The management of women of childbearing age with rheumatoid arthritis: an expert report

Figures & data

Table 1. Considerations at RA diagnosis in WoCBA.

Item	Description
Considerations for the rheumatologist
Disease activity	Confirm remission or low disease activity
Assessing the condition of the joints	Check the range of motion of the joints
Comorbidities/history	Screen for complications such as thyroid disease, hypertension, diabetes, and obesity Screen for immunization status (e.g. rubella) and other autoimmune diseases that may affect pregnancy Screen for autoimmune diseases that may affect pregnancy
Considerations for the OB/GYN specialist
Past pregnancies	Determine past fertility and pregnancy history, and pregnancy-related complications (e.g. miscarriage, stillbirths, preterm birth, hypertensive disorders of pregnancy, gestational diabetes mellitus)
Cervical cancer	Recommend screening for cervical cancer every 2 years, regardless of immediate conception plans
Co-morbid diseases	Screen for sexually transmitted infections (if patients have symptoms)
Other	Check for any other factors (e.g. smoking, family history of genetic disorders) that may affect pregnancy

Table 2. Considerations in the preconception period for WoCBA with RA [5,11].

Item	Assessment Contents
Considerations for the rheumatologist
RA medical history and disease activity	Assess disease activity: indicators such as CDAI are recommended Aim for a certain period of remission before conception Medication review: wash out teratogenic drugs thoroughly, check treatment adherence, recommend multivitamin use
Comorbidities/history	Check for bone deformities (e.g. pelvis) to determine any impact on pregnancy success
Considerations for the OB/GYN specialist
Reproductive history	Review past fertility and pregnancy history, and pregnancy-related complications (e.g. miscarriage, stillbirth, preterm birth, hypertensive disorders of pregnancy, gestational diabetes mellitus)
Comorbidities/history	Recommend cervical cancer screening every 2 years
Risk factors for pregnancy complications	Check risk factors for pregnancy complications such as a history of thrombosis, hypertension, renal failure, etc.
Confirmation of infertility and infertility	If pregnancy is not achieved within 1 year with controlled disease activity, begin infertility treatment
Fertility	Fertility: ovarian reserve: AMH Infertility
Common considerations
Antibody profile	Anti-thyroid antibodies (anti-TG and anti-TPO antibodies) Anti-SSA antibodies (1% of fetuses of positive women are at risk of congenital heart block) Antiphospholipid antibodies when there are factors that may lead to suspicion of complications of antiphospholipid syndrome (e.g. complication of systemic lupus erythematosus, history of miscarriage or stillbirth, abnormal blood clotting times)

Table 3. Management of pregnancy in patients with RA [11].

Item	Monitoring
Considerations for the rheumatologist
Frequency	Visit every 4–6 weeks If disease activity increases or flare-ups are observed, the frequency of visits should be increased
Parameters	General laboratory tests: total blood count, serum uric acid, liver function, urea, creatinine, electrolyte levels, urinalysis Disease activity: CDAI recommended Confirmation of joint condition
Pharmacotherapy	Continue drug therapy Monitor adherence to treatment TNF inhibitors in the third trimester of pregnancy may be reduced or discontinued if symptoms are stable
Considerations for the OB/GYN specialist
Frequency	Once every 4 weeks until Week 23 + 6, once every 2 weeks from Week 24 to Week 35 + 6, and once a week thereafter as with general uncomplicated pregnancies
Parameters	Fetal evaluation: performed between Weeks 18 and 20 to screen for fetal abnormalities Routinely assess fetal development and well-being Prevention of thrombosis: avoid dehydration; consider heparin in patients with overlapping thrombosis risks such as gestational hypertension, older age, and high body mass index
Pregnancy complications	Monitor for signs of pregnancy complications (e.g. hypertensive disorders of pregnancy, gestational diabetes mellitus, renal function)
High-risk cases	Preeclampsia: recommend inpatient management and routine evaluation of blood pressure, maternal weight, blood tests, fetal growth, and fetal well-being Intrauterine growth restriction: increase the frequency of developmental monitoring by ultrasound or other means Patients with anti-SSA antibodies should be carefully monitored using fetal echocardiography; when an anti-SSA antibody-positive RA patient becomes pregnant, referral to a perinatal center is recommended
Nutritional state	Consider the need for nutritional or vitamin supplements, including folic acid [69]

Table 4. Postpartum management of patients with RA.

Item	Assessment Contents
Considerations for the rheumatologist
Clinical examination	Carefully monitor for a flare-up of disease activity up to 6 months postpartum
Pharmacotherapy	Ensure that the patient is receiving treatment with a drug that is not contraindicated during breastfeeding (e.g. MTX, JAK inhibitors)
Considerations for the OB/GYN specialist
Management of perinatal complications	Monitor for wound complications and VTE
Thyroid function	Check thyroid function because of the risk of developing Hashimoto’s disease or postpartum thyroiditis
Vaccination of newborns	Newborns exposed to biological agents in the second and third trimesters of pregnancy should not receive an attenuated live vaccine for the first 6 months of life Other immunization programs may be implemented in the same manner as for the general population

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