Background/Purpose:

Tumor Necrosis Factor inhibitors (TNFi) are increasingly used during pregnancy but are frequently withheld in the second or third trimester to minimize transplacental transfer to the fetus. It is our practice to recommend uninterrupted TNFi treatment throughout pregnancy to avoid the risk of peri- or postpartum disease flare. We evaluated the maternal and fetal outcomes of women who continued their TNFi treatment throughout pregnancy compared to women who interrupted TNFi during pregnancy.

Methods:

Women seen in our clinic from 11/2010-6/2017 with RA, PsA, JIA or AS having been exposed to TNFi during pregnancy were prospectively followed throughout pregnancy and during the postpartum period. Maternal age, medical comorbidities and medication was recorded at the initial visit and disease activity was assessed throughout the follow up period. Adverse pregnancy outcomes were recorded as were the following fetal outcomes: birthweight, neonatal hospitalization and congenital anomalies. Pregnancies were divided into 2 groups: Group 1 included patients who stopped their TNFi at any time during pregnancy and Group 2 included patients who continued their TNFi throughout pregnancy.

Results:

There were 36 women with 42 pregnancies in this cohort. Mean maternal age was 31.9 in Group 1 and 33.9 in Group 2. In Group 1, 11 women had 13 pregnancies and 11 live births. There were 2 first trimester losses (2/13, 15%) one in the setting of active RA. Four pregnancies (4/13, 30.7%) were complicated by a disease flare; one patient with RA miscarried; two patients, one with RA and the other with PsA resumed TNFi therapy. Another patient with AS and IBD failed to achieve disease control after resuming her TNFi and required switching to another TNFi peripartum. Six other patients (6/13, 46%) flared postpartum (4 patients with RA, 1 AS, 1 JIA). In total, 10/13 (77%) flared during or after pregnancy.

In Group 2, 25 women had 29 pregnancies and 31 live births. Three (3/28,10.7%) adverse pregnancy outcomes were reported in 2 patients. One patient had a twin pregnancy and delivered at 33 weeks after developing PPROM at 32 weeks in the setting of a JIA flare. Her second pregnancy was complicated by active JIA before and throughout gestation and HELLP syndrome necessitating a C-section at 39 weeks. Another patient with comorbid APS underwent a C-section at 36 weeks for suspicion of HELLP syndrome. Three (3/29, 10.3%) postpartum flares occurred: one patient with IBD and AS developed anti-infliximab antibodies and responded to another TNFi; one patient with RA required treatment with a different class of biologics; and another was treated with a corticosteroid injection and hydroxchloroquine. There were no other adverse pregnancy outcomes. All offspring were born healthy, with no congenital abnormalities, and all were appropriate size for gestational age. No neonatal infections were reported. Therefore, a total of 4/29 (13.7%) pregnancies were associated with a flare during or after pregnancy.

Conclusion:

Women who discontinued their TNFi during pregnancy, had a higher risk of peri- or post-partum flare compared to those that continued their TNFi throughout pregnancy. TNFi were not felt to be responsible for gestational complications in group 2.

« Back to 2017 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/maternal-and-fetal-outcomes-in-a-cohort-of-patients-exposed-to-tumor-necrosis-factor-inhibitors-throughout-pregnancy/