What is juvenile arthritis?
The term juvenile arthritis (JA) refers to any pediatric rheumatic disease, meaning any condition featuring inflammation or autoimmune activity (the immune system attacking a part of the body) that begins in children below 16 years of age. Such conditions can include arthritis and other diseases. In many cases the term JA refers to a well-known type of JA, juvenile rheumatoid arthritis, which often continues into adulthood, an thus can coexist with pregnancy.
How common is juvenile arthritis in pregnancy?
JA is present in an estimated 1 2 per 1,000 pregnant women.
How is juvenile arthritis diagnosed?
To be classified as JA, arthritis must be recognized by the time that you are 16. Otherwise, it is some type of adult-onset arthritis. Your medical history and physical examination can reveal to your physician that you have some type of arthritis, based on the presence of joint pain and swelling. In the case of juvenile rheumatoid arthritis, you would experience pain and swelling typically in the hands, wrists, knees, feet, and ankles. Other symptoms of arthritic disease include rashes, movement difficulties including limping, dry eyes and eye inflammation, and swollen lymph nodes. You doctor may order imaging studies, such as X-rays, ultrasound, or magnetic resonance imaging, plus blood will be taken for tests that may include rheumatoid factor, erythrocyte Sedimentation Rate (ESR), cyclic citrullinated peptide (CCP), C-reactive protein (CRP), and antinuclear antibody (ANA).
Does juvenile arthritis cause problems during pregnancy?
Many pregnant women with arthritic disease of the rheumatoid type actually notice their symptoms improve during pregnancy, but this comes at a cost as most of these women experience a flare-up of the disease within 3 months after delivery. Those women who do experience a flare-up of RA during pregnancy tend to have longer stays in the hospital, plus they are more likely to require cesarean section (surgical birth).
JA puts you at higher risk for pregnancy complications including preeclampsia (a condition featuring high blood pressure and problems with one or more organs, such as the kidney) and postpartum hemorrhage (severe bleeding after giving birth), and also increases the chances that you will require a cesarean section.
Does juvenile arthritis during pregnancy cause problems for the baby?
JA increases the risk of problems for the developing baby, including very preterm labor and birth, low birth weight and size, a need for neonatal intensive care, and low Apgar score, all of which are associated with physical and learning problems after birth.
What to consider about taking medications when you are pregnant:
- The risks to yourself and your baby if you do not treat the JA
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat juvenile arthritis during pregnancy?
Medications used in JA, particularly the rheumatoid type, consist of those that suppress inflammation or decrease the activity of the immune system. Certain of these medications, such as methotrexate, leflunomide, and COX inhibitors should not be taken during pregnancy. Arthritis drugs that are considered safe during pregnancy include hydroxychloroquine and sulfasalazine, but a group of drugs used frequently in arthritis called non-steroidal anti-inflammatory drugs (NSAIDs), should be avoided during the third trimester. There also are categories of RA medications that are thought to be dangerous but for which research has been limited. This includes biological agents, such as rituximab and other drugs that end with mab. Narcotic agents (opioids) also are used in juvenile rheumatoid arthritis, and these can be harmful to the baby too. On the other hand, there are some medications, such as azathioprine and low-dose aspirin that are thought to be only slightly risky in pregnant women with JA. There are drugs called corticosteroids, which can be given for a short time to combat a flare-up, and then tapered off.
Who should NOT stop taking medication for juvenile arthritis in pregnancy?
This is an extremely difficult decision for the pregnant patient and her doctors. Every drug used in JA has benefits and risks, but since there are so many such drugs it is often possible to replace one drug with another. On the other hand, since most women with JA can expect to improve during pregnancy, the solution is often to plan the pregnancy and stop drug treatment prior to conception. Then, if it turns out that you do have a flare-up in the midst of pregnancy, a drug can be chosen to mitigate the flare-up while keeping the risk to the developing baby at a minimum.
What should I know about choosing a medication for juvenile arthritis in pregnancy?
You may find Pregistrys expert reports about the individual medications to treat juvenile arthritis here. Additional information can also be found in the sources listed at the end of this report.
What should I know about taking a medication for juvenile arthritis when I am breastfeeding?
The various drugs that are effective against JA vary in their tendency to enter breastmilk and in their potential harm to the nursing baby if they do get into the milk. The drugs methotrexate and leflunomide must not be taken if you are nursing, or you must not breastfeed if you are taking these drugs. Although rheumatoid JA tends to subside during pregnancy, it also tends to flare-up soon after delivery. In order to encourage breastfeeding, doctors have considered how quickly the drugs move through the mothers system. For certain drugs, this has led to ideas on how to get the best of both worlds in a sense. With the steroid prednisolone, for instance, it is known that it builds up in breastmilk mostly during the first four hours after a dose is given. You may be able to wait four hours after receiving each dose, then pump out the milk and discard it, wait for new milk to accumulate and nurse the infant from that new milk. A lactation consultant can help you work out a schedule that will allow you to maintain your milk supply, or you may choose to feed your baby infant formula or a combination of breastmilk and formula.
What alternative therapies exist besides medications to treat juvenile arthritis during pregnancy?
Several treatments are under investigation to see whether they can be helpful in JA, particularly rheumatoid JA, and are used sometimes as a secondary treatment in combination with medications. These include occupational therapy, foot orthotics (special shoe inserts designed to support the foot), finger splints, wrist splints, and various diets. Cognitive-behavioral treatment also has been under investigation. So far, evidence that such tactics really help with the symptoms of JA is rather skimpy.
What can I do for myself and my baby when I have juvenile arthritis during pregnancy?
Stay in clo
se contact both with your obstetrician and rheumatologist. Work with your doctors to choose a treatment strategy that minimizes risks for the developing baby, but also protects both you and the baby by reducing flare-ups of your condition.
Resources for juvenile arthritis during pregnancy:
For more information about juvenile arthritis during pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or read the following articles:
- American College of Rheumatology: Pregnancy and Rheumatic Disease
- Mayo Clinic: Juvenile Idiopathic Arthritis