Management of Rheumatoid Arthritis During Pregnancy Planning

Current Medication Safety During Pregnancy

The American College of Rheumatology recommends that hydroxychloroquine be continued throughout pregnancy as it is considered safe and compatible with pregnancy 1, 2
The American College of Rheumatology also recommends that sulfasalazine be continued during pregnancy, but requires daily folic acid supplementation due to its inhibition of folate absorption 1, 2
Both medications have extensive safety data supporting their use during pregnancy and are categorized as "strongly recommend continuing" in pregnancy guidelines, with a strength of evidence considered high 3, 4

For shoulder pain management in patients planning pregnancy, the American College of Rheumatology recommends that NSAIDs can be used in the preconception period but should be discontinued if the patient is having difficulty conceiving 5, 4
During pregnancy, the American College of Rheumatology recommends that NSAIDs can be continued in the first and second trimesters but must be discontinued in the third trimester, with a strength of evidence considered moderate 4, 2
Low-dose prednisone (less than 20 mg/day) can be conditionally recommended if needed for pain control, with a strength of evidence considered low 4, 6

Active rheumatoid arthritis increases the risk of adverse pregnancy outcomes, so optimal disease control should be achieved before conception, according to the American College of Rheumatology 2

The treatment algorithm for shoulder pain management recommends continuing hydroxychloroquine and sulfasalazine throughout pregnancy planning and pregnancy, with a strength of evidence considered high 1, 3
Adding folic acid supplementation (5 mg/day) is recommended due to sulfasalazine use, with a strength of evidence considered high 2

The American College of Rheumatology recommends monitoring disease activity at least once per trimester, with a strength of evidence considered moderate 7
Assessing for medication side effects and adjusting dosages as needed is also recommended, with a strength of evidence considered moderate 4
Monitoring for pregnancy complications, such as preterm delivery and low birth weight infants, is recommended for women with rheumatoid arthritis, with a strength of evidence considered high 2

Both hydroxychloroquine and sulfasalazine are compatible with breastfeeding, according to the American College of Rheumatology, with a strength of evidence considered high 4, 2
NSAIDs can be used during breastfeeding, with ibuprofen being the preferred option, with a strength of evidence considered moderate 4, 2

Discontinuing effective medications unnecessarily due to pregnancy planning can lead to disease flares, according to the American College of Rheumatology, with a strength of evidence considered high 2
Failing to provide folic acid supplementation with sulfasalazine can lead to folate deficiency, with a strength of evidence considered high 2
Continuing NSAIDs into the third trimester can cause premature closure of the ductus arteriosus, with a strength of evidence considered high 4, 2
Overlooking the need for disease control before conception increases risks of adverse pregnancy outcomes, according to the American College of Rheumatology, with a strength of evidence considered high 2