Managing Rheumatoid Arthritis During Pregnancy

Introduction to Rheumatoid Arthritis Management

The American College of Rheumatology recommends achieving disease quiescence before conception using pregnancy-compatible medications, then maintaining control throughout pregnancy with hydroxychloroquine, sulfasalazine, azathioprine, low-dose prednisone (≤10 mg daily), and certolizumab as first-line options 1, 2

Optimize disease control before conception to minimize maternal and fetal risks, as active RA increases the risk of preterm delivery, low birth weight, and fetal loss 3, 4
Discontinue teratogenic medications at least 3 months before conception, specifically methotrexate and leflunomide, and switch to pregnancy-compatible alternatives with several months of observation to ensure disease stability 3

Hydroxychloroquine is strongly recommended throughout pregnancy with an excellent safety profile and potential maternal/fetal benefits 1, 2
Sulfasalazine is strongly recommended as safe throughout pregnancy for disease control 1, 2
Azathioprine/6-mercaptopurine is strongly recommended as a pregnancy-compatible immunosuppressant 1, 2
Certolizumab is strongly recommended throughout pregnancy as it lacks an Fc chain and has minimal placental transfer, making it the preferred TNF inhibitor 1, 2

Other TNF inhibitors (infliximab, etanercept, adalimumab, golimumab) are conditionally recommended during pregnancy, particularly in the first and second trimesters when placental transfer is minimal 1, 2, 6
If disease is well-controlled, consider discontinuing TNF inhibitors in the third trimester to avoid high neonatal drug levels 7, 1
Calcineurin inhibitors (tacrolimus, cyclosporine) are conditionally recommended as compatible during pregnancy 7, 1

Low-dose prednisone (≤10 mg daily) is conditionally recommended throughout pregnancy when clinically indicated 7, 1
Higher doses must be tapered to <20 mg daily, adding pregnancy-compatible steroid-sparing agents as needed to avoid maternal and fetal complications from prolonged high-dose exposure 7, 1

NSAIDs are conditionally recommended in the first and second trimesters, with nonselective NSAIDs preferred over COX-2 inhibitors due to limited data on the latter 7, 1
Discontinue NSAIDs before conception if subfertility is present, as NSAIDs may cause unruptured follicle syndrome 1, 2
NSAIDs are strongly contraindicated in the third trimester due to the risk of premature ductus arteriosus closure 7, 1, 2

Methotrexate and leflunomide are absolutely contraindicated throughout pregnancy due to teratogenic effects 2
Non-TNF biologics (abatacept, rituximab, tocilizumab) should be discontinued at the time of positive pregnancy test due to limited safety data 7, 1
JAK inhibitors (tofacitinib, baricitinib) have no safety data available and should be avoided entirely 7

If RA flares during pregnancy, strongly recommend initiating or continuing pregnancy-compatible steroid-sparing medications, as both uncontrolled disease and prolonged high-dose steroids pose significant maternal and fetal risks 3, 5, 4

Maintain concurrent care with maternal-fetal medicine specialists throughout pregnancy for optimal outcomes 3, 4
Monitor disease activity at least once per trimester with laboratory assessments 5

Do not discontinue all medications assuming pregnancy will induce remission—approximately 40% of patients do not experience remission [@ignore ref removed]
Do not use fluorinated corticosteroids (dexamethasone, betamethasone) for routine RA management, as these cross the placenta extensively 7
Do not delay switching from teratogenic medications—allow several months to establish efficacy of pregnancy-compatible alternatives before conception 3, 4
Do not continue NSAIDs into the third trimester, even if disease control is suboptimal; switch to other pregnancy-compatible options 7, 1, 2