Q&A: Rheumatoid arthritis and reproductive health in women
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Mehret Birru Talabi, MD, PhD, associate program director of the rheumatology fellowship training program at the University of Pittsburgh Medical Center, spoke with Healio about challenges patients with rheumatology face with fertility, how their RA symptoms are affected during pregnancy, and what they can to help improve their symptoms after giving birth.
Healio: Can rheumatoid arthritis impact fertility?
Birru Talabi: Poorly controlled RA does appear to negatively affect fertility. The mechanisms behind this are still unclear. However, individuals who have poorly controlled RA may find that it takes longer to conceive a pregnancy, or may even receive an infertility diagnosis. Sometimes this can be avoided. This is really an important point because some people may feel that they want to stop all of their RA medications prior to trying to become pregnant. While some RA medications are unsafe to use in the context of pregnancy, many medications are indeed safe during pregnancy.
Healio: Can RA symptoms worsen during pregnancy? What is the best approach to treating these symptoms during pregnancy?
Birru Talabi: Many people with RA will find that their symptoms improve during pregnancy. It should be noted, however, that only a small percentage of people — up to 20% — may experience remission during pregnancy. In many cases, people’s arthritis improves but does not completely go into remission. Up to one-third of people may experience some worsening of their symptoms during pregnancy. It’s also important to note that RA tends to flare within 3 to 6 months after delivery, which is a particularly vulnerable time as people have newborn infants and may even have returned back to work and have to deal with what can be a severe disease flare.
Healio: Are patients with RA at an increased risk for pregnancy complications?
Birru Talabi: Many people with RA can have healthy pregnancies. However, preterm birth, preeclampsia and cesarean delivery occur more often among pregnant people with RA than people without RA. One predictor for poor outcomes is uncontrolled disease during pregnancy.
Healio: What should physicians treating patients with RA advise them about childbirth?
Birru Talabi: Physicians should absolutely advise people with RA about childbirth and pregnancy, particularly how their RA might affect pregnancy and childbirth. Many people with RA can have normal childbirth.
Healio: Are there any specific precautions women with RA should take before or after giving birth to improve their RA symptoms?
Birru Talabi: I think this has to be specific to the patient. However, I would advise for people to follow up regularly with their rheumatologists during and after pregnancy. I would recommend that women with RA develop a plan with their rheumatologists about how a postpartum disease flare could be avoided or treated quickly. I strongly advise that women consider using medications that are compatible with breastfeeding, if they choose to breastfeed.
Healio: What unmet research needs exist in RA and reproductive health?
Birru Talabi: I find an important challenge in medicine is that we have largely excluded pregnant people from clinical trials for medications. Certainly, I can understand the need to be very cautious with testing medications in pregnant people. However, because we have so few studies about medication safety in pregnancy, it can be quite difficult to advise people accordingly. While pregnant people have been considered a “protected class” in research, by excluding them from trials, we have actually made them more vulnerable to adverse outcomes during pregnancy because we don't know in some cases how to treat them if their diseases severely worsen during pregnancy. This is a challenge in chronic disease management, especially as more people with chronic diseases are experiencing pregnancy in the United States. That said, we do know that healthy mothers are more likely to have healthy babies, and therefore, effective treatment really is an integral component in the care of the pregnant patient. We are fortunate to have several medications that are safe for pregnant and breastfeeding patients with RA. There are some resources that can help patients to learn more about the compatibility of their medications during pregnancy, including the American College of Rheumatology's Reproductive Health Initiative and the Mother to Baby program through the Office of Teratology Information Specialists.
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