Arthritis and pregnancy

A common worry is that treatment must stop completely in pregnancy. In fact, going untreated can be harmful, because uncontrolled inflammation carries its own risks for mother and baby. The aim is to use medicines that keep the condition under control while being suitable for pregnancy. Many effective treatments can be continued, including hydroxychloroquine, sulfasalazine (taken with folic acid), azathioprine, and several of the anti-TNF biologic medicines. Certolizumab in particular crosses to the baby very little and is often well suited to pregnancy. Steroids such as prednisolone can be used at the lowest effective dose, and paracetamol is the preferred simple painkiller.

Some medicines must be stopped and switched to a safer option before trying to conceive, because they can harm a developing baby. These include methotrexate (stopped at least one to three months beforehand), leflunomide (which needs a special washout procedure, as it lingers in the body for many months), and mycophenolate mofetil. A few medicines, such as cyclophosphamide, are reserved for severe, organ-threatening disease, and the newer JAK inhibitor tablets are avoided for now. Anti-inflammatory painkillers (NSAIDs) are best used only sparingly and are generally stopped from around the middle of pregnancy; they can also make conception take longer, so it is reasonable to pause them when trying for a baby.

Please do not start, stop or change any medicine on your own. Some treatments need to be stopped well before conception, while others are important to keep taking, and stopping them suddenly can trigger a flare. The right plan is individual and is agreed with your rheumatology and maternity teams.

Some autoimmune conditions need particular planning around pregnancy. In lupus, pregnancy is best planned during a settled phase, ideally after the condition has been quiet for around six months, and hydroxychloroquine is usually continued throughout, as it helps prevent flares. Lupus pregnancies carry a higher chance of raised blood pressure and pre-eclampsia, so blood pressure and the kidneys are watched closely. If a mother carries particular antibodies (anti-Ro or anti-La), there is a small chance they can affect the baby's heartbeat, so extra monitoring of the baby's heart is arranged, usually from around 16 weeks.

In antiphospholipid syndrome (APS), the blood is more likely to clot, which can cause recurrent miscarriage or other pregnancy complications. The encouraging news is that this is very treatable: a combination of low-dose aspirin and heparin injections, started early and continued with close monitoring, greatly improves the chance of a successful pregnancy. The blood-thinning tablets used outside pregnancy (warfarin and the newer direct oral anticoagulants) are generally avoided in pregnancy and replaced with heparin, which does not cross to the baby.

With preparation and the right care, the great majority of women with arthritis or an autoimmune condition go on to have healthy pregnancies. The earlier the planning begins, the more can be done to settle the condition, choose suitable medicines and arrange monitoring. If you have an inflammatory arthritis or autoimmune condition and are thinking about pregnancy, now or in the future, a pre-pregnancy review is a worthwhile first step.