Communication key to successful reproductive planning in RA
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Rheumatoid arthritis can complicate reproductive decision-making for women, but communication between provider and patient along with careful planning can lead to successful outcomes.
In an email interview with Healio, Bonnie L. Bermas, MD, Dr. Morris Ziff Distinguished Professor in Rheumatology at UT Southwestern Medical Center, discussed some of the challenges women of reproductive age with RA face, special considerations when planning pregnancy in this patient population, the importance of coordinating care and more.
Healio: What are the challenges for rheumatologists when treating women of reproductive age?
Bermas: The challenges in treating women with RA of reproductive age is several-fold. Pregnancy should be planned for when the disease is under good control on medications compatible with pregnancy. Although 50% to 60% of women with RA will improve during pregnancy, that leaves many women who will not. Active disease during pregnancy increases the risk for preeclampsia and preterm delivery.
Healio: What should rheumatologists consider when discussing contraception with patients? Are there specific concerns related to safety and efficacy of hormonal contraceptives?
Bermas: First and most importantly, the rheumatologist should ask all of their reproductive-aged patients what their plans are regarding pregnancy. If a woman is not planning on becoming pregnant, then she should be counseled regarding contraception. Fortunately, for women with RA, there are no contraindications to hormonal contraceptives. We prefer that patients be on long-acting contraceptive methods, such as an intrauterine device or Depo-Provera, to ensure efficacy.
Healio: What issues could complicate pregnancy in women with RA? How should rheumatologists counsel patients during preconception planning?
Bermas: Women with RA can have an increased risk for preeclampsia and preterm delivery, especially if their disease is active. This is why we want our patients to become pregnant when their disease is under good control with pregnancy-compatible medications. Several of the medications that we use to treat RA are teratogenic, so patients should not be on those medications when trying to become pregnant.
Healio: Is fertility or fertility preservation a significant concern in women with RA?
Bermas: Women with RA have smaller families and take longer to get pregnant. Many factors contribute to this finding. Whether patients with RA have worse ovarian reserve is debated.
Healio: Does RA complicate the use of assisted reproductive technologies?
Bermas: No, women with RA can undergo assisted reproductive technologies.
Healio: How should RA be managed during pregnancy? How can rheumatologists coordinate care with the patient and their obstetrician-gynecologist?
Bermas: Ideally, women with RA should be comanaged with their rheumatologist and a maternal-fetal medicine provider. Most importantly, their provider needs to be knowledgeable regarding medication compatibility.
Although medications such as methotrexate, leflunomide and tofacitinib (Xeljanz, Pfizer) need to be avoided during pregnancy, other medications such as hydroxychloroquine, sulfasalazine, and tumor necrosis factor-alpha blockers can be continued. Other biologics can generally be taken up to conception. Nonsteroidals should be stopped at week 20; flares can be managed with low-dose glucocorticoids for short periods of time. Higher doses and longer duration predispose to pregnancy-induced hypertension, gestational diabetes and preterm premature rupture of the membranes.
Healio: As women proceed along the continuum of care, what issues should be addressed as a patient with RA goes through menopause?
Bermas: Postmenopause is a period during which a woman has an increased risk for osteopenia/osteoporosis. RA and use of steroids increase this risk. Women with RA should get adequate calcium and vitamin D. Bone density screening should also be done earlier in women with RA.
Healio: In what ways can we improve discussion and communication around reproductive health in women with RA?
Bermas: The more providers and patients talk about reproductive health, the better we can take care of our patients.
Healio: Do you have a take-home message for our readers?
Bermas: The vast majority of patients with RA can have successful pregnancies. My favorite days are when I can work with a patient to achieve their family planning goals, whether that be to become a parent, a biological or adoptive one, or remain child-free.
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Healio Interview
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