Pregnancy Problems Seen in PsA and AS



Women with psoriatic arthritis (PsA) or ankylosing spondylitis (AS) were at risk for a variety of adverse pregnancy and obstetric events, a prospective cohort study found.

For instance, compared with healthy controls, women with PsA were at significantly elevated risk for moderate preterm birth, defined as birth from weeks 32 to 37, with an adjusted risk ratio of 1.81 (95% CI 1.01-3.26), according to Chelsey J.F. Smith, MD, of the University of California San Diego in La Jolla, and colleagues.

And among those with AS, there was an increased risk for hospitalization in the neonatal intensive care unit (NICU), with an adjusted RR 1.67 (95% CI 1.05-2.67), they reported in Arthritis Care & Research.

These two inflammatory diseases typically strike at younger ages than other disorders such as rheumatoid arthritis (RA), often during the childbearing years. Yet few studies have addressed pregnancy outcomes in women with these conditions, and the sparse available data have been inconsistent.

Accordingly, Smith and colleagues analyzed data from the Organization of Teratology Information Specialists (OTIS) Autoimmune Disease in Pregnancy Project, including 117 women with PsA, 129 with AS, and 717 healthy controls enrolled in the cohort study from 2004 to 2018.

Covariates included maternal age, parity, BMI, race, smoking, previous adverse pregnancy outcomes, and comorbidities such as diabetes, asthma, and hypertension.

Disease activity was assessed on the Health Assessment Questionnaire (HAQ) along with pain scores and patient global disease activity, and these three measures of disease activity were combined to provide a cumulative Routine Assessment of Patient Index Data 3 (RAPID3) score. Active disease on the HAQ and RAPID3 were defined as scores above 0.5 and 7 or higher, respectively.

In general, women with PsA were older and had higher BMI than controls, and also had more previous spontaneous abortions. Those with AS more often were primigravid, and women in both groups had more comorbidities than controls.

Aside from moderate preterm delivery, mothers with PsA more often experienced these events:

  • Preterm labor: RR 2.05 (95% CI 1.21-3.48)
  • Cesarean delivery: RR 1.63 (95% CI 1.26-2.12)
  • Oligohydramnios: RR 3.79 (95% CI 1.34-10.74)

Along with their infants' requiring hospitalization in the NICU, women with AS also had increased risk for very preterm delivery (RR 10.19, 95% CI 2.09-49.78 for before 32 weeks;) and very low birth weight (RR 11.02, 95% CI 2.24-54.12 for less than 1,500 g); although these events only were reported in three cases.

The researchers also considered the effects of disease activity and medication exposure on outcomes.

Higher numbers of patients had active disease as measured on the RAPID3 than on the HAQ for both PsA (40.8% vs 22.35) and AS (49.1% vs 34.5%). Over the course of the pregnancy, women with PsA showed stable disease activity scores on the HAQ and improvements on RAPID3, whereas scores for both showed slight worsening in AS.

In PsA, active disease at week 32 as measured on both the HAQ and RAPID3 increased the risk for preterm delivery, while there was no association between disease activity or NICU hospitalization or C-section delivery.

In AS, active disease measured by RAPID3 at baseline conferred an increased risk of C-section delivery, and active disease at 32 weeks was associated with an elevated risk for preterm labor. These estimates were quite imprecise, however, the researchers noted.

There was no association for medication use and preterm delivery during the first two trimesters in PsA, but corticosteroid use in the second trimester did show an association with preterm delivery in AS (RR 4.41, 95% CI 1.57-12.41).

An association between preterm birth and inflammatory disease has been observed previously in women with RA, but the potential contributions of disease activity and medication exposure have not been clarified. Another recent report from the OTIS group suggested that preterm delivery in RA may be influenced by high disease activity and corticosteroid exposure.

"Our study suggests that similar trends may exist in PsA and AS, as active disease later in pregnancy was found to increase the risk for preterm delivery in PsA, and second trimester corticosteroid use was found to increase the risk for preterm delivery in AS," Smith and colleagues wrote.

The American College of Rheumatology has recommended avoidance of systemic corticosteroids for AS except in certain circumstances such as for disease flares in pregnancy. In the AS group, 38% used corticosteroids at some time during pregnancy, which was "surprisingly high."

"These findings from our study imply that systemic corticosteroid treatment for flares during pregnancy may not be without risk, and perhaps alternative medications should be entertained first, if clinically appropriate," they noted. "Future studies are needed to confirm the novel findings seen in our study, as well as to continue to analyze the effect of different disease activity measures and medication use on pregnancy outcomes in these two chronic conditions."

A study limitation was its inclusion of mostly white women.

The OTIS research group disclosed funding from multiple companies including AbbVie, Amgen, Apotex, Barr Laboratories, Bristol-Myers Squibb, Celgene, Janssen, Kali Laboratories, Pfizer, Hoffman La Roche-Genentech, Sandoz, Genzyme Sanofi-Aventis, Takeda, Teva, UCB, Seqirus, Regeneron, GlaxoSmithKline, and AstraZeneca.

Smith disclosed support from the NIH.

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