Pregnancy and axSpA
If you have axial spondyloarthritis (axSpA) and are thinking of having a baby, it’s time to talk to your doctors. By working closely with your medical team — particularly your rheumatologist and OB-GYN — it is possible to manage your treatment to help you prepare for pregnancy. Decisions you make with your doctors before conceiving are extremely important for healthy fertility, pregnancy, delivery, and breastfeeding your baby.
AxSpA primarily affects the sacroiliac joints, which link the spine and pelvis, and is caused by inflammation in the immune system. The condition includes ankylosing spondylitis (abbreviated as AS and also known as radiographic axial spondylosis), along with undifferentiated spondyloarthritis, reactive arthritis, enteropathic arthritis (associated with inflammatory bowel disease), and psoriatic arthritis.
Having axSpA does not reduce your fertility. Your chances of getting pregnant with axSpa are believed to be no different from the general population. But it’s important to understand how pregnancy with axSpA may affect you — well in advance of becoming pregnant.
The Importance of Planning Ahead
It’s never too early to initiate a conversation with your doctors about family planning, pregnancy, and how to manage your axSpA in anticipation of pregnancy. Here are some topics to discuss with your health care providers as you consider conceiving a baby.
Reduce Disease Activity
The American College of Rheumatology and EULAR recommends that rheumatic diseases such as rheumatoid arthritis, lupus, or axSpA should be well managed and under control for at least three to six months before pregnancy. They also stress the need for people with rheumatic disease to undergo a pre-pregnancy evaluation to ensure they are healthy enough for pregnancy.
Reducing disease activity before pregnancy can help reduce risks that are associated with axSpA and pregnancy. In fact, disease activity and flares during pregnancy are important predictors for complications in pregnancy, such as:
- Gestational diabetes
- Infection
- Preeclampsia
- Premature rupture of membranes
- Preterm delivery
- Low birth weight
Managing your axSpA is essential for a healthy pregnancy.
Review and Adjust Medications
As you manage your condition in the months leading up to pregnancy and throughout your pregnancy, delivery, and breastfeeding, your doctors may make changes to your medications.
For instance, some conventional disease-modifying antirheumatic drugs (DMARDs) may need to be discontinued. Methotrexate, a DMARD used for peripheral spondyloarthritis, is associated with multiple birth defects and should be discontinued at least three months before conception.
Azulfidine (sulfasalazine) is safe to use during pregnancy. Other drugs may negatively affect fertility, pregnancy outcome, or lactation, and may need to be changed or adjusted.
Make sure to discuss all of your treatment options with your rheumatologist and obstetrician before becoming pregnant. Some drugs used in the treatment axSpA may negatively affect male fertility and reduce the chances of pregnancy. If you or your partner have axSpA, be sure all medications you are both taking are reviewed before trying to conceive.
Genetics and Axial Spondyloarthritis
For some people with axSpA, the risk of passing the condition on to children may be a factor in considering pregnancy.
AS, a type of axSpA, is associated with family history and is linked to the human leukocyte antigen B27 gene, which is hereditary. Research has found that children of women with AS have a 38% chance of developing the condition, compared to 0.5% of the general population.
Pregnancy, Delivery, and Postpartum: What To Expect
Although everyone’s experience can be different, it’s important to have an idea of how your axSpA may be affected by pregnancy and what risks are associated with delivery and after birth.
Pregnancy and Axial Spondyloarthritis Symptoms
In about 40% of pregnancies, people experience is a decrease in axSpA symptoms of pain and stiffness. But most people experience no change or worsening axSpA symptoms, particularly in the second trimester. Be prepared for the typical pregnancy symptoms, such as morning sickness, fatigue, and back pain from pregnancy.
Be sure to maintain your treatment plan, and avoid changing any medications without medical advice. Controlling axSpA disease activity and flare-ups can help prevent preterm delivery and complications for newborns. One study found that women who discontinued safe tumor necrosis factor (TNF) inhibitor therapy (a type of biologic drug) early in pregnancy saw a risk of flares three times greater than women who stayed on their therapy.
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in the third trimester of pregnancy due to the risk of low amniotic fluid and kidney disease in newborns.
Maintain clear and open communication with your rheumatologist, OB-GYN, and primary care physician about your symptoms so you can be monitored for disease activity. It’s important to have a supportive and knowledgeable medical team who understands your condition and treatment plan.
Childbirth With Axial Spondyloarthritis
Most women with axSpA have vaginal deliveries. Because of pelvic and back pain, along with risks for delivery complications, such as premature rupture of fetal membranes and preterm delivery, pregnancies with axSpA have a higher rate of cesarean section births. AxSpa pregnancies result in a 12% higher rate of delivery by elective cesarean section (C-section) than the general population and an 8 percent higher rate for emergency C-section deliveries.
Spinal inflammation and fusion of vertebrae, which are common in people with AS, may make an epidural inadvisable. An epidural is a procedure in which pain medication is injected into the spinal canal before delivery. If you have AS, talk to your doctors about alternative pain relief methods before delivery, if you have concerns about an epidural. In some cases with C-sections, general anesthesia may be used instead of an epidural.
After Delivery
Although research has shown that 60% of women with axSpA have experienced postpartum (after-delivery) flare, a study that followed women for a year after pregnancy showed that disease activity postpartum remained low and stable in most cases.
Nonetheless, caring for a newborn is physically demanding. Infants often require late nights, long hours, and constant rocking and lifting, all of which can compound common axSpA symptoms of fatigue, stiffness, and pain. Physical therapy may help with techniques for minimizing discomfort while caring for a newborn. If breastfeeding, it’s important to discuss anti-inflammatory medications that are considered low risk during lactation.
Talk With Others Who Understand
Hellenic League Against Rheumatism is the patient association for people with RMDS. HELLAR/ELEANA’s members come together to ask questions, give advice, and share their stories with others who understand life with RMDs
References:
- Overview of Types of Spondylitis — Spondylitis Association of America
- Pregnancy and Rheumatic Disease — American College of Rheumatology
- Risk for Adverse Pregnancy Outcome in Axial Spondyloarthritis and Rheumatoid Arthritis: Disease Activity Matters — Rheumatology
- Use Of DMARDs and Biologics During Pregnancy and Lactation in Rheumatoid Arthritis: What the Rheumatologist Needs To Know — Therapeutic Advances in Musculoskeletal Disease
- The Impact of Drugs on Male Fertility: A Review — Andrology
- Is the Current ASAS Expert Definition of a Positive Family History Useful in Identifying Axial Spondyloarthritis? Results From the SPACE and DESIRE Cohorts — Arthritis Research & Therapy
- Ankylosing Spondylitis and Pregnancy — Arthritis Foundation
- Disease Activity During and After Pregnancy in Women With Axial Spondyloarthritis: A Prospective Multicentre Study — Rheumatology
- Impact of Sex on Inheritance of Ankylosing Spondylitis: A Cohort Study — Lancet
- Spondyloarthritis — American College of Rheumatology
- FDA Recommends Avoiding Use of NSAIDs In Pregnancy at 20 Weeks or Later Because They Can Result in Low Amniotic Fluid — U.S. Food and Drug Administration
- Does Inflammatory Arthritis Really Improve During Pregnancy? A Systematic Review and Meta-Analysis — American College of Rheumatology
- Risk Factors for Flare and Treatment of Disease Flares During Pregnancy in Rheumatoid Arthritis and Axial Spondyloarthritis Patients — Arthritis Research & Therapy
- Pregnancy and Delivery in Patients With Rheumatoid Arthritis and Spondyloarthritis — Annals of Rheumatic Diseases