Improving outcomes in pregnancy and psoriatic disease

Approximately two-thirds of women of childbearing age with rheumatic disease worry about family planning and up to half report receiving inconsistent advice from healthcare providers [1]. Dr Oseme Etomi (Guy's and St Thomas' Hospital, UK) discussed pregnancy and how management can be improved for patients with inflammatory diseases [2].

Untreated inflammatory disease is associated with a delay in pregnancy. In a cohort of patients with rheumatoid arthritis, high disease activity was associated with not achieving pregnancy in 67% of participants and 30% of participants with inactive disease did not achieve pregnancy within the first 12 months [3]. Furthermore, untreated disease is associated with poor obstetric outcomes [4].

Thus, there is an increased need for improving care for women of childbearing age, suffering from inflammatory conditions. “Firstly, we should consider all women as pre-pregnant, and not just the ones who indicate they missed their period or have a positive pregnancy test,” said Dr Etomi. “Additionally, we need to be able to talk about sex, address comorbidities, and offer long-acting reversible contraception and pre-pregnancy counselling.”

Stopping medication at the time of conception can lead to disease flares. In patients with rheumatoid arthritis and axial spondyloarthritis, discontinuation of TNF inhibitors at the time of a positive pregnancy test led to a 3.0–3.3 relative increase in flares during the first trimester (P=0.001), while reintroduction of therapy could lead to improved disease control [5]. Good disease control is important. In a Toronto database of patients with psoriatic arthritis, 32% suffered from worsening or ongoing disease during pregnancy, whereas 58% experienced a favourable disease course. The skin activity following pregnancy worsened in 43% of patients but improved or was mostly stable in most patients during pregnancy [6].

Several anti-rheumatic medications can be used during pregnancy. Current guidelines from the British Society for Rheumatology consider corticosteroids (prednisolone), azathioprine, cyclosporin, and anti-TNF medications to be safe to use in all stages of pregnancy, whereas methotrexate should be stopped at least 1 month prior to conception [7]. A meta-analysis of patients with inflammatory bowel disease showed that adverse pregnancy outcomes following ustekinumab were similar to adverse outcomes in the general population [8]. Furthermore, long-term data from the PIANO registry enrolling patients with inflammatory bowel disease did not show increased rates of congenital malformations, spontaneous abortions, preterm birth, or low birth weight following biologics [9].

“To conclude, I think it’s clear that psoriasis and psoriatic arthritis affect a high proportion of women of childbearing age,” said Dr Etomi. “Despite this, many pregnancies remain unplanned. Severe disease increases the adverse outcomes of the mom and baby, making it important to learn from what our colleagues are investigating and share the knowledge to improve the care for these patients.”

1. 
   
   1. Chakravarty E, et al. BMJ Open. 2014;4(2):e004081.
   2. Etomi O. Pregnancy in psoriasis disease. IFPA Conference 2024, 27–29 June, Stockholm, Sweden.
   3. Brouwer J, et al. Ann Rheum Dis. 2015;74(10):1836-41.
   4. Bharti B, et al. J Rheumatol. 2015;42(8):1376-82.
   5. van den Brandt S, et al. Arthritis Res Ther. 2017;19(1):64.
   6. Polachek A, et al. Semin Arthritis Rheum. 2019;48(4):764.
   7. Russel MD, et al. Rheumatology (Oxford). 2023;62(4):e48-e88.
   8. Nielsen OH, et al. Clin Gastroenterol Hepatol. 2022;20(1):74-87.e3.
   9. Mahadevan U, et al. Gastroenterology. 2021;160(4):1131-1139.

Copyright ©2024 Medicom Medical Publishers



Posted on 17 July 202417 July 2024