Pregnancy in Inflammatory Arthritis: What Your Patients Need to Know
Megan Clowse, MD, MPH, from Duke University Medical Center, Durham, NC, discusses 2 studies that examine clinical decision-making with regards to management of medications for inflammatory arthritides in pregnancy, as well as reproductive health concerns.
A transcript of this interview is available below.
Can you talk us through these 2 studies and their clinical implications?
Abstract Number: 1298
Tough Choices: Understanding the medication decision-making process for women with inflammatory arthritis during pregnancy and lactation
Abstract Number: 1308
Answering reproductive health questions that your patients want to know: impediments to family building and risks of contraception
For both of our studies we used the women who participate in CreakyJoints, which is an online community of people with inflammatory arthritis. We asked men and women to participate in a survey about reproductive health. We actually had very low response rates from men, and they didn't seem all that interested in talking about reproductive health. But the women were interested in talking about reproductive health and helping us understand their experiences and the decisions that they had made.
The first abstract looks at decision-making about medication use in pregnancy and lactation. What we found was that when women were just thinking about their most recent pregnancy — and these were pregnancies that had occurred after their diagnosis of inflammatory arthritis — they were very worried about medication use; they were worried about the safety of a lot of the medications. But still many of them did take medications.
What we found was that of the pregnancies that happened after the diagnosis of inflammatory arthritis — we didn't want to have them confused by multiple pregnancies, so we just looked at the most recent pregnancy after a rheumatologic diagnosis — about half of the women took a medication for their autoimmune disease during their pregnancy, and about half did not take any.
Can you discuss your findings on infertility in women with arthritis?
One thing we looked at was infertility; there have been reports for decades that there might be increased infertility in women with rheumatoid arthritis, and this study also found a high rate of infertility. Forty percent of women with rheumatoid arthritis reported infertility or subfertility, which is a very high rate. We would expect that to be somewhere around 10% to 15% in the general population. About half of those women reported using some form of reproductive technology to try to get pregnant, whether it was taking medicines or doing IVF [in vitro fertilization] or something like that. That rate is higher than what we see in other studies; for example, we've recently done a study where we looked at all the patients in our clinic — every young woman with rheumatoid arthritis — and we found a much lower rate of infertility in that group. So I think that because this is an online survey about reproductive health, it is certainly possible that it is somewhat biased, in that women who have infertility are more interested in reporting about it. So it might be somewhat biased and a little bit higher than what we might expect, but I still think it was a clearly significant finding.
When diagnosing a young woman with arthritis, how early do you discuss desired fertility and risks of infertility?
It is important to discuss fertility and pregnancy planning with a young woman at the time of diagnosis of a rheumatic disease. It is important that women start thinking about how they are going to plan pregnancies. One thing we know that is important for women with rheumatic disease is that they need to plan their pregnancies. They don't have the luxury experienced by women who can get pregnant whenever it is convenient or inconvenient for them. Instead, women with rheumatic disease need to time pregnancy so that they are not taking medications that can cause birth defects and that their disease is controlled when they conceive. I think that the message — that most women with rheumatic disease can have a healthy pregnancy, but the key is planning and talking with their doctor — is the key message to get across to women right away.
What is the best approach to discussing fertility in patients who chronically use oral contraceptive pills to avoid menstrual-related flares?
There is a small population of women that we found in the study who were taking birth control pills continuously in order to decrease rheumatoid arthritis flares. We asked women in the study whether having a menstrual period changed their rheumatoid arthritis activity, and about half of the women said that yes, rheumatoid arthritis symptoms fluctuated with their period. Almost all of those women who said that it fluctuated said that it got worse in the days before their period, or in the first couple of days of their period, and then it got better in the other half. So some women seemed to have come across the good idea, potentially, of taking continuous birth control pills continuously, which is considered quite safe, in order to not have menses and therefore not have those flares.
But when those women want to get pregnant, obviously they are going to have to stop their birth control pills. So managing their rheumatoid arthritis with other medications that are considered safe and compatible with pregnancy would be the ideal approach: hydroxychloroquine, sulfasalazine, some NSAIDs [nonsteroidal anti-inflammatory drugs] probably are fine, and TNF [tumor necrosis factor] inhibitors.
How can rheumatologists, in partnership with gynecologists, increase rates of effective contraception in women taking methotrexate?
What are some strategies you advise?
Our study and many other studies have found that an unacceptably high number of women who are taking methotrexate are not using effective birth control. We know that methotrexate causes birth defects at about twice the rate of the general population. So the general population has a birth defect rate of about 3%, and there is a 6% to 7% birth defect rate in people taking methotrexate at the rheumatic dosing that we use. They also have a particularly high rate of pregnancy loss — up to 40% — which is twice what we would expect in this population. So it is important that we have women avoiding getting pregnant on methotrexate as it can cause a lot of heartache in terms of either pregnancy loss or being worried about birth defects.
It is important that women understand why we want them to avoid pregnancy while they are taking methotrexate; there are real risks to them and to their future children when taking methotrexate while conceiving. It is also important to help women with rheumatic disease figure out which birth control methods are safe for them. Fortunately for women with inflammatory arthritis, there is no limitation from a rheumatic standpoint on what kind of birth control they can use. And there are some great long-acting, reversible contraceptives available now, including intrauterine devices that can be left in for 3 years and up to 10 years. They are very effective, and well less than 1% of people who have them get pregnant over the course of a year. An implant that can go under the skin on the arm is another option; it can stay in place for 3 years and gives off a low dose of continuous progesterone that's felt to be very safe for women with rheumatic disease. When the woman is ready to conceive, the implant is taken out, and the patient is ready to go as if she had been on birth control pills. So those are effective forms of birth control that we should be encouraging for our young women who are on teratogenic medications and not ready to conceive.
- Haroun T, Eudy AM, Jayasundara M, et al. Tough Choices: Understanding the medication decision-making process for women with inflammatory arthritis during pregnancy and lactation. Presented at: ACR/ARHP Annual Meeting; November 3-8, 2017; San Diego, CA. Abstract 1298
- Jayasundara M, Eudy AM, Haroun T, et al. Answering reproductive health questions that your patients want to know: impediments to family building and risks of contraception. Presented at: ACR/ARHP Annual Meeting; November 3-8, 2017; San Diego, CA. Abstract 1308