Reproductive Health Outcomes In Women with Psoriatic Arthritis In the Biologic Era
K Murray, L Moore, C O’Brien, A Clohessy, C Brophy, O FitzGerald, ES Molloy, AB Mongey, S Higgins, MF Higgins, P Minnock, FM Mc Auliffe and DJ Veale
Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin,Ireland Rheumatology Department, University College Dublin and St. Vincent’s University Hospital, Dublin, Ireland UCD Perinatal Research Centre, Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
Psoriatic arthritis (PsA) requires close management throughout pregnancy. A multidisciplinary (MDT) approach ensures best outcomes for mother and baby. Previous studies of PsA in pregnancy show conflicting results and many predate the use of biologics.
To prospectively study a series of PsA patients planning pregnancy
Between April 2013 and November 2016, the age, medications, disease control and reproductive health outcomes of PsA patients seen in an MDT rheumatology and reproductive health service (RRHS) were reviewed.
Fifteen women were followed, five of whom later attended with a second pregnancy wish. Median age (range) was 35 (26-42) years.
We recorded 16 pregnancies in 12 women, with 13 live births (one set of twins). 12 births were by spontaneous vaginal delivery and one Caesarean section. There were four miscarriages (2 - 1st trimester, 2 – 2nd trimester). One miscarriage was due to a hyper-coiled umbilical cord, with the other causes unknown. At data collection end point, four women were attempting to conceive. Of these, one is using assistive reproductive therapy and one had previously conceived.
Of the 16 pregnancies, seven were conceived on medications, either a biologic DMARD (bDMARD) (six cases) or oral steroids (one case). No patients were on a synthetic DMARD at conception. In four cases, bDMARDs were discontinued in the 1st trimester. In two cases, they were continued throughout pregnancy (infliximab and certolizumab).
Disease control was adequate prior to pregnancy in 11/16 and remained so in eight cases throughout pregnancy. PsA activity was increased, within 20 weeks of delivery, in 12 cases. In three cases, there was disease remission. One patient was not seen until ten months postpartum. The only postpartum complication was one grade four vaginal tear (on infliximab). At six weeks, six of 13 infants were being breastfed.
These data show high levels of successful pregnancy outcomes in PsA. Six pregnancies were conceived while on a bDMARD. Disease control was adequate in pregnancy, but postpartum flare is common. Miscarriage rates were comparable with the general population (25% versus 20%), but breastfeeding rates were lower (46% versus 55%).