnancy).
Women with RA tend to have slightly smaller or lower birthweight children but this has not been shown to have a long term effect on the individuals.
There is a dearth of literature on the impact of male RA on offspring. Some medications can affect fertility but there isn’t much other than expert opinion to suggest an effect on the child. Advice would be the same as for women…
Practically other than educating on the above information, my best advice is that any person with a diagnosis of RA consults their Rheumatologist prior to trying to conceive. There is a delicate balancing act and maybe some concessions to be made with regards to optimising disease activity without affecting the likelihood/outcome of pregnancy. It is my opinion that there is no place for professionals outside of the Rheumatology consultant or Rheumatology Specialist Nurse to try and provide this counselling without specific training as it is a complex minefield with the medications.
Symptom management, activity modification/maintenance however is very likely going to be required post-partum alongside any necessary management due to the effects of giving birth and here Physiotherapists can play a strong role.
As usual thanks for reading and I hope that you find this useful.
Ince-Askan H, Dolhain RJEM, Pregnancy and rheumatoid arthritis, Best Practice & Research Clinical Rheumatology (2015).
De Man, Y. A., Dolhain, R. J. E. M., & Hazes, J. M. W. Disease activity or remission of rheumatoid arthritis before, during and following pregnancy. Current Opinion in Rheumatology (2014).
Brouwer J, Hazes JMW, Laven JSE, et al. Fertility in women with rheumatoid arthritis: influence of disease activity and medication Ann Rheum Dis (2014).