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RA and pregnancy planning — SCE Rheumatology MCQ

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HardRheumatoid arthritisRA and pregnancy planningSCE Rheumatology

A 32-year-old woman has persistently active rheumatoid arthritis (DAS28 5.8) despite adequate tolerated courses of hydroxychloroquine and sulfasalazine. Methotrexate is inappropriate because she wishes to start trying to conceive immediately, and she meets NHS eligibility criteria for biologic treatment. Infection screening is negative. Following shared decision-making, she wants an effective treatment that can be continued if conception occurs while minimising active placental transfer. Which treatment strategy is most appropriate?

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Correct answer: C — Certolizumab pegol continued through conception and pregnancy

Certolizumab pegol is the best choice. It is a PEGylated anti-TNF Fab′ fragment without an Fc region, so Fc-receptor-mediated placental transfer is low or negligible. It can therefore be continued through conception and pregnancy when clinically required. Infliximab is not the best answer to the stated priority because it crosses the placenta and can remain detectable in the infant. Tofacitinib is contraindicated during pregnancy and should not be continued until pregnancy is recognised. Leflunomide is contraindicated and must be stopped with an appropriate elimination procedure before conception, not after pregnancy confirmation. Rituximab crosses the placenta and may cause transient neonatal B-cell depletion; its SmPC advises contraception for 12 months after treatment, making conception after 3 months inappropriate.

Reference: Electronic Medicines Compendium. Cimzia 200 mg solution for injection, Summary of Product Characteristics, section 4.6 Fertility, pregnancy and lactation. Updated 4 May 2026. https://www.medicines.org.uk/emc/product/7387/smpc