Family Planning and Pregnancy
Is there any event in your life more joyous—and stressful—than having a baby? Every parent wants to do whatever possible to ensure a healthy baby, smooth pregnancy and safe delivery.
If you are living with a rheumatic disease like rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE or lupus) or others, you probably have lots of questions and concerns about starting a family.
- Will my disease affect my fertility and make it harder to conceive?
- Will my medications affect my baby’s health or development?
- Will my disease raise my risk of pregnancy complications?
- Will pregnancy affect my immune system, and if so, how?
- Will my disease make my delivery more complicated?
- Will I feel well enough for pregnancy, delivery, breastfeeding or caring for my new baby?
- Will my arthritis flare if I stop my meds during pregnancy, triggering joint damage or severe pain?
- Can I start taking my arthritis treatments after delivery, or do I have to hold off if I want to breastfeed?
- Will I be able to breastfeed?
- Will my kids also have my rheumatic disease?
All of these questions are very important, but one thing you should know now that will help you put your mind at ease: People who have rheumatic diseases often have safe, uneventful pregnancies. They are able to adapt their lives to have healthy babies. They breastfeed their babies and care for them just as any other parent does. Their children grow up to lead healthy, active, full lives. It might not always be easy, but it is possible.
However, RA, PsA, AS, lupus and other rheumatic diseases like antiphospholipid syndrome (APS) can increase your risk of complications during pregnancy. Some medications for rheumatic diseases can harm a fetus and cause birth defects if you are taking them when you conceive or during the early parts of your pregnancy. And having a rheumatic disease or living with its effects, like joint damage or pain, can make pregnancy or caring for your baby more challenging.
So it’s smart to plan ahead before you start your family.
Tips on Family Planning for People with Rheumatic Diseases
Family planning consultation with your rheumatologist, ob/gyn and/or a maternal/fetal specialist
Before you and your partner try to conceive, you can meet with your doctors to screen for factors that may make conception more difficult, or to identify medical conditions, and medications or lifestyle factors that could negatively impact fertility. Your rheumatologist can create a plan for you to stop taking any medications, such as methotrexate, leflunomide, mycophenolate, cyclophosphamide or others, that could be harmful to your unborn baby.
It’s recommended that you see your rheumatologist about three to six months before you try to get pregnant to make sure your disease is under control. Your rheumatologist can help you switch your medication regime if needed, during pregnancy – some medications may need to be stopped but others can be started to replace these. This allows you to keep your arthritis controlled in a way that may be safer for your baby. Keeping your arthritis under control is important since active inflammation can make it more difficult to conceive or increase the risk of negative pregnancy outcomes.
Remember: Don’t stop taking your medications on your own
Work with your doctor to cycle off these medications or make changes to your treatment plan. Your rheumatologist and ob/gyn need to know all the prescription or over-the-counter medications you are taking or have taken recently. That includes medications you may take for reasons other than your arthritis. You should also tell your rheumatologist and ob/gyn about any herbs, supplements or vitamins you take.
What about recreational drugs such as marijuana, cocaine or others?
Many doctors screen for drugs and alcohol on standard prenatal tests. If you use drugs, it may show up on these tests.
Recreational drug use during pregnancy could put your baby’s health at risk. This is a controversial issue for many women, who may not want to tell their doctor that they use illegal drugs out of fear of legal repercussions. While only you can make the decision about what to tell your doctor, be aware that these drugs can put your baby’s health at risk, and that marijuana and other substances may show up on your screening tests.
If your rheumatologist advises you to wait to try to conceive until your body is clear of certain medications or your disease is in remission, you’ll need to know about contraception. There are many different options to prevent pregnancy. Your doctor can give you information about these options, and how they may work for you and your lifestyle or budget. Don’t be ashamed to ask questions or be completely honest with your doctor about your sex life, or any concerns you have about contraception side effects or effectiveness. Ask any frank questions you have about how to properly use any form of contraception. It’s better to know what you’re doing than to take the chance on an unexpected pregnancy.
For women with lupus — screen for antiphospholipid (aPL), anti-Ro/SSA or anti-La/SSA antibodies
Women with lupus are typically tested for these antibodies. If you test positive twice for high levels of aPL (over 40 units), these antibodies can put you at risk for blood clots, as well as pregnancy loss. Your rheumatologist and obstetrician will consider adding aspirin, and sometimes a stronger blood thinner, to your treatment regimen during pregnancy.
The offspring of pregnant women who test positive for anti-Ro/SSA antibodies are at risk for developing a permanently slow heartbeat (congenital heart block) or a rash. It is important to screen for these antibodies before conception so you can know the risks. Your doctor might recommend extra medications to decrease the risk of the heart problems and ultrasounds to monitor for them during pregnancy.
Ideally, start taking prenatal vitamins BEFORE you get pregnant! They have their biggest impact on the fetus in the initial weeks of pregnancy, often before you even know you’re pregnant. Your doctor can give you a prescription for prenatal vitamins, but you can buy them over the counter at any pharmacy or supermarket (they all contain the same stuff ). Consult with your ob/gyn for recommendations.
Your rheumatologist will supervise any medication changes you make before or at the beginning of your pregnancy. Your doctor can also advise you on prenatal vitamins or supplements you should take, such as folic acid, and ensure that your immunizations are up to date. Your rheumatologist and ob/gyn can both advise you on any changes you should make to your diet, your exercise or physical activity routine, weight management and other lifestyle factors. It’s important to stay active during your pregnancy, including range-of-motion exercises to keep your joints flexible.
If you flare:
Your rheumatologist can schedule regular office visits during your pregnancy to monitor you for any symptoms of a flare. If your disease symptoms flare during your pregnancy, don’t panic! Your rheumatologist can prescribe safe treatments to help you lower your inflammation, control your symptoms and feel better. Post-partum flares are very common, so plan to meet with your rheumatologist soon after delivery.
Telling the difference between pregnancy and flares
When you are pregnant, you may feel symptoms that are pretty similar to those of your rheumatic disease:
- Low back pain
- Swollen ankles, feet or hands
At your medical appointments during your pregnancy, your rheumatologist and ob/gyn can keep track of your symptoms, and assess whether they are due to your rheumatic disease or symptoms of being pregnant. You can work with your doctors to treat your symptoms.
Here is a good guide: If your symptoms feel similar to your typical flare, then they probably are from your rheumatic disease. If they feel different from your usual symptoms, then it’s more likely that they are due to pregnancy.
How often do you need to see your rheumatologist during your pregnancy? It depends on your condition and if you have any flares during your pregnancy. In one recent study, 43% of pregnant moms with RA saw their rheumatologists once a month during their pregnancies, but 42% only saw their rheumatologists once every trimester and 14% only once during their entire pregnancy. Your rheumatologist can advise you on how often you will need to come into the office for a check-up.
If you have lupus or are deemed high-risk, you may need to see your rheumatologist more often during your pregnancy. Your obstetrician should get routine ultrasounds at about 11-14 weeks and 20-24 weeks. In your third trimester, more frequent ultrasounds are recommended to spot any problems with your baby’s growth or healthy heart development. If you have tested positive for anti-Ro/SSA antibodies, repeated fetal echocardiograms may be recommended to identify early changes in the heart rhythm.
How Arthritis May Affect Pregnancy
Your arthritis symptoms may lighten up during pregnancy, especially if you have RA. But also know many women may experience worsening symptoms or disease flares during pregnancy, particularly if medications have been stopped. Everyone is unique. Women with any rheumatic disease could have a flare during pregnancy, so let your rheumatologist and ob/gyn know if you notice any symptoms.
However, the normal—if unpleasant and inconvenient—symptoms of pregnancy may mimic arthritis symptoms, and can even make some joint and muscle problems feel worse.
- Joint pain and pressure on joints may increase. As you gain weight during pregnancy or retain more fluid, joints like your knees, ankles and feet may ache due to this increased pressure. You may notice joint pain when you walk up and down the stairs or move around.
- Water weight gain can make your lower extremities swell too, such as your lower legs, ankles or feet. If you notice any severe swelling, tell your doctor right away.
- As your baby grows, your uterus expands with it. This can put pressure on your spine and back. You may notice back pain, back muscle spasms, or numbness and tingling in your legs.
- The muscles you use to breathe push upward as your baby grows in your uterus. You may notice shortness of breath at times. Talk to your rheumatologist or ob/gyn if you are concerned about shortness of breath or dizziness.
- You will gain weight during your pregnancy. This can put extra pressure on joints that your arthritis has damaged or weakened. Try to keep your weight gain in the range that your obstetrician has recommended, usually around 20-30 pounds if you start out in the ‘normal’ weight range. If you are overweight or obese, talk with your ob/gyn about how much weight you should gain in pregnancy for optimal health. Eat a healthy diet that will nourish both you and your baby.
- Many women experience constipation or other bowel problems during pregnancy. If this happens to you, talk to your doctor. You may be able to take treatments to improve regularity, or change your diet to ease these symptoms. High-fiber foods, plenty of water and regular exercise are healthy ways to promote regularity.
- Weight gain and other normal aspects of pregnancy can make you feel sluggish and tired. Make sure that you stick to the physical activity plan that your doctors give you. Your rheumatologist and ob/gyn can create a safe, healthy exercise plan for you to follow during your pregnancy. They can also refer you to pregnancy exercise classes or therapists that can guide your physical activities.
- Use the same joint protection techniques you always use to prevent pain and injuries: range-of-motion exercises, good posture, hot or cold packs on sore joints, splints or assistive devices if you need support, and good sleep habits. Wear comfortable, supportive footwear to prevent slips or falls.
Mental Well-being and Pregnancy
It’s also normal during pregnancy to feel irritated, anxious, tired or stressed out. Being pregnant and having a chronic rheumatic disease, with extra medical appointments, tests or concerns, can put a strain on your emotions too. If you feel overwhelmed, talk to your doctors. They may be able to answer questions you have so you feel less confused or scared. They can also refer you to mental-health services or counseling if you need it. Many couples attend prenatal support groups to share their questions or concerns with others in their situation. This can help you relax a bit, because you know that you’re not alone and your concerns are normal.