Background/Purpose: Pregnancy is often encountered in women who have inflammatory arthritis (IA), such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile arthritis (JIA) or ankylosing spondylitis (AS). While patients often forego medications during pregnancy due to safety concerns, rheumatologists often are reluctant to start antirheumatic therapy or maintain tight control of disease activity during pregnancy. Uncertainty exists as to the best practice to achieve optimal pregnancy outcomes. Our goals were to evaluate the effects of disease activity and medication exposure on pregnant patients with IA.

Methods: A retrospective, observational cohort study was carried out at one center, enrolling females aged 18-45 years, diagnosed with RA, JIA, AS or PsA who had: 1) >12 months follow-up and a documented pregnancy in this period; and 2) clinic visits that qualified as being preconception (PRE), pregnancy (1^st, 2^nd or 3^rd trimester) and post-partum. Drug exposure was classified as occurring PRE (>1 month before conception), at risk (RISK- 1^st trimester plus 1 month preconception) or during 1^st, 2^nd and 3^rdtrimesters of pregnancy (PREG). Data collected included therapies (DMARDS, biologics, steroids, NSAIDS), modified health assessment questionnaire (mHAQ), tender joint count (TJC), swollen joint count (SJC), pain score, and global arthritis score (GAS). GAS was the sum of TJC (0-28) + pt. pain (0-10) + mHAQ (0-24); and remission (REM) <3; low activity 3-7; moderate activity 8-19; high activity >20 Maternal disease activity was further classified as flared or improved (defined: 20% change in TJC+SJC or >3 increase in joint count if PRE count <2). Fetal outcomes were classified as live births or adverse fetal outcomes (AFO: defined as preterm labor, miscarriages, preeclampsia, fetal growth restrictions, or malformations). A χ2 test of homogeneity was calculated to determine if AFOs were more likely a result of drug exposure or maternal disease activity during pregnancy.

Results: 28 pregnancies (9 RA, 7 PsA, 4 AS, 8 JIA) were observed in 22 patients (8 RA, 6 PsA, 3 AS, 5 JIA). Mean age at delivery was 32 years and disease duration was 10.4 yrs. During PRE the most common drugs used were TNFi (61%), methotrexate (18%), other DMARDS (11%), other Biologics (11%), Prednisone (21%), and NSAIDs (79%). Drug use during PREG: TNFi (57% same), DMARDS (14% same), Prednisone (21% same), NSAIDs (32% less) and no drugs (14% more). Of the 11 PRE patients in REM, 7/11 stayed in REM or LDAS during PREG; 4/11 were in MDAS or HDAS during PREG. Of the 17 PRE patients with GAS >4, only 4/17 improved to REM or stayed in LDAS during PREG; 13/17 were in MDAS or HDAS during PREG. There were 4 AFOs (2 preterm, 2 miscarriage), but no malformations. The 4 AFOs occurred in women with moderate/high disease activity during pregnancy, and none of the women in remission or low disease activity states had an AFO. There was no significant correlation between the different drug therapies and AFOs (p=0.95).

Conclusion: These observational data showed that adverse fetal outcomes were best avoided by being in REM or LDAS and that AFOs are more likely to be related to disease activity and not drug exposure.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effects-of-disease-activity-and-drug-exposure-on-pregnancy-outcomes-with-inflammatory-arthritis/