October 13, 2020

By Emeline Mugisha, M.S.N., M.P.H., R.N.

Rheumatoid arthritis, or RA, is the most common chronic autoimmune disease. Autoimmune disorders occur when your immune system abnormally attacks healthy cells, tissues, and organs in your body, and they impact women more than men. Research shows that women have a higher risk of developing RA during the postpartum period. However, the number of women who develop postpartum RA in the general population is unknown and varies widely across studies (from 0.08% in a Japanese study to 28.3% in a Denmark study).

How do I know if I have postpartum RA?

Early RA tends to impact your smaller joints first, such as those in your fingers. As the disease advances, symptoms may expand to larger joints in your wrists, knees, ankles, elbows, hips, and shoulders. In most cases, RA affects the same joints on both sides of your body.

RA may also affect non-joint structures and organs such as your lungs, heart, and eyes.

Signs and symptoms of RA may include:

• Chronic pain or aching in more than one joint
• Stiffness, tenderness, or swelling in more than one joint
• Fatigue
• Fever
• Weight loss
• Weakness

RA symptoms may range from mild to severe. Additionally, there are times when symptoms are present or worsen (known as flares) and when symptoms improve or stop (known as remission).

Related: De Quervain's Tenosynovitis (Mommy Thumb)

What causes postpartum RA?

The specific causes of postpartum RA are unknown. However, certain factors can increase the risk of developing the disorder. Possible risk factors for postpartum RA include:

• Older age
• Polycystic ovary syndrome (PCOS)
• Endometriosis
• Smoking
• Genetics

Hormone levels may also influence the onset of postpartum RA, but their role remains unclear. Some hormones appear to increase the risk of RA, while others seem to decrease the risk. For example, researchers believe that higher prolactin levels may increase the risk of RA after birth, but this association is inconsistent across studies. In a separate study, researchers found a link between progesterone’s decline after delivery and increased risk of postpartum RA.

Finally, the timing after delivery appears to influence the risk of developing the disease. Specifically, research shows that postpartum RA often occurs in the first 24 months after delivery, with the highest risk occurring during the first three months postpartum.

How is postpartum RA treated?

The first step to manage RA involves seeing a doctor specializing in the diagnosis and treatment of autoimmune conditions. These specialists are called rheumatologists. It is essential to consult a rheumatic disease specialist because RA signs and symptoms are similar to those of other conditions. A rheumatologist will work with you to identify the problem and help ensure you receive the correct diagnosis so that appropriate treatment can begin early.

The treatment plan for RA includes both medications and self-management strategies. In most cases, your rheumatologist will prescribe medications known as disease-modifying antirheumatic drugs. These medications slow the development of RA and prevent deformity of your joints.

In addition to medications, multiple, low-cost, self-management strategies can help relieve pain, improve joint function, and delay disability. These strategies include following your doctor’s recommendations for physical activity, participating in physical activity programs designed to help symptoms related to RA, joining a self-management education class, getting help to stop smoking (if applicable), and maintaining a healthy weight.

What if I already have RA? Will it affect my pregnancy? Will pregnancy affect it?

Pre-existing RA affects pregnancy outcomes in some but not all women. For example, women with RA are more likely to have a cesarean birth (c-section), which is a surgical procedure to deliver your baby. As with any surgery or birth method, complications may occur in a small number of women. However, c-sections are more common among women with more active RA symptoms (such as, the number of swollen joints). Additionally, most studies, but not all, demonstrate an increased risk of preterm births among women with RA. Finally, some studies suggest an increased risk of preeclampsia among women with RA, while other studies do not.

Fortunately, pregnancy has a protective effect on RA. Specifically, symptoms often improve while pregnant, which commonly reduces the need for medication, but they may flare up postpartum. While many women would understandably prefer to stop taking medications during pregnancy and RA remission, it is essential to discuss any potential risks of stopping treatment and your disease flaring with your rheumatologist and maternity care provider.

If I have postpartum RA, am I at risk for any other complications?

Left untreated, postpartum RA can result in both physical and social consequences. For example, women with uncontrolled RA are at increased risk of pain, disability, and developing other chronic diseases such as heart disease and diabetes. Additionally, RA can make it challenging to engage in daily activities, including working for those whose jobs are physically demanding.

Research is conflicting on the associations between breastfeeding and postpartum RA. For example, a study among Swedish women suggests a link between self-reported breastfeeding for more than 17 months and the development of postpartum RA. Most other studies do not support this finding. However, in a UK study, first-time breastfeeding moms were more likely to report RA flares six months postpartum than non-breastfeeding moms. Thus, it is essential to discuss any questions or concerns about breastfeeding with your providers, such as the need for medication, the benefits of breastfeeding, and which drugs are safe for your baby.

Are there any precautions I should take or ways to prevent it?

Currently, there is no known way to prevent RA. However, early treatment and self-management strategies can ease your symptoms and prevent long-term damage to your joints so that you can continue to engage in the activities important to you and increase your quality of life with RA.

Sources:

Alpízar-Rodríguez, D., Pluchino, N., Canny, G., Gabay, C., & Finckh, A. (2017). The role of female hormonal factors in the development of rheumatoid arthritis. Rheumatology (Oxford, England), 56(8), 1254–1263. https://doi.org/10.1093/rheumatology/kew318

American College of Rheumatology. (2018, June). Pregnancy and rheumatic disease. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Living-Well-with-Rheumatic-Disease/Pregnancy-Rheumatic-Disease

Centers for Disease Control and Prevention. (2020, July 27). Rheumatoid arthritis (RA). https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html

Iijima, T., Tada, H., Hidaka, Y., Yagoro, A., Mitsuda, N., Kanzaki, T., Murata, Y., & Amino, N. (1998). Prediction of postpartum onset of rheumatoid arthritis. Annals of the Rheumatic Diseases, 57(8), 460–463. https://doi.org/10.1136/ard.57.8.460

Krause, M. L., & Makol, A. (2016). Management of rheumatoid arthritis during pregnancy: challenges and solutions. Open Access Rheumatology: Research and Reviews, 8, 23–36. https://doi.org/10.2147/OARRR.S85340



Emeline Mugisha, M.S.N., M.P.H., R.N. - Emeline Mugisha is an award-winning, master's-prepared nurse with over a decade of experience in community/public health and clinical health services at the field and management levels. She has co-authored two professional manuscripts in Women's Health Issues and the Journal of Midwifery and Women's Health. She has an M.S. in Public Health Nursing and an M.P.H. from Johns Hopkins University.