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Targeted preconception counseling and a treat-to-target approach help optimize pregnancy outcomes in women with rheumatoid arthritis, according to a new review.

Advances in the management of autoimmune disease have made pregnancy increasingly common over the last decade in patients with rheumatoid arthritis (RA). For all female patients of reproductive age, targeted preconception counseling is strongly advised, according to a review published in the Journal of Clinical Medicine.

“The counseling ensures medication compatibility and planning around disease flares, and it involves a multidisciplinary team comprising rheumatologists, obstetricians, and other specialists to develop individualized care plans,” wrote Ioana Cristina Saulescu, MD, and colleagues from the Carol Davila University of Medicine and Pharmacy.

Women with RA may face a longer time to pregnancy compared with the general population. Fertility may be affected by medications such as anti-inflammatory drugs, especially selective cyclooxygenase 2 inhibitors, or higher doses of corticosteroids, the researchers wrote.

During pregnancy, women with RA are at increased risk for hypertension and preeclampsia. Consequently, a complete past medical and family history, as well as regular blood pressure checks, are recommended for women planning pregnancy. Intrauterine growth restriction and infants small for gestational age, premature rupture of the membrane, antepartum hemorrhage, and preterm delivery are also more frequent in pregnancies of women with RA.

Additionally, pregnancy should be timed for when the disease is well-controlled with approved medication: women should have at least 6 months of low disease activity or remission. The review advises a treat-to-target (T2T) approach leading up to and throughout pregnancy.

“Not long ago, not only future mothers with RA but also treating physicians thought that the natural evolution of RA was going into remission during pregnancy, thus embracing the tendency to lower or completely stop their medication during the 9 months of gravidity,” the researchers wrote. “Recently, the Pre CARA study showed the beneficial effect of a T2T approach in women pursuing pregnancy and during pregnancy, using allowed medication.”

Per the article, “allowed medication” consisted of sulfasalazine and/or hydroxychloroquine as the first line and, as the next step, adding less than 7.5 mg/day prednisone and/or tumor necrosis factor inhibitors.

“Medication adjustments in anticipation of pregnancy according to T2T principles and accepted medication, and a dedicated team with expertise in following AID [autoimmune disease] pregnancy, will contribute to achieving a similar risk rate in RA pregnancy compared to the general population,” researchers wrote.