Postpartum Care of RA: Not an Either/ Or Proposition

Planning for pregnancy can be a difficult task, especially for our patients living with a rheumatic disease. It requires a careful review of current and potential future medication plans, an introspective look at an individual’s beliefs, and some good old guesswork. How soon is a patient going to get pregnant once they start trying? What’s going to happen to their disease as they start weaning off of particularly medications? Will their disease become better controlled or flare once they become pregnant? What’s going to happen after delivery of the new baby?

The experience of pregnancy is an exciting and wonderful time for all women, with or without a rheumatic disease, despite some of the unpleasant side effects that go along with it. Some, though not all, of our rheumatology patients have the benefit of seeing their symptoms retreat. I have seen many women flare during pregnancy, which presents a real challenge – do you treat their symptoms or let them suffer because of the unknown teratogenic effects of medication? As we gain more experience with our biologic and synthetic DMARDs, we are fortunately able to more confidently incorporate these medications into our patient’s pregnancy plan.

But what about the days and weeks after our patients have their (hopefully) healthy baby? This is an issue we sometimes tend to overlook when we are having conversations with our patients. Many women are so focused on what will happen to their disease during pregnancy that they don’t think ahead to what a postpartum plan might look like. This can, however, be among the most challenging periods for our patients.

A few years ago, a 33-year-old patient, ET, came to our clinic 39 weeks pregnant with her second child. She had a C-section scheduled for the following week. ET had specifically asked for an appointment at our clinic to talk about a plan to treat her RA after the delivery of her baby. She had first developed RA symptoms a few weeks after the birth of her first child 2 years ago, and she was concerned that history would repeat itself and her pain would flare following the birth of her second child.

ET’s disease had remained well controlled during the course of her current pregnancy— she only required 5 mg of prednisone PRN for intermittent joint pain. Prior to her pregnancy, she was on a regimen of azathioprine, hydroxychloroquine, and infliximab infusions every 8 weeks, which had kept her disease stable.

At the time of her visit, the plan was to resume azathioprine and hydroxychloroquine once ET’s RA symptoms returned and hold infliximab temporarily until we could gauge ET’s response to the oral medications. ET told us that it was very important to her that she breastfeed her baby as long as possible. This wasn’t a surprise. The first time ET had come to our office was following the birth of her first child, when she had been struggling with joint pain for more 9 months due to an unwillingness to take any medication while breastfeeding. This time around, ET said she wanted to be more proactive about having a plan in place. Yes, she still wanted to breastfeed, but she did not want her disease to flare again.

Fast forward three months, and ET was back with severe joint pain and swelling, especially in her feet. She told us she was having a hard time even carrying her baby around the house. While ET had followed through on her plan to breastfeed, she had changed her mind about medication and avoided going back on either azathioprine or hydroxychloroquine despite our earlier agreement. She was still afraid of how these medications might affect the baby. That sprung me into education mode.

“It is important to remind patients that they need to be able to take care for themselves first so that they are able to properly care for their baby.”

I knew that ET didn’t need to be suffering and could safely transition onto our medication plan, but she needed more coaching to feel safe and secure. Eventually, with lots of reassurance, ET left this visit agreeing (again) to restart her medications. A few weeks later, she said she had been taking her medication, was feeling much better, was able to care for her baby without any physical issues, and was still breastfeeding.

When treating patients with rheumatic disease that become pregnant or are planning on becoming pregnant, it is important to discuss what these women should expect during all phases of pregnancy and during the postpartum period. Part of our job is to prepare them for what is likely to happen with their disease and how potential disease flares may affect how they care for their baby. For example, I have patients who tell me that they are afraid to hold their babies because their hands and wrists are too weak or too painful. This, in fact, happened with ET, who told me she was worried about falling with her baby in her arms due to bilateral foot pain and swelling.

It is important to remind patients that they need to be able to take care for themselves first so that they are able to properly care for their baby. It does no good for a patient with RA to wean herself off of all medications if she subsequently suffers from constant pain that adversely impacts her ability to be the kind of mother she wants to be. I certainly remember when I was a new mom to a colicky newborn. I was paranoid about every dietary choice I made, worrying about anything that could possibly make my new daughter fussier.

That’s the sort of decision all of our patients, including ET, are facing when considering medications to take during and after their pregnancy (many are probably worried about their diet too!). When patients with rheumatic disease choose to breastfeed—which is recommended exclusively during the first 6 months of life by the American Academy of Pediatrics as well as the World Health Organization1,2—they must be made aware of medications that are both safe for their breastfeeding baby as well as effective in helping manage their joint pain and swelling. Patients with RA typically do not breastfeed as frequently as the general population, with one recent study showing that only 9% were still breastfeeding at 26 weeks postpartum compared to 41% of the average population.3 The authors of that study concluded that the disparity is likely due to RA patients’ desire to restart their medication and fear of medication effects on their baby, even though many medications used to treat RA are considered safe to use during lactation.

Postpartum care of RA patients shouldn’t have to be an either/or proposition (ie, either I do something to help with my pain or I do what’s best for the health of my baby). There is enough evidence in the community illustrating that our patients, like ET, can have the best of both worlds. The recent American College of Rheumatology guidelines on reproductive health will hopefully give us even more ammunition to help our patients understand this fact and give us confidence as providers that our advice is backed by research and facts.4

References
1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.
2. World Health Organization. The optimal duration of exclusive breastfeeding: report of an expert consultation. Available at www.who.int/nutrition/ publications/optimal_duration_of_exc_bfeeding_report_eng.pdf. Accessed May 29, 2020.
3. Ince-Askan H, Hazes JMW, Dolhain RJEM. Breastfeeding among Women with Rheumatoid Arthritis Compared with the General Population: Results from a Nationwide Prospective Cohort Study. J Rheumatol. 2019;46(9):1067-1074.
4. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2020;72(4):529-556.

Author Profile:
Carrie Beach BSN, RN-BC
is a rheumatology nurse with the Columbus Arthritis Center in Columbus, OH, and the President-Elect of the Rheumatology Nurses Society

 

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