Higher Odds for Preterm, C-Section Births Seen in Women With PsA

Jeff Craven

October 25, 2021

Disease-modifying antirheumatic drugs (DMARDs) such as biologics may carry an increased risk for preterm birth or cesarean delivery for pregnant women with psoriatic arthritis (PsA), according to a recent study published in Arthritis & Rheumatology.

The risk was particularly high for women with PsA who received biologic disease-modifying antirheumatic drugs (bDMARDs), according to Katarina Remaeus, PhD, of the Karolinska Institute in Stockholm, Sweden, and colleagues.

"The results may indicate that a more severe or active PsA disease that requires antirheumatic treatment during pregnancy, especially bDMARDs, is associated with increased risks of adverse pregnancy outcomes compared to non-PsA pregnancies," Remaeus and colleagues write in their study. "The risk of preterm birth in PsA pregnancies is further influenced by parity with the most increased risks observed in first pregnancies."

In a nationwide, register-based cohort study, the researchers evaluated 921 pregnancies of women with PsA between 2007 and 2017, comparing them to the pregnancies of 9210 women without PsA over the same timeframe. The pregnancies for women with PsA were further categorized based on whether the women had not received antirheumatic treatment in the year prior to and/or during pregnancy (495 pregnancies) or had received antirheumatic treatment at any point in the year before and/or during pregnancy (426 pregnancies).

Of the women in the PsA group who were treated in the year prior to pregnancy (170 women), 39.4% received monotherapy with a conventional synthetic DMARD (csDMARD) such as an antimalarial, methotrexate, or sulfasalazine; 24.1% received oral corticosteroids, and 15.9% received a tumor necrosis factor inhibitor (TNFi), whereas about 20% of women received two or more antirheumatic drugs.

In the group of women treated during pregnancy (256 women), 153 did not receive bDMARDs; of these, 41.8% had monotherapy with either a csDMARD or corticosteroids, whereas the group treated with bDMARDs received TNFi monotherapy (43.7%) or TNFi with corticosteroids (35.9%), TNFi with csDMARD (9.7%), or TNFi with csDMARD plus corticosteroids (9.7%).

A majority of women in both groups (70.1%) were between ages 30-34 years (37.1%) or older than age 35 years (33%) and had delivered more than one child (63.2%). Women in the PsA group were more likely to be born in a Nordic country (91.8% vs. 82.8%), to have a BMI between 30.0-60.0 kg/m2 (19.9% vs. 12.6%), be a smoker (9.2% vs. 5.3%), have hypertension (1.4% vs. 0.8%) or diabetes (1.3% vs. 0.5%) prior to pregnancy, and have a higher level of education (>12 years; 50.1% vs. 43.3%), compared with women in the non-PsA group.

The results showed women in the PsA group were more likely to experience preterm birth (adjusted odds ratio, 1.69; 95% CI, 1.27 - 2.24) and undergo an elective (aOR, 1.77; 95% CI, 1.43 - 2.20) or emergency C-section (aOR, 1.42; 95% CI, 1.10 - 1.84). The group at highest risk for preterm birth with regard to parity were women with PsA having their first child (aOR, 3.95; 95% CI, 1.43 - 10.95).

Women who received antirheumatic treatment were at greater risk for experiencing preterm birth (aOR, 2.30; 95% CI, 1.49 - 3.56), and this risk was even higher for treatment with bDMARDs, compared with women without PsA (aOR, 4.49; 95% CI, 2.60 - 7.79). Use of bDMARDs also was associated with higher risks for spontaneous preterm birth (aOR, 4.73; 95% CI, 2.53 - 8.87), preterm birth between 32-36 weeks' gestation (aOR, 5.06; 95% CI, 2.91 - 8.79), elective C-section (aOR, 2.72; 95% CI, 1.61 - 4.59), emergency C-section (aOR, 2.06; 95% CI, 1.04 - 4.07), and preeclampsia (aOR, 2.88, 95% CI, 1.35 - 6.17).

The researchers note that women with PsA should be evaluated for preterm birth particularly if they are having their first child, and "from a clinical point of view, all women with PsA, regardless of antirheumatic treatment, should be counseled about pregnancy outcomes and receive individualized monitoring during pregnancy."

Are Adverse Outcomes Linked to Disease Activity or Treatment?

Patients in the study had a higher risk of adverse outcomes when they had a PsA diagnosis, and when they received antirheumatic treatment — but were the adverse outcomes associated with a patient's high disease activity or need for antirheumatic treatment?

"Our interpretation is that a PsA disease that requires continued antirheumatic treatment during pregnancy is more severe than PsA that does not require treatment," Remaeus and colleagues write. "Thus, the increased risk of adverse outcomes in pregnancies with maternal antirheumatic treatment is probably attributed to disease severity rather than an effect of the medication itself."

Dr Anja Strangfeld

Anja Strangfeld, MD, PhD, of the German Rheumatism Research Centre in Berlin, Germany, told Medscape Medical News that the results of the study are important because it is one of the first to report differences in risk in pregnancy outcomes for women with and without PsA.

"The information is relevant to guide rheumatologists in advising patients with PsA when planning the first or subsequent pregnancies," she said. "The results are reassuring in reporting that the elevated risk for PsA patients for adverse pregnancy outcomes is low in patients not in need of antirheumatic medication, presumably in low-disease activity."

However, the study is still unclear on whether the association between adverse pregnancy outcomes in patients are the result of higher disease activity or the need for antirheumatic treatment, she explained.

"[I]t was only hypothesized that those patients under bDMARD treatment are/were in high disease activity. There [is] no information on disease activity in the data sources, which limits the results," she said. "The investigation still does not solve the important question — if adverse pregnancy outcomes are rather related to high disease activity or the medication to treat this situation."

There was no specific funding for this study. The study authors and Strangfeld have disclosed no relevant financial relationships.

Arthritis Rheumatol. Published online October 20, 2021. Abstract

Jeff Craven is an independent journalist living in Wilmington, Delaware.

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