Background/Purpose:   Disease activity is considered to improve in approximately 75% of patients with rheumatoid arthritis (RA) during pregnancy. This figure, however, is derived from historical data from mostly retrospective studies, which lack standardised and objective measures of disease activity. More recently, prospective studies have been carried out in patients with various forms of inflammatory arthritis using validated disease activity scores, which have shown a more modest improvement in disease activity during pregnancy. We carried out this systematic review of prospective studies to examine whether inflammatory arthritis truly does improve during pregnancy.

Methods:   A systematic review of PubMed, EMBASE/Medline, Cochrane and LactMed databases was performed using the terms ‘pregnan*’, ‘lactat*’, ‘breastfeeding’, ‘breast feeding’, ‘rheumat*’, ‘inflammatory arth*’, ‘arthritis’, ‘psoria*’, ‘spondyloarthropath*’ and ‘ankylosing spondylitis’. Exclusion criteria included: retrospective, <5 subjects, no validated disease activity scores and abstracts. Two reviewers independently assessed each study for quality and extracted data using a predesigned proforma. A chi-square test for heterogeneity was performed to determine whether findings were consistent between studies, and random effects meta-analysis was used to account for the heterogeneity observed. A 95% confidence interval was calculated for final data analysis.

Results:   Of 762 articles screened, 86 were selected for full length review and 14 eligible for the final analysis, including 965 pregnancies (939 with RA, 6 with juvenile idiopathic arthritis (JIA), 20 with ankylosing spondylitis (AS)). A significant amount of heterogeneity between studies was noted (I²= 76.3%). All studies utilised the DAS(3)28 (for RA), RADAI (for RA and JIA) or BASDAI (for AS) to measure disease activity. Overall, disease activity improved in 523 pregnancies (54.3% (95% CI 51.0-57.6%)); this total comprised 510 patients with RA (54.3% (95% CI 51.0-57.7%)), 5 patients with JIA (83.3% (95% CI 36.5 – 99.1%)) and 8 patients with AS (40.0% (95% CI 21.5-58.5%)). Post-partum disease activity was recorded in 808 pregnancies and flares were noted in 48.57% of pregnancies (95% CI 45.02 – 52.02%) overall, of which 47.97% (95% CI 44.4 – 51.46%) were in patients with RA (793 pregnancies), 66.6% (95% CI 24.11 – 94.0%) were in patients with JIA (6 pregnancies) and 89.9% (95% CI 50.67 – 99.42%) occurred in patients with AS (9 pregnancies). Pregnancy outcomes were only reported in 2 studies (of 303 pregnancies) with no increase in adverse events.

Conclusion:   We found that half of all patients with RA had an objective improvement in disease activity during pregnancy and a similar proportion relapsed post-partum. In contrast, patients with JIA were more likely to improve during pregnancy and relapse post-partum whilst patients with AS in pregnancy were less likely to improve and far more likely to relapse post-partum. This information is vital when counselling patients with inflammatory arthritis pre-partum and considering alterations in therapy to ensure maintenance of disease control with medications that are compatible with pregnancy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/does-inflammatory-arthritis-really-improve-during-pregnancy-a-systematic-review-and-meta-analysis/