If you have nr-axSpA and are trying to conceive or pregnant, working with your rheumatologist and obstetrician/gynecologist to manage your condition is an important part of ensuring both your health and the baby’s.
How Pregnancy Can Affect nr-axSpA
How pregnancy impacts nr-axSpA disease activity can vary from one woman to another, according to Eric Ruderman, MD, a rheumatologist and professor of medicine at Northwestern University Feinberg School of Medicine in Chicago. “I’ve had some patients who are better during pregnancy, and some who aren’t,” says Dr. Ruderman. In general, symptoms appear to remain stable during pregnancy in women with nr-axSpA. In a Norwegian study published in March 2018 in the journal Rheumatology, researchers looked at disease activity before, during, and after 179 pregnancies in women with nr-axSpA or its sister condition, ankylosing spondylitis. The researchers tracked symptoms such as fatigue, back pain, and the duration and severity of morning stiffness at regularly scheduled doctor visits before conception through 12 months after delivery. They found no dramatic spikes or drops in disease activity during the time frame evaluated in the study, but there was a slight increase during the second trimester. That said, the study authors note that more research needs to be done to evaluate whether this represents a true increase in worsening of symptoms, which they noted would be expected to more likely occur in the third trimester, and what might be behind the slight uptick, if anything. Another thing to consider: In some cases, back pain may have nothing to do with nr-axSpA. Given that back pain is generally common during pregnancy, says Ruderman, you may experience novel back pain during your pregnancy that isn’t related to the disease. “It’s a different kind of pain,” Ruderman emphasizes. “I’ve had women tell me, ‘This is not my spondylitis pain. This is mechanical back pain from carrying a baby.’”
How Nr-axSpA Can Affect Pregnancy Outcomes
Even though your nr-axSpA may not change significantly during pregnancy, there’s evidence that the condition may affect other aspects of your pregnancy or your baby’s health. While there’s no evidence that nr-axSpA has an effect on fertility, says Ruderman, once they become pregnant, women with the disease may have a higher risk for certain complications and adverse outcomes. In a study published in March 2018 in Rheumatology, researchers found that women with nr-axSpA or ankylosing spondylitis had a higher risk of developing gestational diabetes, preeclampsia, an infection, or a premature rupture of membranes (amniorrhexis) than women without these conditions. Their babies were also more likely to be born preterm and to be smaller than average for their gestational age. The good news? The study found no increase in risk for cesarean delivery (C-section) in these women.
Treating Nr-axSpA During Pregnancy
The higher risks associated with pregnancy in women who have nr-axSpA mean it’s important to take a proactive treatment approach to minimize your disease activity, according to Ruderman. It’s unlikely your doctor will recommend changing or reducing the dose of your nr-axpA medications, at least initially. “For the most part, rheumatologists have become comfortable using these drugs through pregnancy and nursing,” says Ruderman. If your symptoms improve during the course of the pregnancy and you can start stretching out your doses, “That’s great,” he notes, but it’s a secondary concern to making sure your disease is well controlled. For most women with nr-axSpA, the main drug treatment before, during, and after pregnancy will be a biologic, says Ruderman. While there’s not much data on newer biologic drugs, the safety data on older options called TNF inhibitors indicate there’s little to no risk of adverse outcomes in babies when these drugs are taken during pregnancy. One reason it’s important to continue taking a biologic as needed during pregnancy is to avoid steroids whenever possible, says Ruderman. “If you stop the biologic and end up having to take prednisone, it’s a step backwards,” he notes. When you take steroids, there’s a higher risk of gestational diabetes, preeclampsia, and other pregnancy-related problems. Nonsteroidal anti-inflammatory drugs (NSAIDs) are another class of drugs sometimes prescribed for nr-axSpA. These may be problematic at certain stages of pregnancy, says Ruderman. “There is some concern about developmental issues in the baby with the use of NSAIDs in the first trimester, so a lot of obstetricians recommend against it when trying to get pregnant and in the first 8 to 12 weeks,” he notes. NSAIDs may also cause changes in your developing baby’s circulation around the time of delivery, says Ruderman, so you should avoid taking them during the final 2 weeks or so of pregnancy.
Managing Nr-axSpA Postpartum While Also Protecting Your Baby’s Health
After you deliver your baby, it’s important to continue taking prescribed medications to control your nr-axSpA. Very little of injected or infused biologic drugs are present in breast milk, says Ruderman, so this shouldn’t be a safety concern if you’re breastfeeding. One potential concern related to biologics is that if you took one during pregnancy, it may be present in your baby’s system for about three months after birth. In theory, this means it could be riskier for your baby to receive a live vaccine during this window, but no data actually highlight this risk, says Ruderman. “The worst case is that you push back vaccination until 3 months or so after birth, because at that point there’s no drug [left in the baby’s system].” If you experience a symptom flare after giving birth and need to take steroids to get it under control, it’s important to keep the dose as low as possible if you’re breastfeeding, says Ruderman. Keeping your disease controlled with a biologic drug is ideal, so you can avoid steroids.
Looking Ahead: Parenting With nr-axSpA
Many new parents — women and men — experience lower back pain due to the physical demands of caring for a new baby and the stress involved, says Ruderman. And as your child grows, picking up a heavy toddler or trying to keep up with an active child can pose challenges when you have a chronic condition that can cause pain, mobility issues, and fatigue. If you’re having trouble with your mobility due to nr-axSpA or unrelated back pain, it’s important to lean on your partner, family, and friends when possible to help complete tasks around the house and care for your baby. But many people with nr-axSpA end up not needing much, if any, extra help, says Ruderman. Both during and certainly after your pregnancy, it’s important to stay physically active, says Ruderman. Be sure to work with a physical therapist or trainer who is an expert in inflammatory arthritis to develop an exercise routine that keeps your core and lower back muscles as strong and flexible as possible. “The stronger the muscles are around your spine, the more support you have,” he notes. By doing what you can to manage your symptoms, you can concentrate on enjoying your time with your child without your condition getting in the way.
