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Abstract Pregnancy can create a challenge for physicians caring for women with rheumatic diseases. For many women with rheumatoid arthritis (RA), pregnancy can provide a reprieve from long-term joint pain and inflammation, but others will not experience remission and will continue to need medication. Systemic lupus erythematosus (SLE) may remain quiet in some women, but in others may become more aggressive during pregnancy, putting both mother and foetus at risk. Women with limited scleroderma can do remarkably well, but scleroderma renal crises can be difficult to manage. A third of pregnancies in women with antiphospholipid syndrome (APS) may be refractory to our best therapy. In general, active inflammation from rheumatic diseases poses a stronger threat to the well-being of both mother and foetus than many immunosuppressant medications. Therefore, continued immunosuppression with the least risky medications will allow for the most optimal pregnancy outcomes. Previous articleView issue table of contentsNext article As treatment for rheumatic diseases improves, more women with these illnesses are willing and able to start a family. This adds complexity to our treatment of young women with lupus, rheumatoid arthritis (RA), and other diseases. We must now address contraception, pregnancy planning, and medication risks early with our patients in order to optimize pregnancy success. Fertility and contraception In general, rheumatic disease does not appear to impair fertility. Comparisons of the total number of pregnancies and living children between women with and without systemic lupus erythematosus (SLE) demonstrate this point (1). Even during times of severe SLE activity, women with SLE are able to conceive. A survey of 214 patients with scleroderma, 167 patients with RA, and 105 normal controls found that 2–5% of patients in each group had difficulty conceiving and 12–15% of patients had a 1-year delay in conception (2). Although the total number of pregnancies in women with RA may be slightly lower than in the general public, this seems to be more closely tied to personal choice than infertility (3). For this reason, discussions of birth control are particularly important. Women taking teratogenic medications, in particular cyclophosphamide, methotrexate, leflunomide, and mycophenolate mofetil, require effective contraception to prevent pregnancy.Women with rheumatic disease can use most forms of birth control without major concerns about side-effects. In particular, the intrauterine device (IUD) and progesterone-only methods (either Depo-Provera® subcutaneously every 3 months or the Implanon® implant every 3 years) are effective long-term contraception. Two randomized placebo-controlled trials demonstrated that women with stable, mild SLE can take oestrogen-containing oral contraceptives without increasing SLE activity (4, 5). These studies, however, did not include women with moderate to severe disease and exogenous oestrogen may increase the risk for thrombosis to an unacceptable level. Finally, all women should be aware of emergency contraception; progesterone-only pills taken within 72 h of unprotected intercourse are safe and effective.RA and pregnancy The majority of pregnancies in women with RA are without complication; the mother has a decrease in her arthritis pain and the baby is born healthy. Pregnancy outcomes are generally favourable for women with RA (6–11) (Table 1). The risk for preterm birth, however, does seem to be increased for women with RA. An ongoing prospective study of pregnancies found that one out of every four women with RA delivered early, compared to 1 in 10
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