Pregnancy and arthritis

If you have arthritis or lupus and you are thinking about having a baby you may be concerned about the effect of the pregnancy on your illness, and the effect of your illness on the pregnancy and your baby. Because these conditions are so variable it’s best to seek individual advice from your doctor or specialist nurse before you try for a baby.

Some women with severe lupus may be advised against having a baby as pregnancy can put an enormous strain on your heart, lungs and kidneys. For others it will be safe to proceed under careful supervision.

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Whether you have arthritis or lupus you should think about the medications that you (or your partner) are taking as some of these can affect the pregnancy or even harm an unborn baby. However, with planning, it’s usually possible to alter your treatments so that you have a successful pregnancy and a healthy baby.

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Planning for a baby

If you have arthritis or lupus it’s best to discuss your pregnancy plans with your doctor or specialist nurse before conception. This is because of the drugs you’re likely to be taking for your arthritis.

When is the best time to have a baby?

It’s better to try for a baby while you are in a good phase with your arthritis so you can reduce the drugs you need to take during the pregnancy. Some drugs may have to be stopped before conception. For example:

You shouldn’t become pregnant or try to father a child while you are on methotrexate, cyclophosphamide or leflunomide as they can harm the unborn baby (see the section Drugs, pregnancy and breastfeeding).
Some recent studies suggest that non-steroidal anti-inflammatory drugs (NSAIDs) may make it more difficult to conceive and, if taken around the time of conception, may increase the risk of miscarriage, so you might want to discuss this risk with your doctor (paracetamol has not been linked with either of these problems).

Stopping your drugs may make your arthritis worse, but your doctor will be able to advise you on drugs that are safe to take. You may also be able to use other pain relief treatments, such as physiotherapy and acupuncture.

What supplements should I take?

All women who want to have a baby should take a folic acid tablet (0.4 milligrams) every day from 3 months before the time of conception until 12 weeks into the pregnancy. This is particularly important if you’ve ever been given methotrexate for your arthritis as this can affect your body’s supply of folic acid (see the section Drugs, pregnancy and breastfeeding). Folic acid will reduce the risk of your baby having a defect in the spinal canal (spina bifida). You can get folic acid from supermarkets, health food shops or chemists.

You should avoid supplements other than folic acid and iron supplements unless you have a specific deficiency, such as a lack of vitamin D. Asian women may be particularly susceptible to vitamin D deficiency due to low exposure to sunlight and a diet which is low in this vitamin (see Osteomalacia).

If you’re taking steroids during pregnancy you may also be advised to take calcium and vitamin D tablets to help protect your bones from thinning (osteoporosis).

Should I stop all my drugs before becoming pregnant?

Generally, you shouldn’t stop taking prescribed drugs without talking to your doctor. Your doctor will prescribe the safest combination of drugs at the lowest reasonable dose to reduce the risk of the tablets causing problems with the pregnancy.

Does it matter if the father is taking drugs for arthritis?

Some drugs, such as methotrexate, sulfasalazine or azathioprine, can reduce your sperm count, and methotrexate can also cause miscarriage or abnormalities such as spina bifida. Your doctor will advise you to stop these drugs well before trying to father a child. This is discussed in more detail in the section Drugs, pregnancy and breastfeeding.

What are the chances of my child having arthritis?

Couples who are contemplating pregnancy often worry that their baby may develop arthritis in later life. Most forms of arthritis do run in families to some extent, and the chances vary depending on the type of arthritis you have. However, for most types the chances of passing it on to your children aren’t very high, and shouldn’t usually affect the decision to have children. You should discuss the risks in your particular type of arthritis with your doctor.

Osteoarthritis

Most forms of osteoarthritis don’t have a strong tendency to be passed on from parent to child. In most forms, other factors – such as age, joint injury or being overweight – play a more important part.

One common form of osteoarthritis that does run strongly in families is nodal osteoarthritis. This mainly affects women and causes firm knobbly swellings on the fingers and often swelling at the base of the thumb, just above the wrist. Nodal osteoarthritis often doesn’t start until the 40s or 50s, around the time of the menopause, so you may not develop it while you are of child-bearing age. The chance of nodal osteoarthritis being passed on from mother to daughter is about 1 in 2 (50%).

Rheumatoid arthritis

Although rheumatoid arthritis tends to cluster within families, the tendency to pass it on from parent to child isn’t very strong. Research is continuing in this area, but the risk of a child inheriting rheumatoid arthritis from a parent is around 1 in 30 (about 3%) so they’re far more likely not to get it.

Ankylosing spondylitis and HLA-B27

The chance of a child inheriting ankylosing spondylitis is estimated at about 1 in 6 if the parent has the gene HLA-B27, and about 1 in 10 if not. However, the way that ankylosing spondylitis (AS) runs in families isn’t straightforward so it’s best to discuss this with your rheumatologist. When ankylosing spondylitis occurs in a family where other members have it, it tends to be less severe than when there’s no apparent family link.

HLA-B27 and other conditions

Other conditions are also associated with HLA-B27, including psoriatic arthritis and reactive arthritis. However, these are less strongly linked with HLA-B27 than ankylosing spondylitis. The risk for psoriatic arthritis is probably similar to the risk for rheumatoid arthritis at about 1 in 30, although the risk of the child developing psoriasis is higher.

Lupus (SLE)

If you have lupus the chances of your child developing it in later life are about 1 in 100. Because of the way the genes involved work, there’s actually a greater risk of other relatives developing the disease – for example, 1 in 33 (3%) for the sister of someone with lupus (the risk is lower for brothers).

During the pregnancy

It’s recommended that all pregnant women have an ultrasound scan at 11–12 weeks for dating and possibly to check for Down’s syndrome. A further scan is carried out at 18–20 weeks to check on normal development of the baby.

Will I be able to do my exercises?

It’s important for your arthritis to keep exercising for as long as possible during the pregnancy. As your pregnancy advances and you gain weight you may find it easier to exercise in the swimming pool where the water will help to support your weight.

Will the pregnancy affect my arthritis?

The effect of pregnancy on arthritis varies with the type of arthritis:

Most women with rheumatoid arthritis will be free of flare-ups during pregnancy, although the arthritis will return after the baby is born.
If you have osteoarthritis, particularly of the knee or hip, the increase in your weight as the baby grows may cause you problems.
Other disorders, such as ankylosing spondylitis, may improve or become worse – there’s no consistent pattern.

The effect of lupus (SLE) on pregnancy is outlined in the section Lupus (SLE) and pregnancy.

Will the arthritis affect my pregnancy?

Types of arthritis other than lupus don’t harm the baby, or increase the risk of problems during pregnancy. However, you should take care about the drugs you take while you are pregnant, as they can sometimes affect the pregnancy.

You should have a normal labour. Movement of the back and particularly the hips may aggravate pain if you have arthritis in these joints. However, different positions can be used in childbirth which should allow you to give birth naturally. If you have a lot of problems with your back, it’s a good idea to talk to an anaesthetist about whether you should have an epidural for pain relief. It’s not always possible, especially in ankylosing spondylitis, to perform an epidural. However, the anaesthetist will tell you about other options that are available.

Lupus (SLE) and pregnancy

Will the pregnancy affect my lupus?

Most women with lupus who become pregnant do so during a quiet phase or ‘remission’. You may stay in remission or have flare-ups during pregnancy, although flare-ups involving the skin and joints are less likely towards the end of pregnancy.

You should take care about the drugs you take during pregnancy. However, the risk of a problem to the baby may be greater if you don’t take the drugs or if you stop them suddenly. There are many drugs that can be safely used in pregnancy to treat your flare-ups, including steroids and immunoglobulin (see the section Drugs, pregnancy and breastfeeding).

Will the lupus affect my pregnancy?

Some women with lupus do have a higher risk of complications during pregnancy, though most will have a successful pregnancy. Your pregnancy will be closely monitored, and your obstetric consultant will need to see you frequently in the antenatal clinic. There is a higher risk of miscarriage if you have lupus, and the miscarriage may be later than usual in the pregnancy – up to 24 weeks if you also have antiphospholipid syndrome).

Planning your pregnancy will mean that your lupus specialists and the obstetric team can work closely together. They may advise you not to have your baby at your local hospital but at a more specialist site where they can work better as a team and with the best facilities to look after very small babies.

You and your baby may be checked more often than most women during pregnancy. If your lupus is mild you probably won’t need any extra scans. However, you may need additional scans if:

your disease is more severe, especially if your kidneys are affected
you test positive for lupus anticoagulant
you carry the anticardiolipin antibody in your blood.

The medical team will also use other ways of monitoring your baby which may include taking regular traces of its heartbeat and checks on the blood flow to the womb and the umbilical cord (using ultrasound scans). Your blood pressure and urine will also be checked.

What types of problem can happen with lupus later in pregnancy?

If you have kidney disease from your lupus or if your blood pressure is high before you become pregnant, your blood pressure may increase (pre-eclampsia) so you will need regular checks for blood pressure and for protein in your urine. High blood pressure can cause severe headaches and visual disturbances, so you should talk to your doctor if you develop these symptoms during pregnancy.
Your baby may not grow as fast as normal (growth retardation).
Your waters may break much earlier than usual or you may go into labour early (pre-term delivery).

There’s some evidence that a low-dose aspirin tablet taken every day can lower the risk of some of these problems. Your doctor will discuss this with you when you first go to the antenatal clinic.

The problems above are more likely if blood tests show that you have antiphospholipid syndrome. If you have this condition you will usually see a consultant with a particular interest in ‘high-risk’ pregnancies. You’ll be given a low-dose aspirin tablet to take every day, but you may also need daily injections (which you can give yourself) of a blood-thinning drug (anticoagulant) called heparin. This does not cross the placenta so it doesn’t affect your baby.

Will the lupus affect my labour?

You should have a normal labour. However, if you go into labour too early, the doctors may try to stop you labouring, with drugs, to allow more time for the baby’s lungs to mature. Doctors may sometimes feel that it’s safer (for you or for the baby) if your baby is delivered by Caesarean section.

Will the lupus affect my baby?

There is a risk of babies born to mothers with lupus being smaller than usual at birth. If this happens, your baby may need to spend a few days in the newborn (neonatal) nursery. If your baby is born very early, s/he will spend longer in the nursery and may need help initially with breathing.

If you carry Ro antibodies in your blood, there’s a chance that your baby’s heartbeat may become slow (congenital heart block). This problem develops during the pregnancy and continues after the birth. Only a few women with these antibodies will be affected by this, but your doctor will carefully monitor your baby’s heartbeat during the pregnancy. It’s possible that steroid tablets may help prevent this complication, but medical trials are still under way. Some babies affected in this way may need to have a heart-pacing device inserted after birth, but most will do very well.

After the birth

Coping with the demands of a small baby is exhausting for any new mother, and for a woman with arthritis the stresses can be much greater. Women with rheumatoid arthritis may find that their arthritis flares up again in the weeks after the birth (often after going into remission during the pregnancy).

Following the birth, a physiotherapist or occupational therapist may need to be involved in the aftercare, as holding, dressing, washing and feeding a baby can all be difficult because of stiffness. Ask your doctor how to go about getting help.

If you already have another small child or children, you may need to arrange for extra help in caring for them. Extra support from a partner, other family members or friends is crucial in sharing the care of a small baby, and help from social services can also help you to manage in the first few months after the birth.

What about my medication?

If your drugs for arthritis were stopped before or during the pregnancy most doctors recommend going straight back on to them, except where the drugs would stop you breastfeeding (see the section Drugs, pregnancy and breastfeeding). Because of the benefits of breastfeeding, some women prefer to wait until the arthritis flares up again before returning to their medication. Ask your doctor or rheumatology nurse specialist for advice on this.

If you have a flare-up shortly after the birth, perhaps before the disease-modifying anti-rheumatic drugs (DMARDs) have started working again, then your doctor may give you a short course of steroids. If only one or two joints are troublesome these can be safely injected with steroids. Physiotherapy can also be helpful during this time.

Will I be able to breastfeed?

Yes. Breastfeeding is best for your baby. Even if you only breastfeed for a few weeks it will give your baby a better start in life, so the doctors and midwives will try very hard to keep you on drugs that won’t affect your baby through your milk. Drugs you take while breastfeeding may pass into the breast milk, although in small amounts, so it’s sensible to take as few as possible.

Many drugs (particularly DMARDs such as ciclosporin, gold injections, cyclophosphamide, methotrexate, and leflunomide) must not be taken at all while breastfeeding – if these drugs are necessary then the baby should be bottle-fed.

Sulfasalazine and hydroxychloroquine have been used successfully in breastfeeding women, but you should discuss this with your doctor first. Steroids are excreted in small amounts in breast milk, but side-effects on babies are very unlikely especially in doses less than 40 mg per day of oral prednisolone.

Most NSAIDs don’t enter the breast milk in large quantities, except high-dose aspirin and this should be avoided. Drugs such as ibuprofen, indometacin and diclofenac can be used but doses should be kept to a minimum, and you should check with your doctor first.

See the section Drugs, pregnancy and breastfeeding, below, and Arthritis drugs & medication.

Drugs, pregnancy and breastfeeding

Most drug manufacturers and our drug information leaflets recommend avoiding drugs during pregnancy or while breastfeeding – but this doesn’t mean the drug will harm your baby. In some cases there is only limited information available, but we do know that, for most drugs, many pregnant or breastfeeding women will take them without any problems. We strongly recommend that you discuss each drug you take with your doctor – either when you are planning a family or as soon as possible if you unexpectedly become pregnant.

Paracetamol

Strictly speaking, paracetamol, like most drugs, isn’t recommended for use during pregnancy or while breastfeeding. However, it’s a good form of pain relief and is frequently used by women who are pregnant or breastfeeding without causing any problems. Most women can take the usual dose, even during pregnancy, but if your liver or kidneys are not working properly you may be told to use a lower dose.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs include aspirin, ibuprofen and indometacin. Although, they’re not generally recommended during pregnancy, they are sometimes used. NSAIDs may reduce the amount of fluid in the womb surrounding the baby, but they don’t cause abnormalities. Some studies suggest that taking NSAIDs may make it more difficult to conceive and that they may increase the risk of miscarriage if taken around the time of conception.

It’s best to use the lowest dose of NSAIDs you can and your doctor may advise reducing or stopping them towards the end of pregnancy. Large doses of NSAIDs taken towards the end of pregnancy may cause a blood vessel in the baby's heart to close early, while the baby is still in the womb, rather than at birth. (This blood vessel redirects the baby’s blood to allow it to get oxygen from its lungs, rather than the placenta.) This problem usually resolves itself completely if the NSAIDs are stopped. NSAIDs might also be stopped during delivery as they can prolong the labour and cause excessive bleeding.

If you have lupus or antiphospholipid syndrome you may need to take low-dose aspirin throughout pregnancy, especially if you’ve had previous miscarriages. Low-dose aspirin doesn’t affect the delivery or the blood vessel in the baby’s heart.

Most NSAIDs don’t enter the breast milk in large quantities, but high-dose aspirin should be avoided while breastfeeding.

Corticosteroids (‘steroids’)

These are often used in pregnancy. There’s no evidence that steroids harm your baby and doctors often give them during pregnancy to help the baby’s lungs to mature (usually when labour begins before 34 weeks). If you’re planning a family or find you are pregnant while you’re taking steroids, don’t stop taking them, but discuss things with your doctor.

If you’re taking steroids regularly, you may be slightly more likely to develop high blood sugar (diabetes of pregnancy), so you may need to have a glucose tolerance test at 26–28 weeks. This problem usually clears up when the steroids are stopped. You won’t need a test if you’re taking the steroids temporarily to help mature the baby’s lungs.

If you’ve been on high doses of steroids for a long time you may be given an extra boost of steroids to help your body cope with the stress of labour. This is routine in this situation. Women taking steroids throughout pregnancy are sometimes advised to take supplements of calcium and vitamin D to help prevent osteoporosis.

Steroids are excreted in small amounts in breast milk, but side effects on your baby are very unlikely at doses less than 40 mg daily of oral prednisolone.

Disease-modifying anti-rheumatic drugs (DMARDs)

Azathioprine

This can lower the sperm count in men and may affect the eggs in women. Azathioprine isn't generally recommended during pregnancy or while breastfeeding. However, women who’ve taken azathioprine have gone on to have normal pregnancies and healthy babies. If you’re planning a family or become pregnant while taking azathioprine, you should talk to your doctor as soon as possible.

Ciclosporin

Ciclosporin is used widely in people who’ve had transplants as well as for arthritis, and many women who have used the drug have had successful pregnancies. However, it’s best not to take ciclosporin while pregnant, and you shouldn’t breastfeed while taking it as the drug is excreted in breast milk. If you’re planning a family or become pregnant while taking ciclosporin, you should talk to your doctor as soon as possible.

Cyclophosphamide

Cyclophosphamide can reduce fertility in both men and women, so you may be advised to ‘bank’ sperm or have ovarian tissue stored before you start treatment with cyclophosphamide. If possible the drug should be stopped at least 3 months before trying for a baby, and should be avoided during pregnancy as it is likely to be harmful. Bottle-feeding is recommended if you need to take this drug after the baby is born.

Gold injections

Gold injections don’t appear to affect fertility. The drug does cross the placenta so it’s not recommended during pregnancy. However there have been no reports of this harming the baby. Gold is excreted in the breast milk and may cause a rash and kidney problems in the baby, so women who wish to continue with this drug should bottle-feed.

Hydroxychloroquine

This drug is frequently taken to prevent malaria as well as for arthritis and so far it doesn’t appear to increase the risk of birth abnormalities even at higher doses. Women with lupus have used it successfully during pregnancy. However, if you’re planning a family or become pregnant while taking hydroxychloroquine, you should talk to your doctor as soon as possible. You should not breastfeed if you are taking this drug.

Leflunomide

Leflunomide may cause birth defects and should be avoided before and during pregnancy. Reliable contraception should be used when taking this drug.

Leflunomide stays in the body for a long period of time. If you wish to have a baby you should allow at least 2 years from stopping this drug before trying to become pregnant. For this reason doctors sometimes avoid using it in women who may want a baby. The waiting period can be reduced to 3 months if you have a special treatment to ‘wash out’ the leflunomide from your body. Men should stop taking the drug, have the 'wash out' treatment, and then wait 3 months before trying to father a child.

Leflunomide shouldn’t be used while breastfeeding. If you’re planning a family or become pregnant while taking leflunomide, you should talk to your doctor as soon as possible.

Methotrexate

This affects both eggs and sperm. It can also cause miscarriage, or abnormalities such as spina bifida. Reliable contraception is essential whether you are male or female. Methotrexate must not be taken while you are pregnant or breastfeeding, and should be stopped at least 3 months (although some doctors recommend up to 6 months) before you try to become pregnant or to father a child. If you’re planning a family or become pregnant while on methotrexate, you should speak to your doctor as soon as possible.

Penicillamine

Penicillamine isn’t generally recommended and can cause problems if taken in high doses in early pregnancy. However, a number of women have had successful pregnancies while taking this drug.

Sulfasalazine

This can cause a low sperm count, but this is reversible. If a man has difficulty trying to start a family it might be better changing to another treatment. Many women have used the drug successfully during pregnancy and while breastfeeding, but we recommend that you discuss it with your doctor if you’re planning a family, become pregnant, or wish to breastfeed while taking sulfasalazine.

Biological therapies

The biological therapies include adalimumab, anakinra, etanercept, infliximab and rituximab. They’re all relatively new drugs and there’s therefore little experience of their effects either during pregnancy or while breastfeeding. Women of childbearing age must use contraception while taking these drugs. The drugs should be stopped 5–6 months before trying to become pregnant or to father a child. The drugs may pass into the breast milk and the effects on the baby aren’t yet known.

If you’re taking methotrexate along with a biological drug, you should also follow the advice for methotrexate.