Pregnancy and preparing for delivery can bring up a variety of questions and concerns about your health, especially if you have an inflammatory rheumatic disease like axial spondyloarthritis (axSpA). Axial spondyloarthritis, a disease that causes inflammation in the spine, pelvis, or sometimes the sacroiliac joint at the bottom of the spine, may result in joint damage and symptoms like chronic back pain, stiffness, fatigue, and sometimes disability.

People with axial spondyloarthritis who are pregnant or are planning a pregnancy may have particular concerns about how their disease may affect pregnancy and the health of a newborn. A person with axial spondyloarthritis may have questions about how axSpA symptoms and medications may affect their ability to get pregnant, the course of a pregnancy, the delivery process, and breastfeeding.

There are also questions regarding how a pregnancy might affect axial spondyloarthritis symptoms, disease activity, and how typical pregnancy symptoms present in a person with axSpA.

Members of MySpondylitisTeam pose questions about axial spondyloarthritis and pregnancy like, “How did you have children while dealing with ankylosing spondylitis or another condition? Did being pregnant interfere with flare-ups? Did you medicate?”

Although a person with axial spondyloarthritis who wants to become pregnant may need to undergo additional preparation and planning with their obstetrician and rheumatology team, having axial spondyloarthritis does not pose any major risks to a pregnancy or newborn.

How Axial Spondyloarthritis May Affect Pregnancy

When planning a pregnancy, it’s important to understand how any health condition or disease you have would affect a pregnancy. There is not a great deal of research on pregnancy in people with axial spondyloarthritis, specifically. However, existing research shows that having axial spondyloarthritis or ankylosing spondylitis, a type of axial spondyloarthritis, should not negatively affect one’s ability to conceive or bring a healthy baby to term.

Pregnancy Complications and Axial Spondyloarthritis

Understanding the effects of axial spondyloarthritis on pregnancy and delivery outcomes is difficult because there is not a wealth of research on the subject. One study conducted in 2018 examined 244 pregnancies in people with rheumatoid arthritis, axial spondyloarthritis, and healthy controls and found that pregnant women with rheumatoid arthritis or axial spondyloarthritis had an increased risk of pregnancy complications.

Complications included:

• Preeclampsia — High blood pressure during pregnancy
• Gestational diabetes — A type of diabetes that can occur during pregnancy
• Infections
• Delivering a small-for-gestational-age infant, which poses health risks for the infant
• Preterm delivery, or delivering the infant too early, also poses health risks for the infant

The study found that active disease was a major predictor of pregnancy complications in women with rheumatoid arthritis or axial spondyloarthritis. Therefore, management of axial spondyloarthritis disease activity before and during pregnancy could help decrease the chance of complications.

Cesarean Sections and Axial Spondyloarthritis

Cesarean sections (C-sections), whether elective (planned ahead of time) or due to an emergency, are more common in people with axial spondyloarthritis. Research studies have found that birth via C-section was more common in people with rheumatoid arthritis, spondyloarthritis, or ankylosing spondylitis as compared to healthy controls.

Obstetricians may have a preference to plan C-sections in women with arthritis or other inflammatory joint diseases, explains the British National Axial Spondyloarthritis Society. Axial spondyloarthritis symptoms like hip pain and stiffness also present difficulties for a vaginal delivery and may make the chance of C-section delivery more likely.

Inflammation of the spine due to axial spondyloarthritis or ankylosing spondylitis may also affect a pregnant person’s ability to receive an epidural, or an injected pain killer into the spinal cord to numb the lower half of the body during delivery. For those with axial spondyloarthritis and severe spinal inflammation, other forms of pain relief may need to be discussed with an obstetrician before delivery.

Axial Spondyloarthritis Medications, Pregnancy, and Breastfeeding

Some medications used to treat axial spondyloarthritis may affect pregnancy and the ability to conceive. However, some axial spondyloarthritis medications should not have any effect on pregnancy, and because they may help to keep active disease symptoms under control, they can be safely used throughout pregnancy. Discuss any medications taken for axial spondyloarthritis with your rheumatologist and obstetrician before trying to become pregnant.

Methotrexate, a type of disease-modifying antirheumatic drug (DMARD) used to treat ankylosing spondylitis, should not be taken during conception or pregnancy because of its potentially harmful effects. Sulfasalazine, another DMARD, is considered safe to continue during pregnancy but its use should be discussed with a rheumatologist.

It is generally advised that nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen should be used with caution and stopped after 32 weeks of pregnancy.

Recommendations for taking tumor necrosis factor (TNF) inhibitors are somewhat mixed, due to a lack of research on the effects of these medications during pregnancy. It also depends on one’s current use and needs for the TNF inhibitor to keep their axial spondyloarthritis symptoms under control. Some biologic TNF inhibitors are thought to be safe for use before the third trimester.

Corticosteroid injections and oral steroids may also be safe to use during pregnancy, but it is very important to discuss all medications with a rheumatologist and obstetrician before attempting to conceive.

After delivery of the infant, most axial spondyloarthritis medications are safe for breastfeeding, and only relatively small amounts of medication can be passed through breast milk. Make sure to discuss axial spondyloarthritis medication management, plans for breastfeeding, and any concerns about lactation with your doctors, especially in the case that your axial spondyloarthritis symptoms change after delivery.

How Pregnancy May Affect Axial Spondyloarthritis and Its Symptoms

If you have axial spondyloarthritis and want to become pregnant, another important issue to consider is how pregnancy may affect axial spondyloarthritis disease activity and symptoms. Some people report that their symptoms of axial spondyloarthritis worsen during pregnancy, and others report that they improve, so there is no definitive pattern of how pregnancy affects axial spondyloarthritis symptoms.

Disease Activity During Pregnancy

Some women with axial spondyloarthritis or ankylosing spondylitis may experience increased disease activity and symptoms like stiffness, tenderness in the spine, and back pain during pregnancy. Pain in the back or hips may increase, especially in the third trimester, when the baby grows and puts stress on these joints.

A research study in Rheumatology examined disease activity during and after pregnancy in women with axial spondyloarthritis and found that women reported worse pain and the highest disease activity in the second trimester of pregnancy. Disease activity was measured through a score called the Bath Ankylosing Spondylitis Disease Activity Index that assesses symptoms like fatigue, back pain, joint swelling, tenderness, and morning stiffness. Overall, the study found that disease activity in women with asXpA was low and stable throughout pregnancy and up to one year after delivery.

A different study assessed disease activity and flares in people with rheumatoid arthritis and axial spondyloarthritis during pregnancy and found that stopping TNF inhibitors was a risk factor for disease flares and higher disease activity (measured through levels of C-reactive protein, a marker of inflammation) during pregnancy. The study’s findings indicate the benefits of continuing TNF inhibitors during pregnancy for people with axial spondyloarthritis to keep disease activity and symptoms under control.

Disease Activity After Delivery

Disease activity after delivering a baby is another consideration to prepare for and discuss with your health care providers. A disease flare may be more likely in the three months after delivery. Pay attention to your axial spondyloarthritis symptoms and tell your rheumatologist if they worsen.

Even if axial spondyloarthritis symptoms don’t increase or decrease after delivery, symptoms like fatigue may make it more difficult for a person with axial spondyloarthritis to care for a newborn. Some people with ankylosing spondylitis report feeling pain when holding their babies to breastfeed. Consult your obstetrician or a lactation consultant who has experience with arthritis for advice on breastfeeding and caring for your newborn when you have axial spondyloarthritis symptoms.

Infections After Delivery

Another concern is the risk of infections after delivery. Some medications used to treat axial spondyloarthritis suppress the immune system, which increases the risk of infection after delivery. Contact your doctor if you believe you may have an infection, as they can prescribe antibiotics or other medications to treat them.

Preparing for Pregnancy With Axial Spondyloarthritis

Preparing for pregnancy with axial spondyloarthritis requires discussing your plans with your rheumatology team and obstetrician and practicing effective birth control until you are ready to try to have a baby. Your doctors will advise you on which medications to continue or stop throughout conception and pregnancy.

The American College of Rheumatology recommends that rheumatic disease should be controlled for at least three to six months before attempting pregnancy. The severity of axial spondyloarthritis and its symptoms may affect how you approach a pregnancy. If you have a high-risk profile, seek out care from a rheumatologist and obstetrician with experience managing high-risk pregnancies.

For example, if you have severe hip immobility due to axial spondyloarthritis, you need to discuss the possibility of having a C-section. If you have severe spinal inflammation, you need to discuss other forms of pain management if you cannot receive an epidural during delivery.

Discuss with your doctors how to best manage your axial spondyloarthritis symptoms after delivering a baby. Taking care of yourself and your axial spondyloarthritis symptoms is very important so that you will have the energy to care for your newborn. Don’t be afraid to ask your partner, family members, or friends for help and support with childcare, especially if you experience a flare after delivery, even months later.

Talk to Others Who Understand

If you have more questions about pregnancy with axial spondyloarthritis, joining a support group and asking others about their experiences may be helpful.

MySpondylitisTeam is the social network for people with spondylitis. On MySpondylitisTeam, more than 74,000 members come together to ask questions, give advice, and share their stories with others who understand life with spondylitis

Do you have axial spondyloarthritis and plan to become pregnant? Have you had a child? Share your experience in the comments below, or start a conversation by posting on your Activities page.