Pregnancy, Family Planning & Arthritis

Pregnancy, Family Planning & Arthritis

It can be difficult to cope with a pregnancy and family planning while also coping with arthritis. Learn more about the stages of pregnancy and family planning and how your arthritis may impact them.

Immune-suppressing Drugs May Not Harm Fetuses

Taking the drugs in early pregnancy may pose less risk than previously thought.

By Linda Rath

Taking medications for autoimmune conditions – including inflammatory types of arthritis, connective tissue disorders and inflammatory bowel disease – during the first trimester of pregnancy does not appear to put a fetus at greatly increased risk of a bad outcome, according to Vanderbilt University researchers. Their study, published online in Arthritis & Rheumatism recently, is one of the first to describe the effects of immunosuppressive drugs on a developing fetus.

“Autoimmune conditions [such as rheumatoid arthritis and lupus] affect millions of women in the United States, including many women of childbearing age. Yet we have very limited data to guide women and healthcare providers about whether to continue immunosuppressive medications during pregnancy,” explains lead author William Cooper, MD, professor of pediatrics and of health policy at Vanderbilt University School of Medicine in Nashville, Tenn.

Currently, women of childbearing age may be counseled to use one or two types of birth control while on certain medications. Those wishing to have a child are told to stop taking certain drugs and to go through a “wash out” period, so that the medication can flush out of their system before they become pregnant.

But Dr. Cooper points out, “Up to 50 percent of pregnancies are unplanned and women may become pregnant while taking a potentially harmful drug.”

Because clinical trials of medications are rarely, if ever, performed on pregnant women, most of the available information comes from animal studies or case reports. To obtain more definitive data, Dr. Cooper and colleagues conducted an observational study using statistics from three large health plans – Tennessee Medicaid, Kaiser Permanente Northern California and Kaiser Permanente Southern California. Together, the plans cover more than 8 million people each year.

A total of 608 mothers and their infants were included in the study. Although the women were economically, racially and geographically diverse, all had an autoimmune condition, such as RA, lupus or scleroderma, and all had been treated with an immunosuppressive drug before or during pregnancy. Prescribed medications included methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine, Sulfazine), azathioprine (Azasan, Imuran), corticosteroids and tumor necrosis factor (TNF) inhibitors (Humira, Enbrel and Remicade).

Of the women studied, 402 took an immunosuppressive medication in the first trimester, when fetuses are thought to be most vulnerable to its effects, and 35 used medication only in the second and third trimesters. The remaining 171 mothers used immunosuppressive drugs before becoming pregnant but not after.

Among the more than 600 pregnancies, there were a total of 68 adverse outcomes. Twenty-five infants had serious birth defects (such as cleft palate or club foot), 33 had life-threatening complications and there were 10 fetal deaths. (The infants were followed through the first three months of life – the period when most neonatal deaths occur and the majority of birth defects are diagnosed.)

Surprisingly, researchers found no statistically significant difference in outcomes for women treated with immunosuppressive drugs in the first trimester compared with those treated before becoming pregnant. (Because some autoimmune diseases can themselves increase the risk of birth abnormalities, healthy women were not used for comparison).

Of particular note were the findings on methotrexate, which the U.S. Food and Drug Administration identifies as a category X medication, meaning it can cause birth defects and fetal death. Yet the Vanderbilt researchers found that of 23 infants exposed to methotrexate in the first trimester, only one developed a birth defect, and it was a type not normally associated with the drug.

Dr. Cooper points out that most reports linking methotrexate with birth defects looked at higher doses, typically used in cancer treatment rather than the lower doses used to treat RA. Still, he stresses that his research doesn’t prove that methotrexate is safe.

One problem is the relatively small size of the study. Small studies often fail to find significant effects that a larger study would have detected. Yet Dr. Cooper believes the findings do provide “a critical piece of information to help guide women and their doctors.”

“Some of the medications in our study are recently approved and haven’t been extensively studied for use in pregnancy, although they are increasingly used and heavily marketed,” he says, referring to TNF inhibitors. “We thought it was important to take a look at them. …As we move forward, it will be important to do larger studies that provide more information.”

For now, he says each case is unique and women with autoimmune conditions should work closely with their health care providers to decide the best course of action to ensure optimal health outcomes for themselves and their babies. 

John M. Davis III, MD, a rheumatologist at Mayo Clinic in Rochester, Minn., adds a similar note of caution.

“Although it’s reassuring that the authors didn’t find evidence of a large increase in adverse fetal outcomes from first trimester exposure to immunosuppressive medications, the study had a low rate of events, which limits the power of this study to detect small but potentially meaningful increases in risk. As the authors acknowledge, further studies of a larger sample size are needed. But in the meantime, this information should be useful to women and their physicians in discussing the risks and benefits of immunosuppressive therapy before and during pregnancy.”

Alana Levine, MD, a rheumatologist with the Barbara Volcker Center for Women and Rheumatic Diseases at Hospital for Special Surgery in New York, is more optimistic, saying, “The results of this study are reassuring, particularly for those women who become inadvertently pregnant while taking these immunosuppressive medications. Now we may be able to allay the fear that early fetal exposure to some of these medications, particularly methotrexate, is as harmful as we currently believe.”

Pregnancy and Arthritis

Is it possible to have arthritis and a baby, too? You bet.

By Mary Anne Dunkin

The decision to have a baby is one of the most important ones any couple will ever make. But when the prospective mother has arthritis, the decision requires additional considerations: Can her body with withstand the stresses of pregnancy and childbirth? Can she safely stop her medications until her child is born? Does she have the stamina – and support – to care for a newborn and toddler? Could her disease have a negative effect on her child?

Arthritis has the potential to affect pregnancy at every stage – from conception to the weeks following birth. And pregnancy can make a difference – either good or bad – on a mother’s arthritis. But predicting the course of pregnancy – much less the course of a variable disease during pregnancy – is impossible.

Despite such uncertainties, doctors who have studied arthritis during pregnancy and pregnancy during arthritis have found some common problems shared by women with certain forms of arthritis and related diseases and at certain stages. (For information about pregnancy and specific types of arthritis, see the list here.)

For example, regardless of the form of arthritis you have, the medications you take for it have the potential to affect your pregnancy and/or your unborn child. Furthermore, if you suffer from morning sickness during your pregnancy, your ability to absorb oral medications may be affected. Speaking to your doctor about your medications before you become pregnant is essential.

If you struggle with fatigue because of your disease, the added stress of pregnancy may make it worse. Likewise, if you have back pain, your growing belly may exacerbate it, and increasing weight will place more stress on weight-bearing joints. And certainly any chronic disease presents challenges to caring for a newborn and growing child.

Doctors have also found some not-so-common problems and problems specific to certain forms of arthritis at certain stages of pregnancy. However, there are also findings that should ease fears and reassure couples who long for a baby – and those who find they are unexpectedly expecting one.

Your Pregnancy Health Care Team

When most women plan a pregnancy or become pregnant, they rely on one doctor – their OB/GYN – for advice and care. If you have arthritis, however, you’ll need to continue seeing your rheumatologist as well. If you have lupus or scleroderma – or if you develop any problems during your pregnancy – your OB/GYN will probably refer you to a high-risk obstetrician. If he doesn’t volunteer, you should bring up the possibility yourself.

If arthritis affects your spine or hips, ask if your obstetrician has experience working with women with disabilities – unfortunately, most doctors don’t, says Michael Lockshin, MD, professor of medicine and OB/GYN at Weill Cornell Medical College and director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York. If possible, find out the same about the anesthesiologist who will be working with you in the delivery room, should you need a C-section or pain medication during vaginal delivery.

Finally, you’ll probably want to stay in touch with your primary care physician. If you are a member of a health maintenance organization, this may be a necessity for medical coverage of your pregnancy.

 The good news is that, armed with knowledge and the help of a knowledgeable health care team, most women with arthritis and related conditions can have successful pregnancies and healthy, happy babies.

Tips for Coping With Pregnancy and Arthritis

Author Suzie May gives advice on becoming a parent with arthritis.

Arthritis Today interviewed Suzie May, who authored the book Arthritis, Pregnancy and the Path to Parenthood. Here are some words of wisdom, advice and encouragement from her book.

On deciding to become a parent:

I believe many factors should be considered when making the decision to bring a child into this world. While some considerations are purely feelings of the heart, others are clearly and importantly practicalities of the mind. There is no doubt that having a child is a big decision and its impact is life long, life changing and should not be entered into lightly. For some people, the desire to become a parent is an unshakable inner passion. For others, it is something that must be contemplated and carefully thought out based on personal, professional, financial and practical circumstances.

On surviving uncertainty and difficult days:

One of the many qualities that women (and men) with chronic health conditions generally possess is an incredible inner strength and determination. Remind yourself of the physical and emotional challenges you already deal with on a daily basis and trust that you will be able to cope with whatever pregnancy presents for you. Most importantly, stay focused on the magical gift you will receive at the end of this challenge – your new baby – who undoubtedly make it all worthwhile.

On coping with flares during pregnancy:

Remind yourself often that while your disease may still be active and cause you great pain and limitation, your body is busy creating life. While it maybe be easy (and understandable) to get upset with your body for causing you so much pain and frustration, remember to also acknowledge the amazing job it is doing. Try to focus on the beautiful and very special baby you are creating and how amazingly courageous and strong you are to be, despite your arthritis, achieving your goal of having your very own family.

On nurturing your relationship with your partner:

It is important to recognize the pressure and strains put on your intimate relationships. While partners are generally wonderfully supportive, the also have feelings. They may feel anger, frustration, sadness or helplessness and may need time out from thinking or talking about your health, just as you do from time to time. It is important to recognize your partner's needs and allow him or her opportunities to feel, talk and deal with them.

On accepting support from friends:

Some people support you by being at the end of the phone when you need a cry, others arrive on your doorstep with a hot meal and some magazines to take your mind off things, or offer to do your washing and take your baby for a walk to the park while you sleep. Try to establish a close network of people whom you can turn to. Put their phone numbers on your refrigerator and call them when you need help. Allow people who love you to help, even when you feel embarrassed or uncomfortable about it – you would do it for them!

For more about Arthritis, Pregnancy and the Path to Parenthood, visit www.suzieedwardmay.com.

Ankylosing Spondylitis and Pregnancy

Learn how ankylosing spondylitis will impact your pregnancy.

By Mary Anne Dunkin

If you have ankylosing spondylitis, you have about an equal chance of having your disease improve, worsen or stay the same during the course of your pregnancy, according to a 1998 study of 939 women with the disease. The study also found that women with peripheral arthritis (that is, arthritis in joints away from the spine) were more likely to experience improvement during pregnancy than those whose arthritis was confined to their spine.

If your disease was active when you became pregnant, it is more likely to flare shortly after you deliver your baby. As many as 60 percent of women had a flare of their disease after delivery, the study found.

Having ankylosing spondylitis is unlikely to affect your baby; however, it can affect your baby’s delivery. Spinal inflammation or fusion may make it difficult or inadvisable for a doctor to perform an epidural, a procedure in which pain medication is injected between the vertebrae directly into the outer layer of the spinal canal; it is the most common form of pain control used in both vaginal and Cesearan births. Women with severe spinal involvement should discuss alternative pain-relief methods with their doctors before delivery. If a C-section is a necessity – as it often is in women with ankylosing spondylitis – you may need to have general anesthesia.

 “Any form of arthritis that involves the hips may make vaginal delivery difficult,” says Michael Lockshin, MD, professor of medicine and OB/GYN at Weill Cornell Medical College and director of Volcker Center for Women and Rheumatic Diseases at the Hospital for Special Surgery in New York. “The biggest problem is that you have to be able to spread your legs fairly wide. A baby is a pretty big package to get through there.” For that reason, women with arthritis – even if their disease is inactive and their pregnancy uncomplicated – may be more likely to deliver by C-section.

Rheumatoid Arthritis and Pregnancy

It helps to know what to expect during your pregnancy.

By Mary Anne Dunkin

If you have RA and decide you want to start a family, you probably won’t have any more trouble getting pregnant than other women. As many as one in five couples have difficulty conceiving, regardless of any known medical condition. Although some studies show that women with RA have fewer children than otherwise healthy women, that may represent a choice to limit family size rather than a reduced ability to conceive or carry a baby to term. A 2006 study by researchers at the University of California, San Francisco, found that women with diagnosed with RA before the birth of their first child had the fewest pregnancies and children.

Before you try to conceive, it’s important that you speak with your doctor about the medications you're taking. Some can affect an unborn child from the very earliest days of pregnancy and because the effects of certain drugs can remain in the body for a period of time after you stop taking them, ideally, you should work with your doctor to taper off harmful medications – and perhaps switch to less risky medications – for at least a few months before you try conceive.

Before you get pregnant is also the best time to speak to your doctor about prenatal vitamins and supplements of folic acid, which can help reduce the risk of certain birth defects. Your doctor may also recommend a calcium and vitamin D supplement, but will probably advise that you avoid any over-the-counter herbal remedies.

First Trimester

If you unexpectedly find yourself pregnant and haven’t spoken with your doctor about medications – now is the time. Some drugs, such as leflunomide (Arava), methotrexate and cyclophosphamide (Cytoxan) can cause birth defects can cause birth defects. If you’re taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, your doctor may let you continue to using them – at least for a while. The greatest risk of these drugs comes later in pregnancy, when they may interfere with labor, affect amniotic fluid production or cause excessive bleeding during delivery. If you need medications to keep your disease under control, your doctor may put you on a corticosteroid, such as prednisone, that reduces arthritis inflammation but crosses through the placenta only minimally.

One of the first symptoms of pregnancy for any woman is fatigue. For women who already experience fatigue with rheumatoid arthritis, fatigue may worsen. Otherwise, pregnancy should have little effect on arthritis during this trimester; nor should arthritis have any effect on pregnancy. If you have relatively mild disease during the first trimester, there’s good news: Your disease is likely to remain mild through pregnancy, according to a 2008 study conducted by researchers in the Netherlands and reported in Arthritis & Rheumatism. If your disease is active during the first trimester, there’s a good chance it will improve a little later in your pregnancy.

Second Trimester

Approximately 70 percent of women with RA experience an improvement in symptoms beginning in the second trimester and lasting through about the first six weeks after delivery, says J. Bruce Smith, MD, assistant compliance officer for research at Thomas Jefferson University in Philadelphia and a rheumatologist whose research has focused largely on autoimmune disease and pregnancy. Fatigue may improve as well.

There are a number of theories why disease symptoms improve, including increased levels of anti-inflammatory cytokines and hormonal changes that occur during pregnancy. Researchers are continuing to study the phenomenon.

Exactly why some women with improve while others don’t is unknown, but a new study out of the Netherlands shows that women who are negative for rheumatoid factor and a type of autoantibody called anti-CCP are more likely to improve during pregnancy. Research also suggests that the father’s genetic contribution may play a role. The more genetically dissimilar a baby is to its mother, the better – at least as far as the mother’s disease goes.

Third Trimester

If your disease was mild to start with or improved during the second trimester, it will likely stay mild through the third trimester. However, fatigue may become worse as you grow heavier and closer to delivery.

Labor and Delivery

Having rheumatoid arthritis may slightly increase your risk of a premature baby, but does not increase your risk of having a baby with low birth weight, according to a 2006 study by researchers at the University of Washington, Seattle.

Women with RA are also more likely to have their babies delivered by Cesarean section. “Any form of arthritis that involves the hips may make vaginal delivery difficult,” says Michael Lockshin, MD, professor of medicine and Ob/Gyn at Weill Cornell Medical College and director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York “The biggest problem is that you have to be able to spread your legs fairly wide. A baby is a pretty big package to get through there.” For that reason, women with arthritis – even if their disease is inactive and their pregnancy uncomplicated – may be more likely to deliver by C-section.

If you took corticosteroids for more than two or three weeks during pregnancy, your doctor will likely give you stress doses of corticosteroids during delivery and monitor your baby after delivery to make sure she is producing adequate corticosteroids on her own.

Infection is a possibility after any delivery. If you are taking medications that suppress your immune system, however, infection is more likely. Most infections can be cleared up fairly easily and quickly with available antibiotics.

Postpartum

If you’ve enjoyed milder disease during your pregnancy, there’s a fair chance your disease will worsen again – at least for a while – after you deliver.

In a 2008 study out of the Netherlands, 39 percent of RA patients studied had at least one moderate flare postpartum.

While all new mothers need help from family or friends, you may especially welcome their help as a new mother with RA. You may find yourself having to deal with a disease flare at the same time you are trying to recuperate from childbirth and adjust to parenthood.

After you deliver, it is important to discuss medication choices with your doctor again, particularly if you plan to breast feed. Certain medications – including methotrexate and leflunomide – should not be taken during breastfeeding because of their potential effects on the baby. Others – including prednisone, certain NSAIDs and hydroxychloroquine – are probably safe and may be prescribed on a case-by-case basis.

Scleroderma and Pregnancy

Get the information you need to plan for pregnancy.

By Mary Anne Dunkin

If you have recently been diagnosed with scleroderma and would like to start a family, the experts’ best advice is to wait. “No woman with scleroderma should attempt to get pregnant within three years of diagnosis, because disease complications [including hypertension and kidney damage] are likely to show up within the first three years of the disease and could complicate a pregnancy,” says Virginia Steen, MD, professor of medicine at Georgetown University Medical Center in Washington, D.C. “If you get through these critical early years of the disease without complications, it’s probably safe to have a baby,” she says.

First, however, it is important to speak with your doctor about your medications.

Aside from cyclophosphamide (Cytoxan), which can cause ovarian failure, most drugs used for scleroderma don’t have severe effects on fertility; however, some can affect an unborn child from the very earliest days of pregnancy. Because the effects of certain drugs can remain in the body for a period of time after you stop taking them, ideally, you should work with your doctor to taper off harmful medications – and perhaps switch to less risky medications – for at least a few months before you try conceive.

Before you get pregnant is also the best time to speak to your doctor about prenatal vitamins and supplements of folic acid, which can help reduce the risk of certain birth defects. Your doctor may also recommend a calcium and vitamin D supplement, but will probably advise that you avoid any over-the-counter herbal remedies.

First Trimester with Scleroderma

Drugs continue to be a concern in the first trimester and throughout pregnancy. If you didn’t discuss medications with your doctor before you got pregnant, now is the time.

Some drugs, such as Cytoxan, can cause birth defects. Others, such as methotrexate, can cause miscarriages. If you’re taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, your doctor may let you continue to using them – at least for a while. The greatest risk of these drugs comes later in pregnancy, when they may interfere with labor, affect amniotic fluid production or cause excessive bleeding during delivery. If you need medications to keep your disease under control, your doctor may put you on a corticosteroid, such as prednisone, that reduces arthritis inflammation but crosses through the placenta only minimally.

There is some evidence that scleroderma may become more active during pregnancy, but this is debated. Dr. Steen has found the disease generally does not get worse during pregnancy, provided the woman has waited past the first three years of diagnosis to become pregnant – the most critical period in the development of complications, whether a woman is pregnant or not. On the other hand, scleroderma can affect later stages of pregnancy.

Second Trimester with Scleroderma

If you have scleroderma and worry that your stiff skin won’t accommodate your expanding belly, that’s one worry you can put aside. Dr. Steen, who says she has never seen a woman whose skin interfered with or was damaged by pregnancy.

Likewise, concerns about Raynauds’s phenomenon – a common complication of scleroderma and some other arthritis-related diseases in which the blood vessels to the extremities go into spasms in response to cold temperatures or stress – can be laid to rest. Raynaud’s often eases as your blood flow increases in pregnancy. Heartburn, on the other hand, will probably get worse during pregnancy.

If you have anti-Ro or anti-La antibodies, this is the time the effects on the baby become evident. These antibodies, also known as SS-A and SS-B, can cross the placenta and are associated with inflammation in the baby’s heart, leading to a condition called heart block which interferes with electrical impulses that tell the heart to beat. Beginning around your 15^th week of pregnancy, your doctor will monitor the fetus by fetal echocardiogram either monthly or weekly, depending on your antibody levels (called titers) and medical history. Echocardiogram is a procedure that uses ultrasound waves to view the action of the heart as it beats. If heart block is detected, your doctor will probably prescribe dexamethasone, a corticosteroid medication that crosses the placenta to help minimize the inflammation. Your doctor will continue to treat and monitor you throughout your pregnancy, because heart block may necessitate early delivery of the baby. If your baby hasn’t developed heart block by week 25, it’s not going to happen, says Michael Lockshin, MD, professor of medicine and Ob/Gyn at Weill Cornell Medical College and director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York.

Late in the second trimester, women with scleroderma are also at risk of toxemia (also called preeclampsia) – high blood pressure that develops during pregnancy and is accompanied by excessive fluid retention and protein in the urine. While toxemia is a risk late in pregnancy for any woman, women with antiphospholipid antibodies tend to get toxemia earlier.

Recent research has also shown that women with preeclampsia are likely to have a mutation in at least one of three genes associated with a rare disorder called hemolytic uremic syndrome, which triggers a potentially fatal, out-of-control immune response. This finding suggests that doctors may one day be able to screen women for risk of preeclampsia and that an experimental drug for hemolytic uremic syndrome could potentially be useful in the treatment of preeclampsia.

In the meantime, treatment for preeclampsia is primarily bed rest. The problem doesn’t resolve until the baby is born, so your doctor may have to deliver the baby by Cesarean-section as soon as it is mature enough to survive outside the womb, as late as possible and not before the 25^th week of pregnancy.

Another problem that can occur in scleroderma is placental insufficiency, a condition in which blood flow through the placenta isn’t sufficient to supply the necessary nutrients to the baby. The reason may be thickening or blockage of the blood vessels in the placenta and the result may be a low-birth weight baby.

Third Trimester with Scleroderma

During the final months of pregnancy preeclampsia and placental insufficiency continue to be risks for women with scleroderma. If you have preeclampsia, you’ll continue to stay on bed rest – possibly in the hospital – for the rest of your pregnancy. Placental insufficiency may lead to premature labor and delivery. Either of these conditions may necessitate an early delivery.

Labor and Delivery with Scleroderma

Although women with scleroderma may be concerned that a lack of tissue “stretchability” may present a problem during delivery, Dr. Steen says that is very rarely the case. In the event that a woman with scleroderma does have to have to a have a C-section, both doctors and patients have worried about how the incision will heal. Dr. Steen, however, has found no increased healing problems among those patients.

Infection is a possibility after any delivery. If you are taking medications that suppress your immune system, however, infection is more likely. Most infections can be cleared up fairly easily and quickly with available antibiotics.

Sjögren’s Syndrome and Pregnancy

Know the facts before becoming pregnant.

By Mary Anne Dunkin

As with other arthritis-related conditions, Sjögren’s syndrome occasionally presents its own set of problems during pregnancy. Experts advise that women with Sjögren’s syndrome who are planning to get pregnant as well as those who have suffered miscarriages be tested for antibodies including antiphospholipid antibodies, lupus anticoagulant and anticardiolipin antibodies and anti-SS-A.

In rare cases, antiphospholipid antibodies, lupus anticoagulant, anticardiolipin antibodies have been associated with recurrent miscarriages; anti-SS-A has been associated with congenital heart block, an abnormality of the rate or rhythm of the fetal or infant heart. If you have a positive anti-SS-A, your doctor may want to monitor your baby by fetal echocardiogram, a procedure that uses ultrasound waves to view the action of the heart as it beats. If heart block is detected, your doctor will probably prescribe a corticosteroid medication that crosses the placenta to help minimize the inflammation. Your doctor will continue to treat and monitor you throughout your pregnancy, because heart block may necessitate early delivery of the baby. But Robert I. Fox, MD, a rheumatologist at Scripps Memorial Hospital in La Jolla, CA, stresses that is rare. “It is important to reassure patients that the vast majority of women with Sjögren’s syndrome have babies with no congenital abnormalities,” he says.

As with other forms of arthritis, Sjögren’s syndrome is likely to flare after delivery. Your doctor may prescribe a corticosteroid at the time of delivery and in the weeks after to control flares.

Arthritis Medications in Pregnancy: What’s Safe, What’s Not?

Find out which medications are OK to take when you are pregnant, planning to become pregnant or breastfeeding.

In pregnancy, more than any other time, you and your doctor must weigh the benefits and risks of the medications you are taking. Some medications may be required to keep your disease under control – or even save the life of your unborn child – while others may actually cause pregnancy loss or irreparable damage to your baby.

Similarly, some are safe during pregnancy, while others can be passed through your milk, potentially harming your baby.

Following is a breakdown of the drugs most commonly used for arthritis. While some are contraindicated during pregnancy and/or breastfeeding, others may be used – or even advised. In all cases, it’s necessary to work with a rheumatologist and high-risk obstetrician to determine what’s best for you and your baby.

Arthritis Medications That Are Dangerous/Off-limits During Pregnancy

• Chlorambucil (Leukeran) – may cause miscarriage or birth defects
• Cyclophosphamide (Cytoxan) – may cause miscarriage or birth defects
• Leflunomide (Arava) – may cause miscarriage or birth defects
• Methotrexate (Rheumatrex) – may cause miscarriage or birth defects
• Warfarin (Coumadin) – may cause birth defects or severe hemorrhage

Arthritis Medications That Are Probably Safe During Pregnancy

• Azathioprine (Imuran) – not associated with increased risk of fetal abnormalities
• Cyclosporine (Neoral, Sandimmune)
• Corticosteroids (in general) – are considered relatively safe in low doses; however, they may increase the risk of some problems in the mother including hypertension and gestational diabetes and may cause babies to be small for their gestational age.
•  Specific corticosteroids:
  • Betamethasone (Celestone) – crosses placenta, used in late pregnancy to aid lung development in fetuses at risk of premature birth
  • Dexamethasone (Decadron, Hexadrol) – also used in late pregnancy to aid fetal lung development; used in mid- and late pregnancy to treat fetal heart block
• Heparin (Calciparine, Liquaemin) – may be used to prevent placental blood clots in women with antiphospholipid antibodies
• Hydroxychloroquine sulfate (Plaquenil) – probably safe, according to a series of small studies
• Intravenous immunoglobulin
• Low molecular weight heparin – may be used to prevent placental blood clots
• Sulfasalazine – not shown to adversely affect fetus

Arthritis Medications With Unknown Risk During Pregnancy

• Abatacept (Orencia) – no adverse effects have been reported in animal studies; however, there are no studies of the drug’s safety in human pregnancy
• Anakinra (Kineret) – no adverse effects have been reported in animal studies; however, there are no studies of the drug’s safety in human pregnancy
• Celecoxib (Celebrex) – Large doses cause birth defects in rabbits; effects on people are not known.
• TNF inhibitors – adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade) – There are no controlled studies in human pregnancy; however, numerous case reports and animal studies suggest they are safe.
• Rituximab (Rituxan) – The drug may pass to the infant, causing depletion of B-cells. Long-term results are unknown.

Arthritis Medications With Variable Safety During Pregnancy

• Aspirin – safety is variable and depends on dose and time of use; low doses may protect against pregnancy loss in women with antiphospholipid antibodies, yet may cause bleeding in mother and baby if used too close to delivery; risks of high doses are unknown
• Nonsteroidal anti-inflammatory drugs (NSAIDS) – naproxen (Naprosyn), ibuprofen (Motrin, Advil), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), indomethacin (Indocin) – Safety is variable and depends on dose and time of use; use near delivery is not advised

Arthritis Medication While Breastfeeding

Arthritis Medications That Are Dangerous/Off-limits While Breastfeeding

• Methotrexate (Rheumatrex, Trexall) – drug is excreted in breast milk and can accumulate in the baby’s tissues
• Leflunomide (Arava)
  Azathioprine (Imuran)

Arthritis Medications That Are Probably Safe While Breastfeeding

• Hydroxychloroquine (Plaquenl) – probably safe; however, should be discontinued if baby developed jaundice
• Infliximab (Remicade) – not shown to pass through breast milk
• Prednisone (Deltasone) – Low doses are safe during breastfeeding; however, the drug may suppress breast milk production.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) – probably safe during breastfeeding providing the newborn does not have jaundice
• Sulfasalazine (Azulfidine)

Arthritis Medications With Unknown Risk While Breastfeeding

• Celecoxib (Celebrex)
• Other TNF inhibitors
• Abatacept (Orencia)
• Anakinra (Kineret)