Background Pregnancy is commonly encountered in women who have immune mediated inflammatory arthritis such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile arthritis (JIA) or ankylosing spondylitis (AS). They are often diagnosed with these diseases during their fertile years; yet, data is scant on how disease activity and drug exposure affects maternal outcomes.
Objectives Our goals were to chart medication use during pregnancy and to determine what is more likely to cause adverse fetal outcomes (AFOs): disease activity or drug exposure.
Methods This is an observational study at a single clinic of females aged 18–45 years, diagnosed with RA, JIA, AS or PsA who had: 1) >12 months follow-up; 2) documented pregnancy during this period; and 3) clinic visits that qualified as being preconception (within 12 months of conception), pregnancy (1st, 2nd or 3rd trimester) and post-partum (within 12 months after delivery). Drug exposure was classified as occurring preconception (PRE- ≥1 month before conception), at risk (RISK- 1st trimester plus 1 month preconception) or during 2nd and 3rd trimesters 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) calculated from TJC (0–28) + pain (0–10) + mHAQ (0–24) where remission (REM) <3; low activity 3–7; mod 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 AFOs: 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 26 pregnancies (8 RA, 6 PsA, 4 AS, 8 JIA) were observed in 20 patients (7 RA, 5 PsA, 3 AS, 5 JIA). This number represents 7.5% of all clinic women who were fertile with these diagnoses. Mean age at delivery was 31.6 years and disease duration was 10.8 yrs. During PRE the most common drugs used were TNFi (62%), methotrexate (20%), other DMARDS (12%), other Biologics (8%), Prednisone (23%), and NSAIDs (81%). Drug use was relatively unchanged in PREG: TNFi (58% same), DMARDS (15% same), Prednisone (23% same), NSAIDs (31% less) and no drugs (15% more). Of the 10 PRE patients in REM, 5/10 stayed in REM or LDAS during PREG; 3/10 were in MDAS or HDAS POST pregnancy. Of the 16 PRE patients with GAS ≥4, only 4/16 improved to REM or stayed in LDAS during PREG; 10/16 were in MDAS or HDAS POST pregnancy. There were 4 AFOs (2 preterm, 2 miscarriage), but no malformations. The 4 AFOs occurred in women with high flare rates during pregnancy, and none of the women in remission or low disease activity states had an AFO (p=0.1422). There was no significant correlation between the different drug therapies and AFOs (p=0.5885).
Conclusions These observational data show that during pregnancy, patients with inflammatory arthritis, the majority still require drugs to control their disease. Only 15% of women were able to get off of therapy. While fetal outcomes were primarily favorable, AFOs were seen in patients with the highest disease activity, and not by drug exposure.
Disclosure of Interest None declared