Juvenile Arthritis During Pregnancy and Breastfeeding

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Juvenile arthritis (JA) is a term that is applied to what doctors usually call juvenile idiopathic arthritis (JIA). The name applies to conditions that begin by age 16, and in which inflammation, or  immune system activity against body parts such as joints (autoimmune activity) is a major feature. In the past, JIA was called juvenile rheumatoid arthritis, because it was thought to be a pediatric version of adult rheumatoid arthritis (RA). However, in most cases of JA, the child does not have elevated levels of a protein called rheumatoid factor (RF), which is elevated in most (although not all) cases of adult RA.

Different types of arthritis fall into the category of JIA. They typically continue into adulthood, and so they often co-exist with pregnancy. In fact, 1-2  out of 1,000 pregnant women have some form of JA. JA is present in an estimated 1 – 2 per 1,000 pregnant women.

The diagnosis of JA depends on your medical history, physical examination, laboratory tests and, often, imaging of joints. To be classified as having JA, you must have been diagnosed by the time you were 16 years of age. The main feature that can alert your doctor that JA is a possibility is joint swelling. This swelling can be anywhere: hands, wrists, knees, feet, or ankles. JIA is furthermore classified based on the number of joints affected. If no more that 5 or 6 joints swell, the condition is called oligoarthritis, which develops more often in very young children and very rarely in children above 10 years of age. On the other hand, children ages 10-16 more often develop polyarthritis, meaning that the swelling occurs in many different joints, though not necessarily all at once. During the history and physical examination, doctors are on the lookout for fever and rashes, movement difficulties such as limping, dry eyes and eye inflammation, and swollen lymph nodes. Imaging studies, such as X-rays, ultrasound, or magnetic resonance imaging (MRI) may be ordered. In all cases, a girl being evaluated for JA will be given blood tests that may include RF, Erythrocyte Sedimentation Rate (ESR), cyclic citrullinated peptide (CCP), C-reactive protein (CRP), and antinuclear antibody (ANA).  There are different tests for ANA, which when elevated can be a sign of another condition called systemic lupus erythematosus (SLE). However, when ANA is elevated in children with JIA, there is a high risk of problems with the eyes. In such cases, an ophthalmologist must be involved in managing the patient.

JA often improves during pregnancy, especially if the arthritis is RA, but the condition can then flare-up about three months after you deliver. Also, having arthritis increase the chances that you will stay longer in the hospital after delivering, and the likelihood that you will need a cesarean section (surgical birth). JA increases the risk of problems for the fetus, 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. JA can increase the chances of complications during pregnancy, such as preeclampsia (a condition featuring high blood pressure and problems with one or more organs) and postpartum hemorrhage (severe bleeding after delivery).

Treatment of JA depends greatly on medication. The basic strategy of medication is suppress the immune system to reduce inflammation. Common arthritis medications given in moderate to severe cases include methotrexate, leflunomide, and COX inhibitors, but these drugs cannot be taken during pregnancy. Arthritis treatments that are safer during pregnancy include hydroxychloroquine and sulfasalazine and non-steroidal anti-inflammatory drugs (NSAIDs), but these should be avoided during the third trimester. Other drugs , called “biological agents” include ritoximab and other drugs that end with “mab”. There is concern that these drugs might be dangerous during pregnancy, but there is also a lack of research. There are drugs called opioids, also called narcotic agents, given for the pain of arthritis; these too can be harmful to the baby. Medications such as azathioprine and low-dose aspirin that are thought to be only slightly risky in pregnant women with JA. Finally, medications called corticosteroids, are fairly safe and can be given against an arthritis flare-up, and then tapered off.

Medications that are given to women with JA vary in terms of how much they enter breast milk and their potential to harm to an infant that you are nursing. Methotrexate and leflunomide must be avoided if you are nursing. If you must take these drugs, then you mustn’t nurse. Although rheumatoid JA tends to improve during pregnancy, it also tends to flare-up soon after you deliver. As for steroid medication, with good timing it is possible to reduce the amounts then enter the milk that the child consumes. With the steroid prednisolone for instance, it is known that it builds up in breast milk mostly during the first four hours after a dose is given. This means that you can wait four hours after receiving each dose, and then pump out her milk and discard it. After that, you can wait for new milk to accumulate and breastfeed the infant from that new milk. All of this is difficult, so you may find it more reasonable to feed your newborn one of the many excellent infant formulas that are available.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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