In a cohort of women with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), the effect of their conditions considerably varied before, during, and after pregnancy, thereby emphasizing the importance of patients and clinicians working together for informed decision making at all stages, according to findings published in Scientific Reports.
Given the concerns faced by childbearing women with RA or PsA, the study investigators had the following objectives: (1) to better understand fertility within this population; (2) to describe their peripartum periods in terms of preconception counseling, time to pregnancy, requirement for infertility treatment, unplanned/planned pregnancy, number of pregnancies prior to and after inflammatory arthritis (IA) diagnosis, pregnancy outcomes, disease activity during and after pregnancy, type of delivery and breastfeeding; (3) to better understand choices made regarding RA/PsA medications; and (4) to better understand fetal and maternal outcomes in terms of neonatal, labor, and delivery complications. To this end, investigators conducted a retrospective survey-based evaluation of the peripartum period in patients with RA/PsA participating in the Rheumatoid Arthritis Pharmacovigilance Program and Outcomes Research in Therapeutics prospective cohort in northern Alberta, Canada, which is a prospective inception cohort of IA patients on biologics, ongoing since 2004.
Of the 162 patients completing the survey, 234 pregnancies occurred among 103 patients, with 164 pregnancies occurring before RA/PsA diagnosis and 70 occurring after diagnosis. Outcomes included 1.9% stillbirths, 15% therapeutic abortions, 23% miscarriages, and 96% live births. Some 33% of the participants had fewer children than desired due to RA/PsA disease activity (14/34), RA/PsA medications (15/34), social reasons (5/34), infertility (5/34), and other comorbidities (5/34).
Among the 63 pregnancies occurring after diagnosis (and excluding those ending in therapeutic abortion), 49% obtained preconception counseling. In terms of disease control, discontinuing medication, and complications — including gestational diabetes, preeclampsia/eclampsia, pregnancy-induced hypertension, placental abruption, multiple pregnancies, intrauterine growth restriction, disease flares, and hospitalizations — no statistically significant differences were found between those receiving preconception counseling (31/63) vs those who did not (32/63).
Although 65% (41/63) of pregnancies occurring after diagnosis described good disease control during pregnancy, 73.7% (28/38) experienced disease flares in the first 3 months postpartum (19/28, 67.9%). IA medications were discontinued in 79% of pregnancies, and 35% (22/63) of pregnancies occurred while patients were on biologics at or prior to conception. Five patients continued biologic therapy for all or part of their pregnancies (3/5 with complications: ectopic pregnancy, flare, intrauterine growth restriction, multiple birth).
Gestational age at time of delivery was 37 to 40 weeks in 66% (83/126) of prearthritis vs 58% (33/57) of postarthritis pregnancies. Comparing pregnancies before RA/PsA diagnosis with those after diagnosis, no statistically significant differences were found for fertility treatment, pregnancy planning, neonatal complications, birth defect frequency, or pregnancy and labor/delivery complications. Neonatal ICU admissions were significantly lower in prearthritis pregnancies compared with postarthritis pregnancies. No pregnancy complications were seen in 24 of 54 pregnancies in women on medications compared with 6 of 9 pregnancies in women not on medications.
Study investigators concluded that these findings show “peri-partum complications in RA/PsA patients do not significantly increase in patients with good disease control; however, neonatal ICU admissions are increased in women with RA/PsA revealing the importance of decision-making before, during and after pregnancy. Most patients discontinued RA/PsA medication during pregnancy and…only a minority of patients continued biologics during pregnancy…. Therefore, providing patients with medication and disease information is essential to ensure that patients make informed and educated reproductive decisions.”
Dissanayake TD, Maksymowych WP, Keeling SO. Peripartum issues in the inflammatory arthritis patient: A survey of the RAPPORT registry. Sci Rep. 2020;10(1):3733.