eMedicine Specialties > Rheumatology > Rheumatoid Arthritis

Rheumatoid Arthritis and Pregnancy: Follow-up

Author: Katherine Temprano, MD, Assistant Professor of Internal Medicine, Associate Program Director, Rheumatology Fellowship Program, Division of Rheumatology, University of Kentucky Medical Center
Coauthor(s): Shannon Colleen Florea, MD, Fellow, Department of Internal Medicine, Division of Rheumatology, University of Kentucky Medical Center; Elizabeth Scarbrough, MSN, Rheumatology Nurse Practitioner, University of Kentucky Chandler Medical Center
Contributor Information and Disclosures

Updated: Jun 22, 2009

Follow-up

Further Inpatient Care

Issues directly related to management of rheumatoid arthritis (RA) are best managed on an outpatient rather than an inpatient basis, and a visit with a rheumatologist should be scheduled shortly after hospital discharge, if possible.

Further Outpatient Care

  • Patients with RA must be monitored closely following delivery because most are likely to have arthritis flare-ups during the postpartum period.
  • Hyperprolactinemia has been associated with worsening of RA.11 Thus, it is possible that breastfeeding may increase the likelihood of arthritis flare-ups.

Inpatient & Outpatient Medications

  • NSAIDs can be used with caution, provided newborns do not have jaundice, because NSAIDs can displace bilirubin and predispose patients to kernicterus. There are insufficient data on COX-2 inhibitors and breastfeeding. If NSAIDs must be used during breastfeeding, only NSAIDs with a known safety record should be used.18
  • Prednisone can be used safely during breastfeeding because small amounts (5% of the glucocorticoid dose) are secreted in breast milk. At doses higher than prednisone 20 mg once or twice daily, breast milk is recommended to be pumped and discarded 4 hours following the steroid dose to minimize drug exposure to the infant.47
  • Hydroxychloroquine is found in human breast milk, and the infant may be exposed to 2% of the maternal dose/kg/day.48 While the elimination is slow and there is a potential risk for accumulation in the infant, most experts feel that the drug may be continued while breastfeeding. Hydroxychloroquine can potentially displace bilirubin and result in the development of kernicterus. The drug should be discontinued if the neonate has jaundice.
  • Methotrexate is excreted in breast milk in low concentrations and can accumulate in neonatal tissues; thus, it is contraindicated during lactation.49
  • Leflunomide is contraindicated during lactation.18
  • Only negligible amounts of sulfasalazine were found to transfer into breast milk.50 Sulfasalazine is believed to be safe during nursing, although the American Academy of Pediatrics has cited one reported case of bloody diarrhea in an infant as a reason to use caution with this drug during nursing.51
  • Breastfeeding is contraindicated during azathioprine therapy, as the drug is transferred into maternal milk.52
  • Because there are no data on the use of anakinra, abatacept, or rituximab in breastfeeding, lactation should be avoided during therapy with these agents.18
  • No studies have evaluated TNF-alpha antagonists and breastfeeding, but a few cases reports have been published on the subject. In one case, infliximab levels were measured in the breast milk of a nursing patient with Crohn disease, but no detectable amounts were found, either because a lack of secretion or because the infliximab concentration was undetectable with standard assays.53 In another case report, etanercept was found to be secreted in the breast milk of a patient with RA.54 Until more data are available on TNF-alpha antagonists and lactation, breastfeeding should probably be avoided during TNF-alpha therapy.

Transfer

Transfer may be required for surgical intervention.

Deterrence/Prevention

Health care providers should discuss contraception use in patients who are taking DMARDs considered to be a potential risk.

Complications

Complications may result from adverse effects of drugs in the fetus.

Prognosis

The long-term effect of pregnancy in patients with RA is unknown. Current data suggest that parity has no consistent effect on the risk or severity of RA.16

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to inform patients of teratogenic effects of certain DMARDS
  • Failure to inform patients about the potential adverse effects of the drugs recommended during pregnancy on maternal and fetal health
  • Failure to diagnose pregnancy before starting teratogenic disease-modifying agents
  • Failure to instruct patients against breastfeeding while on certain drugs
 


More on Rheumatoid Arthritis and Pregnancy

Overview: Rheumatoid Arthritis and Pregnancy
Differential Diagnoses & Workup: Rheumatoid Arthritis and Pregnancy
Treatment & Medication: Rheumatoid Arthritis and Pregnancy
Follow-up: Rheumatoid Arthritis and Pregnancy
References
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References

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Further Reading

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Keywords

rheumatoid arthritis and pregnancy, RA, arthritis, DMARDs and pregnancy, disease-modifying anti-rheumatic drugs, disease-modifying antirheumatic drugs, spontaneous abortions, preeclampsia, preterm delivery, pregnancy complications, pregnancy management, adverse fetal outcome, decreased sexual drive, ovulation dysfunction, impaired hypothalamic-pituitary-adrenal axis, impaired HPA axis

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Contributor Information and Disclosures

Author

Katherine Temprano, MD, Assistant Professor of Internal Medicine, Associate Program Director, Rheumatology Fellowship Program, Division of Rheumatology, University of Kentucky Medical Center
Katherine Temprano, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American College of Rheumatology
Disclosure: Nothing to disclose.

Coauthor(s)

Shannon Colleen Florea, MD, Fellow, Department of Internal Medicine, Division of Rheumatology, University of Kentucky Medical Center
Shannon Colleen Florea, MD is a member of the following medical societies: American College of Rheumatology
Disclosure: Nothing to disclose.

Elizabeth Scarbrough, MSN, Rheumatology Nurse Practitioner, University of Kentucky Chandler Medical Center
Elizabeth Scarbrough, MSN is a member of the following medical societies: American College of Rheumatology, Council for the Advancement of Nursing Science, and Sigma Theta Tau International
Disclosure: Nothing to disclose.

Medical Editor

Bryan L Martin, DO, Chief, Allergy Immunology Department, Walter Reed Army Medical Center; Associate Professor of Medicine and Pediatrics, Uniformed Services University of the Health Sciences; United States Army Consultant in Allergy Immunology and Immunizations
Bryan L Martin, DO is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ajay K Singh, MB, MRCP, MBA, Associate Professor of Medicine, Harvard Medical School; Clinical Chief, Renal Division, Director of Dialysis, Brigham and Women's Hospital; Consulting Staff, Faulkner Hospital
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals Obstetrics/Gynecology Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Vice Chair for Research and Education, Department of Obstetrics/Gynecology, Tufts Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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