Pregnancy

The latest information on pregnancy and axial SpA (AS)

This information is for anyone with axial spondyloarthritis (axial SpA) including people with ankylosing spondylitis (AS)

Discuss your plans in advance

The single most important piece of advice that we can give about planning a family is to discuss it with your rheumatology team in advance.

Many obstetrics services in the UK are now lead by community midwives. We recommend  you explain to your midwife early on in your pregnancy that you have axial SpA (AS) and would like to see the obstetrician to develop a care plan tailored to your needs.

Your midwife will also be able to make sure you see the anaesthetist well in advance of your labour to discuss any concerns you may have and to ensure they fully understand your axial SpA (AS) and how it affects you.

Fertility and axial SpA (AS)

Having AS will not directly affect your ability to conceive. However some medications, including sulfasalazine can cause a fall in sperm count and so can lead to a temporary decrease in male fertility. This effect is reversed when you stop taking the medication.

Do make sure you discuss this issue with your rheumatologist.

Pregnancy and axial SpA (AS)

Having axial SpA (AS) does not have a harmful effect on the course of pregnancy or on the wellbeing of your unborn child.  The rate of miscarriage, stillbirth, and small for gestational age infants among women with axial SpA (AS) is similar to that of other healthy women.

Women with axial SpA (AS) generally have healthy babies and they carry them to full term.

Women with axial SpA (AS) are no more likely than other healthy women to get pre-eclampsia or to go into premature labour.

Symptoms during pregnancy

There is no pattern to women’s axial SpA (AS) symptoms during pregnancy. Some find their symptoms improve, some find they stay more or less the same and others find they get worse.

Exercising during pregnancy

It’s important for you to keep exercising for as long as possible during your pregnancy. This will help both with your general health and with your axial SpA (AS). As your pregnancy advances and you gain weight you may find it easier to exercise in the swimming pool where the water will help to support your weight.

Medications and pregnancy

The ideal is that you do not take any medication while you are pregnant and breast feeding.

The reality is that you may have active axial SpA (AS) at some point in your pregnancy and need pain relief. It will be important to discuss this with your rheumatology team, ideally in advance, so that you know what options are going to be available to you. This will avoid situations where your axial SpA (AS) flares up and you don’t know what medications you can and cannot safely use.

Anti inflammatories

The advice on anti inflammatories during pregnancy is divided into NSAIDs (including  ibuprofen, naproxen and diclofenac) and coxibs, or COX-2-specific NSAIDs (including  celecoxib and etoricoxib).

NSAIDs

The British Society for Rheumatology (BSR) Guideline notes NSAIDs:

  • Should be used with caution during the first trimester as some large scale studies have found a slightly raised risk of miscarriage.
  • Can be taken during the second and third trimester but should be stopped by week 32.
  • Can be taken while breastfeeding

Coxibs

The BSR Guideline notes that there is not enough data on the use of coxibs or COX-2-specific NSAIDs and therefore they should be avoided during conception and pregnancy.

Read the BSR Guidelines on analgesia during pregnancy.

Steroids

If you are having pain in one or two specific joints you might find a local steroid injection into the joint useful. Single injections of steroid should not affect pregnancy. However, do make sure your doctor knows you are pregnant before having a local steroid injection.

The BSR Guideline notes oral steroids can be used during every stage of pregnancy and breast feeding. If you are taking oral steroids (prednisolone) and  are planning a family or are pregnant  discuss things with your GP or rheumatologist.

Read the BSR Guidelines on use of steroids during pregnancy

Never stop steroids abruptly.

Disease modifying anti rheumatic drugs (DMARDs)

Methotrexate should not be taken during conception or pregnancy. Both men and women using these drugs should take contraceptive precautions. After stopping methotrexate, men and women should continue using contraception for at least 3 months before trying to get pregnant.

Sulfasalazine is considered safe in pregnancy, but it’s important to discuss your personal situation with your rheumatologist before becoming pregnant. This advice applies to both men and women.

Anti TNF therapy

The advice is that Anti TNF should not be routinely used during pregnancy. If you are on anti TNF therapy it is very important that you discuss your options with your rheumatology team before becoming pregnant. You may well decide that you do not want or need to take anti TNF during pregnancy.

Current advice is that if anti TNF is needed during pregnancy:

  • adalimumab (Humira) and etanercept (Enbrel) should be avoided during the third trimester. This is due to a theoretical increased infection risk in new born babies.
  • infliximab (Remicade, Remsima and Inflectra) should be stopped at 16 weeks. This is again due to a theoretical increased infection risk in new born babies.

If these drugs are continued later in pregnancy to treat active disease then live vaccines should be avoided in the infant until seven months of age.

Based on limited evidence certolizumab pegol Cimzia) is compatible with all three trimesters of pregnancy and has reduced placental transfer compared with other TNFi.

Read the BSR Guidelines on use of anti TNF therapy during pregnancy

Childbirth

You should have a normal labour.

Sacroiliac joint or hip problems, even including a total hip replacement, should not necessarily stop you from giving birth naturally. There are different positions that you can use which would make you more comfortable. Talk about different positions to your midwife.

It’s a good idea to make an appointment to talk to your midwife (or ideally an anaesthetist) in advance about pain relief during your labour. Lots of women opt for an epidural during labour. Occasionally this may be technically more difficult to administer to women with axial SpA (AS). Your midwife or anaesthetist will be able to tell you about other options that are available.

We do know that caesareans do tend to be carried out more frequently among women with axial SpA (AS). Sometimes this is because obstetricians prefer to do an elective caesarean section in women with inflammatory joint disease.

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