Updating on pregnancy in rheumatoid arthritis

ABSTRACT

Introduction

Rheumatoid arthritis (RA), the most prevalent autoimmune disease in reproductive years, exhibits a higher incidence in females, suggesting involvement of estrogens, genetics and environmental factors in disease onset. Literature shows smaller families in RA patients, driving increased interest in Assisted Reproductive Techniques.

Areas covered

This review elucidates how immunotolerance mechanisms contribute to favorable pregnancy outcomes in RA, emphasizing the need for a careful pregnancy planning to mitigate fetal complications and postnatal flares, which surpass those in the general population. A thorough medication evaluation, orchestrated by a multidisciplinary team, is imperative during pregnancy, weighing potential teratogenic effects against safer alternatives to balance medication safety with disease control. A systematic literature search on PubMed and MEDLINE, using specific terms, covered relevant academic journals up to the latest date.

Expert opinion

This narrative review comprehensively addresses pregnancy-related considerations in RA patients, prioritizing meticulous disease management with pregnancy and breastfeeding-compatible drugs in line with the latest recommendations and registry data. The focus remains on evaluating glucocorticoids, conventional, and biological disease-modifying drugs for compatibility during pregnancy and breastfeeding. Additionally, the evolving landscape of targeted synthetic drugs during pregnancy is explored, providing insights into the latest developments in rheumatological care.

KEYWORDS:

• Pregnancy
• rheumatoid arthritis
• fertility
• lactation
• treatment
• contraception

Article highlights

• In clinical settings, adopting a gender medicine approach is vital to address reproductive health concerns, including contraception, fertility-related issues, and family planning.

• Pregnancy planning during remission phase or low disease activity is essential to achieve successful pregnancies minimizing potential maternal and fetal complications.

• The favorable course of pregnancy in RA is attributable to heightened immunotolerance rather than to an increase in Th2 activity. Conversely, during postpartum frequent disease flares occur due to the physiological elevation of proinflammatory cytokines and pro-inflammatory hormones like prolactin.

• An increased number of drugs are now accessible for use during pregnancy and lactation, enabling optimal disease management in mothers with reduced risk of adverse effects on the unborn child.

• The epigenetic modulation exerted by hormonal changes during pregnancy seems to explain the clinical changes observed in presence of autoimmune rheumatic diseases

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants, or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

We thank the European Alliance of Association for Rheumatology (EULAR) Study Group on Neuro Endocrine Immunology of the Rheumatic Diseases (NEIRD) for the continuous cultural support.

Additional information

Funding

This paper was not funded.