Neonatal-Perinatal Medicine Specialist Questions Rheumatoid Arthritis

RA and pregnancy

I have rheumatoid arthritis and I am 28 years old. I would really like to have children some day, but I know I can't have kids while I take methotrexate. how is pregnancy handled for someone like me?

16 Answers

You are correct regarding the use of methyltrexate in pregnancy as well as many other commonly used drugs in RA patients. In fact many RA drugs must be discontinued many months prior to conception to ensure complete clearance.
Drugs used in pregnancy include corticosteroids and NSAIDS, but your obstetrician will work closely with your rheumatologist in determining which drugs are best for you as an individual.
Fortunately, RA symptoms tend to improve during pregnancy due to naturally occurring substances produced as a result of the pregnancy.
I urge you to consider pregnancy earlier rather than later due to increasing risks with increased age and you should see your gynecologist for preconception counseling prior to stopping any contraceptive method you may be using.

Kathie Boyd
This is an in-depth conversation Nd I would recommend you find a MFM in your area to discuss prior to conception. I feel you are in the Kansas City area I would be happy to see you.
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You are correct about not being able to take methotrexate during pregnancy. The good news is pregnancy state improves rheumatoid arthritis in 70% of women. This lasts all throughout pregnancy only to flare up during the postpartum period. There are alternative medications that can be used during conception and pregnancy such as steroids, NSAIDs, azathioprine etc depending on symptoms. The hardest part is getting pregnant, women with RA can take a long time to get pregnant, on average over 12 months. Hope this helps, good luck! RB
Speak with your obstetrician.
While you take methotrexate it is advisable to avoid pregnancy. You can control RA with natural techniques and some patients were so successful that they lead normal lives, free of pain and with no arthritis issues. Change your diet to avoid any nightshades, eliminate grains and dairy and any sugar (look up autoimmune diet on google). Also consider looking at whether or not you have intestinal permeability (leaky gut) since it has been implicated in causing the autoimmune dysfunction that leads to RA, lupus, Hashimoto's etc
If you plan to have pregnancy , then stop methotraxate 3 months before your plan and you can take plaquanil before(while planningfor pregnancy) and during pregnancy and also RA itself has less chances to flare up during pregnancy. so less medications needed. also prednisone can be useful if needed. 
The goal is to control the Rheumatoid Arthritis as best as possible before pregnancy. The more the inflammation is controlled, the less likely you will require therapy during pregnancy. As you mentioned, Methotrexate is teratogenic, which means harmful to the fetus, therefore must be stopped three months prior to conception. If you do require therapy during pregnancy, low dose steroid therapy can be taken.

The most important thing is for you to have a great trusting relationship with your rheumatologist. Let them know what you are thinking about. It will be important to discuss if and when you are planning to get pregnant. Methotrexate is associated with birth defects. If you start thinking about conception, you will want to be off methotrexate for at least a few weeks before you start trying. Often but not always the RA will go into a remission during pregnancy. If that occurs you will need little or no medications throughout the pregnancy. However if the RA flares there are still some medications that you can take safely during pregnancy such as low dose prednisone and hydroxychloroquine (plaquenil). You will also want to discuss if you plan to breast feed as that will impact what medications you can take for the RA after you deliver the baby. It will be important to re-start medication post partum because even if the RA goes into remission during the pregnancy, it often flares after the baby is born.
You will need to keep your rheumatologist up-to-date on your plans for having kids. Your medications may then need to be changed to one that is safer. Remember, this will also depend on what you have taken in the past and how well your disease is controlled. However, most immune disorders tend to remain dormant during pregnancy and this is usually the case with RA. The tricky part is management of the disease while you are trying to conceive and your rheumatologist's expertise will be crucial.
Your doctor who prescribes Methotrexate must revisit his advice on this drug for you. The doctor should weigh the severity of arthritis and the use of the drug. May change the treatment, if possible, so that you can pursue getting a safe pregnancy.
You would need a rheumatologist and a pregnancy specialist for this.
With pain medicines. Small doses of cortisone and physiotherapy, but ideally you should consult and follow the advise of your rheumatologist.
You need to have a preconceptional counseling with MFM and they will suggest what else you can take and still become pregnant.
You will need to hold Methotrexate for at least 3 months. Depending on how active your RA is, you should discuss with your rheumatologist about hydroxychloroquine, which is safe in pregnancy and/or an anti-TNF like Cimzia, which is recognized as safe in pregnancy. Pregnancy may induce a state of remission in some patients as well. I would avoid prednisone due to risk for gestational diabetes.
I have many patients with RA who have had successful pregnancies. As a rule, autoimmune disorders such as yours wane in pregnancy, so that is good. While MTX is not safe, steroids are. You should plan a consultation with a perinatologist (high-risk Ob) and your rheumatologist about how your care would go, and meanwhile, get as healthy as you can.