Managing Rheumatoid Arthritis During Pregnancy

Introduction to 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, 3

The American College of Rheumatology suggests counseling all women with RA early and periodically about family planning, emphasizing that entering pregnancy with quiescent or low disease activity dramatically improves maternal and fetal outcomes 4, 5, 6
Switch from teratogenic medications (methotrexate, leflunomide) to pregnancy-compatible alternatives at least 3 months before attempting conception, allowing several months to establish efficacy and tolerability of the new regimen 4, 5, 6

The American College of Rheumatology strongly recommends continuing hydroxychloroquine if already prescribed, or starting if not on it and no contraindication exists, due to its excellent safety profile and potential maternal and fetal benefits throughout pregnancy 10, 6, 8
The American College of Rheumatology strongly recommends sulfasalazine as safe throughout pregnancy for disease control 3
The American College of Rheumatology strongly recommends azathioprine as a pregnancy-compatible immunosuppressant, but notes that it should not be used for treating RA specifically in pregnant women according to FDA labeling 3
The American College of Rheumatology strongly recommends certolizumab throughout pregnancy as the preferred TNF inhibitor due to lack of Fc chain and minimal placental transfer 3

The American College of Rheumatology conditionally recommends low-dose prednisone or methylprednisolone (≤10 mg daily) throughout pregnancy when clinically indicated, as both are equally safe with potential maternal and fetal benefits 3, 11

The American College of Rheumatology strongly recommends initiating or continuing pregnancy-compatible steroid-sparing medications rather than relying solely on high-dose glucocorticoids if RA flares during pregnancy 6, 8, 7, 3

The American College of Rheumatology recommends monitoring disease activity with laboratory assessments at least once per trimester, and maintaining concurrent care with maternal-fetal medicine specialists throughout pregnancy 6, 8, 7, 4, 5, 3

The American College of Rheumatology advises against discontinuing all medications assuming pregnancy will induce remission, and against delaying switching from teratogenic medications, as unplanned pregnancies in RA patients carry greater risk than planned pregnancies on compatible medications 1, 2, 9