Rheumatoid Arthritis in Pregnancy

Rheumatoid arthritis in pregnancy is chronic inflammatory polyarthritis in a pregnant woman. Most women improve during pregnancy and many flare in the first 3 months after delivery. It matters because several drugs (methotrexate, leflunomide) are harmful to the fetus, and uncontrolled disease raises the risk of growth restriction and preterm birth.

• Risk factors for active disease: high disease activity at conception, rheumatoid factor and anti CCP positivity, smoking.
• Disease control before conception gives the best outcome.
• Paracetamol, hydroxychloroquine, sulfasalazine and azathioprine are compatible with pregnancy.

Women have symmetrical swelling, pain and morning stiffness lasting over 1 hour in small joints of the hands and feet, with fatigue. Examine the cervical spine and hips because they affect anaesthesia and delivery.

• Morning stiffness for 60 minutes or more.
• Nodules and deformities in long-standing disease.
• Differential diagnosis: systemic lupus erythematosus, viral arthritis, reactive arthritis, psoriatic arthritis, osteoarthritis, gout, septic arthritis, carpal tunnel syndrome of pregnancy.
• Complications: joint damage, flare after delivery, atlantoaxial instability, anaemia of chronic disease, growth restriction, preterm birth, drug effects on the fetus.

The approach is clinical with markers of activity.

• Full blood count, C-reactive protein, rheumatoid factor, anti cyclic citrullinated peptide antibodies; erythrocyte sedimentation rate rises in normal pregnancy and is unreliable.
• Antinuclear antibody and anti Ro and anti La antibodies; creatinine, liver enzymes, urinalysis.
• Disease activity score with 28 joint count each trimester.
• Neck X-ray (flexion and extension) with shielding or MRI for suspected cervical spine disease before anaesthesia.

The principle is the lowest effective dose of compatible drugs, with a plan for postpartum flare.

• Supportive: physiotherapy and joint protection; splints; warm packs; rest; sleeping position with pillow support; anaesthetic review of neck and jaw movement.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); hydroxychloroquine 200 mg oral 12-hourly (maximum 5 mg/kg daily); sulfasalazine 500 mg oral 12-hourly increased to 1 g 12-hourly (maximum 3 g daily) with folic acid 5 mg oral daily; azathioprine 1 to 2 mg/kg oral daily (maximum 150 mg); prednisolone 5 to 10 mg oral daily for flares (maximum 15 mg); NSAIDs only before 20 weeks and for no more than 3 days, such as ibuprofen 400 mg oral 8-hourly; stop methotrexate 3 months before conception and leflunomide with cholestyramine 8 g oral 8-hourly for 11 days; give hydrocortisone 100 mg IV 8-hourly in labour for women taking prednisolone 7.5 mg or more daily.
• Procedures: intra articular methylprednisolone 40 mg for severe single joint flare; caesarean section only for obstetric reasons or hip disease.
• Special groups: women with cervical spine disease or limited jaw opening need planned anaesthesia; breastfeeding is compatible with hydroxychloroquine, sulfasalazine, azathioprine and prednisolone, and methotrexate is contraindicated; babies of women taking sulfasalazine receive vitamin K 1 mg IM.
• Red flags: hot swollen single joint, fever, severe neck pain with weakness, rash, falling platelets.
• Follow-up: joint review each trimester; restart therapy within 6 weeks of delivery if disease flares; review at 6 weeks and 3 months postpartum.