Arthritis and pregnancy

Questions to ask yourself

Deciding to become pregnant should be a conscious decision for all women. Since it will probably be one of the greatest decisions a woman ever has to make, it is important that she has the information to do so.

If you have arthritis and are pregnant or are thinking about having children, you may want to ask yourself these questions, if you haven't already:

• Am I ready?
• Will my arthritis go away?
• Will my child inherit arthritis?
• How will arthritis affect my pregnancy?
• How will pregnancy affect my arthritis?
• How can I plan ahead for my pregnancy?
• How can I make it easier to care for myself and my baby after birth?

This information aims to help women with arthritis answer these and other questions. As you review this information, list the pros and cons of having a child. Then, refer to this list as you and your partner make a decision. Since arthritis and pregnancy affect everyone differently, the answers to these questions will be different for everyone.

Self-test

Any couple who is thinking of having a baby will have certain physical, emotional, and financial issues to consider before conceiving the child. A woman with arthritis will have particular concerns related to arthritis. The self-test will help evaluate the physical ability of a woman with arthritis to care for a new baby. Following the test are some questions to think about and discuss with others.

Self-test for strength and endurance

This test will give you a good idea of how caring for a baby will affect you physically and what problems you may have to work on before having a baby. Try the activities below and list any problems you have with certain ones. Your therapist, doctor, or nurse can help you work out the problems. (Note: the weight and structure of a bag of potatoes is used to mimic the motions of carrying and lifting a baby.)

• Can I lift a 10 lb. bag of potatoes from the height of my bed?
• Can I hold a 10 lb. bag of potatoes in one arm while sitting for at least 10 minutes?
• Can I go up and down stairs easily while carrying a 10 lb. bag of potatoes?
• Can I walk around the house carrying the 10 lb. bag of potatoes for up to 10 minutes?
• Do I get more pain in my hips, knees and/or feet when I am carrying the 10 lb. bag of potatoes?
• Can I screw on and off the top to a baby bottle?
• Can I push a diaper pin through a thick diaper?
• Can I get through my average day without taking a nap?
• Can I bend my neck (chin to chest) to see the baby if I were holding it close to me?

Other questions for you, your family, and your doctor to consider

Any major life decision should be made at a time when you are not under stress. You need to be clear about why you wish to get pregnant and when you wish to do so. The why might be very difficult to answer, because we're all influenced by previous life experiences, current roles and relationships, and by our frame of mind. It's not uncommon, for instance, for some women to choose pregnancy when they are feeling lonely and depressed, thinking that a new baby will change things for them. You might want to ask yourself the following questions when thinking about how you feel about having a baby:

• Am I expecting a new baby to fill a void in my life?
• Do I want to get pregnant only to try to relieve some of the pain I'm having from my arthritis?
• Are there people around me who can help me when I'm not feeling well?
• Is this a good time to have a baby, personally, emotionally and financially?

If you're not sure how you feel about some of these questions, discuss your feelings with your family and friends. You might also find it helpful to talk to your doctor or other health team members. These people can also refer you to a counselor or someone specially trained to help with these issues, or to other women in similar situations.

Will arthritis go away during pregnancy?

Rheumatoid arthritis may improve at any time during pregnancy. In most women, it usually improves by the end of the fourth month. While joint swelling may decrease, pregnancy women may still have some joint pain or stiffness due to existing joint damage.

Lupus may stay the same, improve, or flare (get worse) during pregnancy. To decrease the chances of a flare, the lupus should be in remission for six months before you become pregnant. This means not only that you feel well, but that blood tests and other tests for the disease are also normal.

Research on scleroderma and other types of arthritis is not as conclusive. Some studies report that scleroderma flares, while others report that it improves.

If illness does improve during pregnancy, it may flare two to eight weeks after your baby is born. Proper planning and treatment before, during and after pregnancy, however, can help decrease pain and swelling and help improve your ability to function. You and your health care team can work together on ways to do this.

Having an abortion will NOT prevent a flare. Any type of delivery--whether from a spontaneous abortion, a therapeutic abortion, or a stillbirth--could cause a flare.

Will a child inherit arthritis?

Probably not. While the causes of most forms of arthritis are not known, some forms tend to appear in families more often than others. These types of arthritis are called "familial", yet heredity is never the single factor that determines if a person develops arthritis. Other factors, such as the environment (exposure to certain viruses or chemicals) also may have an effect.

Scientists have found certain genetic markers that may indicate if some people have a higher risk for getting some types of arthritis. However, the relationship between these markers and the actual development of arthritis is still unclear and does not mean you will pass arthritis on to your child. Generally, there is no way to tell if your child will ever have arthritis in the future.

How does arthritis affect pregnancy?

The physical changes that normally occur during pregnancy may affect joints and muscles in the following ways.

1. Joints may become looser and less stable. This may cause a pregnan woman to "waddle" when she walks.
2. Knee problems may become worse due to increased weight, or because the muscles along the side of the knee become weaker. This might cause knee pain, especially while going up or down stairs or when straightening the knee.
3. As the uterus grows, your spine curves slightly to support it. This can lead to muscle spasms in the back. Sometimes this can also cause pain, numbness and tingling in the legs.
4. Much more blood flows through the body during pregnancy, so it is important that the heart is functioning normally. If your heart is functioning normally, there shouldn't be any problems. If you have any heart problems such as pericarditis (inflammation of the sac surrounding the heart) or myocardltis (inflammation of the heart muscle) your doctor may ask you to delay pregnancy until these problems are under control.
5. Water weight gain may increase stiffness, especially in weight-bearing joints (hips, knees, ankles, and feet). It may also cause problems with carpal tunnel syndrome--a condition that causes pain, numbness, and tingling in the thumb, index, and middle finger. This usually goes away after delivery. Report all water gain to your obstetrician during your office visit. Report any unusual water gain beyond the lower legs, such as in the thighs or face to your doctor right away.
6. Breathing: The breathing muscles will move upward due to the growing baby. This may cause only mild shortness of breath. If you have significant shortness of breath or a change in your breathing, contact your doctor right away.

Controlling the arthritis

Health care team

Follow your treatment plan

You're probably already following a treatment plan for your arthritis. Once you become pregnant, you and your doctor may have to change some parts of this plan slightly. As a pregnant woman with arthritis, your plan should include:

• arthritis medicines: know what arthritis medicines you're taking and how they will affect your baby
• exercise: to keep your muscles strong and your joints flexible
• diet: eat a balanced diet
• joint protection: learn ways to ease joint pain and to reduce stress on your joints
• stress management: to help ease the emotional ups and downs of pregnancy.

Medications

You've probably wondered whether you should continue taking your arthritis medicines. While it would be ideal to be off all medicines during pregnancy, this is not always possible. Talk to your doctors about the medicines you're taking and which ones are safe to take while you're pregnant. Some medicines are used more often than others during pregnancy, and your doctor may prescribe medicines other than those listed below. Some medicines just haven't been used enough to know whether or not they'll cause problems to your baby during pregnancy. The most important concern, of course, is keeping you and your baby as healthy as possible.

Discuss any medicines you use--either prescription or over-the-counter--with your doctor(s). If you must take medicines during your pregnancy, your doctor will give you the lowest possible dose and will monitor the effect of the medicine on you and the baby. Do not start or stop taking any prescription or over-the-counter medicines without first contacting your doctor.

Taking medicines while breast-feeding

Any medicines you take may be passed to your baby through breast milk. Here. are some tips to consider if you intend to breast feed.

• Any medicines you take may be passed to your baby through breast milk. Here. are some tips to consider if you intend to breast feed.
• Talk to your doctors and to your baby's doctor about your medicines and their possible effects on your baby.
• Never take any prescription or over-the-counter medicines without first checking with your doctor or pharmacist.
• Take your medicines after the baby's morning feeding, so less medicine will be passed through your milk.

Exercise

You probably already have an exercise program to follow for your arthritis. While you'll want to continue exercising to keep your joints in their best condition, you'll also want to make sure the exercises don't harm your baby. Discuss your exercise program with your doctors before you begin, especially if you have:

• heart problems
• phlebitis (inflammation of the veins, usually in the legs)
• a serious infection
• severe high blood pressure
• high risk for premature labor
• incompetent cervix (a problem that could cause your baby to be born prematurely)
• any bleeding from the uterus
• any problems with the fetus

If your arthritis improves during your pregnancy, you may wish to exercise more than usual.

Exercise tips:

• Practice range-of-motion exercises to help keep your joints flexible.
• Exercise to strengthen your muscles--especially the quadriceps muscles (the large muscles above your knees)--before you become pregnant. Strong muscles will provide better support for your joints. Talk to your obstetrician about the types and amount of muscle strengthening (isometric) exercise you should do. Too much of the wrong type of exercise could reduce the amount of blood flowing to the baby, which can cause problems.
• Try walking or swimming. These are general exercises that help keep your muscles strong, increase your endurance, and are generally safe for pregnant women.

Diet

Good nutrition is very important for your health and for your baby's health. You should eat a balanced diet and practice good eating habits before, during, and after your pregnancy, especially if you are breast-feeding. A dietitian, nutritionist, or other health care worker can help you plan a balanced diet.

Arthritis may cause eating problems, due to:

• a reduced amount of saliva (as in Sjogren's syndrome)
• tooth problems
• mouth sores
• problems with food sticking in your esophagus
• trouble opening your mouth due to jaw pain

Also, joint pain may make it difficult to prepare meals, so you may be less likely to eat a balanced diet. If you're taking prednisone, you may need a special diet to help avoid high blood sugar which may be caused by the medication. Discuss these problems with your doctor.

Some possible problems and solutions associated with pregnancy and diet are discussed here.

Problem 1. Weight gain or weight loss

Gaining too much weight will put more stress on your joints. The extra weight of pregnancy can make this problem worse. But if you do not gain enough weight, you and your baby may not be getting enough nutrients you both needs to stay healthy.

Most doctors suggest you gain between 20-30 pounds during pregnancy. To do this, you must balance diet and exercise. Here are some questions you should consider:

• How much and what types of exercise can by joints handle?
• How long can I exercise at one time?
• Are my arthritis or arthritis medicines decreasing my appetite and causing me to lose weight?
• Am I taking any medications, such as prednisone, that may increase my appetite and cause me to gain weight?
• Is emotional stress causing me to eat too little or too much?

Your obstetrician or dietitian can help you plan a diet that takes these factors into consideration. If your arthritis, for instance, prevents you from getting as much exercise as you would like, then you will not need as many calories as someone who is more physically active. But you still will need to pay close attention to your diet, to make sure you get enough vitamins and minerals.

Problem 2. Nausea and vomiting

Nausea and vomiting can lead to problems that could affect you and your baby.

To reduce nausea:

• Eat small, frequent meals.
• Eat slowly and chew food thoroughly.
• Avoid greasy, fried foods.
• Eat toast or crackers when you get up in the morning.
• Avoid drinks that might upset your stomach, such as coffee and fruit juices.
• Talk to your doctor about your arthritis medicines and how they might be affecting your nausea.

Problem 3. Heartburn

Heartburn usually gets worse as your uterus enlarges and pushes up on your stomach.

Talk to your doctor about this and how your arthritis medicines might be affecting your heartburn.

To reduce heartburn:

• Eat small, frequent meals
• Decrease caffeine in your diet
• Avoid fried, fatty, and spicy foods
• Avoid carbonated drinks, such as soda
• Raise the head of your bed by placing 6" blocks beneath it
• If you use antacid, choose one which is low in sodium

Problem 4. Constipation

Bowels may slow down during pregnancy and cause constipation. Some forms of arthritis, such as scleroderma, also cause bowel changes.

Contact your doctor immediately if you are having bloating, gas, diarrhea, or constipation problems beyond what your doctor thinks is normal for you.

To relieve constipation:

• Eat high-fiber foods (whole-grain breads, fresh fruits and vegetables, cereals with bran, beans such as kidney and pinto)
• Drink 6-8 glasses of water daily
• Exercise (such as walking or swimming)
• Try a high fiber laxative, such as Metamucil

Joint protection

The extra weight of pregnancy may make your joints hurt more. To avoid further damage to your joints, it's important to learn ways to protect your joints from extra stress and strain. Here are some ways to do this.

• Avoid pain-relief medicines when possible. Talk to your doctor before you use any pain relief medicines and ask about exercises, heat and cold applications, and other things you can do to reduce pain.
• Use hot or cold packs on your joints. This is safe to continue throughout your pregnancy.
• Use splints. They may be especially helpful for your hands and knees. Talk to your occupational therapist or other health care worker about having splints made for you.
• Rest whenever possible. This can help relieve pain in your weight bearing joints, such as your hips, knees, ankles, and feet.
• Try relaxation exercises, such as biofeedback or visual imagery.
• Wear comfortable shoes (such as jogging shoes) that give you good support. Shoes should have a 1" to 1 1/4" heel, good arch support, roomy toe box, and firm heel-counter. Lace-up or velcro-closure shoes provide the most support.
• Practice good posture and gait at all times.
• Sleep on a firm, supportive mattress to reduce muscle spasms.
• Ask your obstetrician about using support hosiery to reduce fluid retention in your legs, ankles, and feet.
• Notify your doctor of any increased pain in joints and muscles and of any numbness or tingling in your hands or feet.
• Exercise to keep your joints flexible and your muscles strong.

Sexuality

The fatigue, nausea, and emotional changes of pregnancy often cause sexual desire and the frequency of intercourse to decrease during your first three months. Desire often increases during the second trimester, but may decease again during the third trimester when you may feel uncomfortable and/or unattractive. Fatigue or fear of another pregnancy may decrease sexual desire after your baby is born. The additional pain and fatigue of arthritis may make these problems worse. If these changes are a problem for you, talk openly with your partner about them. Often, open communication can help solve many of these problems.

Alcohol

Asking for help

If joint problems, pain, or fatigue decrease a woman's ability to care for her baby, she may feel that she's an inadequate mother. She may feel this way especially when the arthritis flares. It's important for women with arthritis to remember that they are capable of caring for thier children, but that they may need help. Accepting help does not make anyone less of a mother--it simply means they are accepting responsibility for their children's well-being.

If you are troubled by such thoughts, it may be helpful to talk to someone who specializes in these problems.

Surgery

Labor and delivery

Labor and delivery are not usually particularly difficult for women with arthritis. However, you'll want to find a comfortable position during the labor and delivery process. You probably can deliver your baby as most women do: vaginally, lying on your back. If this position is uncomfortable, you may want to lie on your side or sit in a rocking chair or birthing chair. Even if you have had a hip replacement, you may be able to deliver your baby vaginally without complications.

As with any pregnant woman, you may need monitoring and certain blood tests during labor and delivery. However, the amount of monitoring you may need will depend on how active your disease is. If you have lupus or scleroderma, your fetus probably will be monitored throughout labor. In some cases, it may be necessary to check the fetus' blood during labor to determine if there are any problems that might require the baby to be born by cesarean section rather than vaginally.

Follow-up plan

A follow-up plan should include:

• visiting a doctor regularly--to monitor the arthritis (you may also have to see other specialists, such as a nephrologist or neurologist, depending on the type and severity of your arthritis)
• resuming an exercise program--to help keep your joints functioning (your doctor must first approve this)
• knowing which medications (if any) you should take and if you can breast-feed your baby while taking them.
• knowing how much activity your joints can handle and how you can pace your activities to avoid joint stress

Saving energy

Saving energy is important for any mother. After a baby is born, a woman with arthritis may feel fatigued more often. Some of this will be due to the arthritis, and some due to the loss of sleep and extra energy required to take care of a baby.

Saving energy means performing tasks in ways that require the least amount of energy possible. Women with arthritis can do this by organizing tasks and by planning ahead. Here are some tips to help save energy and time while caring for a baby.

Bathing:

• Place the bathing basin so it's not necessary to lean over, kneel, or reach up to bathe your baby. For example, the basin might be placed on the counter top next to the sink or in the kitchen sink.
• If placed in or near the sink, the basin can be filled with a hose attached to the kitchen faucet. A wash mitt may help a woman with hand problems wash her baby.
• Wear an apron with large pockets in which to place bathing supplies. Shampoo, soap and a bathing mitt will fit nicely and can be returned to their location easily.
• Sit on a high kitchen stool next to the sink while bathing the baby.
• Use a basin that has a plug to drain the water out of it, so you don't have to lift it to empty it. Use a foam rubber basin with an infant headrest, so you don't have to support the baby while bathing it.
• Place your baby in an infant car seat or table top seat for bathing.

Dressing:

• Position the dressing table at waist height for ease in dressing the baby.
• Choose baby clothing that is made of stretchy materials and has few small buttons and snaps. Replace some fasteners or buttons with Velcro fasteners. Use a button hook to button small buttons.
• Place disposable diapers or washable diapers in large bags so they can be dragged rather than lifted.
• Use a zipper pull to close zippers.
• Use shoes with Velcro closure tabs so tying bows won't be necessary.
• Use disposable diapers with plastic tape tabs, or sew Velcro tabs onto cloth diapers rather than using safety pins. If you choose to use cloth diapers with safety pins, puncture a bar of soap with the safety pin so the pin will slide into the diaper more easily.

Feeding:

• To avoid stiffness during nighttime feedings, place a warm blanket over a comfortable chair before retiring. When sitting down, wrap the blanket around yourself.
• Sit in a chair that has arm rests to support the arms while holding the baby.
• If you have difficulty flexing your neck in order to see your baby, place a pillow on your lap so it will raise the baby up in your arms and out slightly so that you can see him or her. This will also help position the arm that is holding the baby bottle. Nursing mothers can also use this position.
• If your feet are stiff and it's difficult to get out of bed for nighttime feedings, do gentle range-of-motion exercises, especially to your ankles before rising at night. A doctor, nurse, or therapist can show how to do the exercises. Also, keep a comfortable pair of shoes, sneakers or slippers next to your bed.
• If it's difficult to hold the baby close to the body while bottle feeding, place the baby in an infant seat on a table.
• If nursing, try to lie on your side while feeding your baby rather than sitting upright and holding the baby.
• If you have hand problems, ask a family member to prepare baby bottles in advance, and keep the bottles in the refrigerator for the day.

Lifting and carrying:

• When carrying the baby, place most of the baby's weight on your largest joint, such as the forearm. You may find it more comfortable to hold the baby close to you with both arms rather than with one.
• Lift and hold the baby with the arms rather than the hands. This decreases the stress on wrists and fingers.
• Use a lightweight stroller that is easy to push and does not require you to bend low to place your baby inside.
• Elevate the playpen on a wooden platform so you don't have to bend over as much. Be sure the legs of the playpen are firmly anchored to the platform.
• Raise the crib mattress, so you don't have to bend over to pick up your baby.

Other tips:

• Use a cart with wheels to help you move equipment around the house and to eliminate multiple trips for small items.
• REST as much as you can. If possible, take a nap when your child does. If you need to rest while your child is awake, ask family, friends, or a hired person to care for him or her.
• Use room intercoms so you can hear your baby when he or she is sleeping. This will save you from walking to the baby's room frequently. Infant intercoms are available in most department stores.
• Keep items you need during the day for the baby in the area of your home where you will be working most of the time.
• Use long-handled tongs to reach high cupboards and to pick up toys.
• As your child becomes a toddler, he or she may be able to move faster than you can. To keep one step ahead of your baby, "child-proof" your home. For example, cover electrical outlets, and put dangerous substances out of reach.

Always discuss any problems with a doctor and health care team. They can help you work around the problem, so you and your baby will be as healthy as possible.

Credits

Some of this material may also be available in an Arthritis Foundation brochure. Contact the Washington/Alaska Chapter Helpline: (800) 542-0295. If dialing from outside of WA and AK, contact the National Helpline: (800) 283-7800.

Adapted from the pamphlet originally prepared for the Arthritis Foundation by Diane M. Erlandson, RN, MS, MPH, Patricia A. Fraser, M.D., Michael Greene, M.D., Martha K. Logigian, MS, OTR/L, Mary Myers, OTR, MEd, and Connie Roberts, RD, MS. This material is protected by copyright.