Biologic, Antirheumatic Drug Use May Increase Risk of Adverse Pregnancy Outcomes in Women With Psoriasis

Risk of preterm birth and Cesarean delivery may be elevated in women with psoriasis, especially those undergoing anti-rheumatic treatment during pregnancy. Study findings were published recently in Arthritis & Rheumatology.

Known to impact women in childbearing age, psoriasis has been found, albeit in scarce data, to be associated with several maternal and neonatal pregnancy outcomes. Moreover, adverse links regarding rheumatic disease and pregnancy outcomes have indicated that disease activity/severity may play a key role, as well as the therapies used to manage symptoms.

“As ongoing anti-rheumatic treatment around the time of pregnancy often is required to control disease activity of psoriasis, one may hypothesize that women treated with anti-rheumatic drugs before/during pregnancy have a more severe and active psoriasis disease compared to untreated women,” noted researchers. “Anti-rheumatic treatment may on the other hand improve clinical and inflammatory measures.”

Seeking to further assess risk of adverse pregnancy outcomes in women with and without psoriasis, as well as how anti-rheumatic treatment before and during pregnancy affects these outcomes, they conducted a nationwide cohort study of Swedish women with psoriasis (n = 921) and those without (n = 9210) during respective pregnancies between 2007 to 2017 (matched 1:10 on maternal age, year, and parity).

In the analysis, risk was stratified for presence, timing, and type of anti-rheumatic treatment, which included oral corticosteroids and conventional or biological disease modifying anti-rheumatic drugs. Further adjustments were made for body mass index (BMI), smoking, educational level, and country of birth (Nordic or non-Nordic), with the outcome preterm birth stratified by parity (primiparous or parous).

“Psoriasis pregnancies were divided into 495 psoriasis pregnancies without any treatment one year before pregnancy up until delivery and 426 psoriasis pregnancies with presence of any anti-rheumatic treatment in the same time frame,” added researchers.

“The latter pregnancies were further stratified into 170 pregnancies with treatment only in the year before pregnancy (ie, no treatment during pregnancy) and 237 pregnancies with treatment both in the year before and during pregnancy—19 pregnancies with treatment only during pregnancy were added to the 237 pregnancies…resulting in 256 pregnancies with anti-rheumatic treatment during pregnancy.”

Among the study cohort, women with psoriasis pregnancies were shown to be more often born in Nordic countries, (91.8% vs. 82.8%) and more likely to be obese (19.9% vs. 12.6%), a smoker at first antenatal visit (9.2% vs. 5.3%), and have a higher level of education (> 12 years; 50.1% vs 43.3%) than those without psoriasis during pregnancy. Diagnosis of pre-gestational hypertension and diabetes were also more likely in women with psoriasis pregnancies.

In comparing women with and without psoriasis during pregnancy, those with psoriasis were found to be at significantly increased risk of preterm birth (adjusted OR (aOR), 1.69; 95% CI, 1.27-2.24) and Cesarean delivery, including both elective (aOR, 1.77; 95% CI, 1.43-2.20) and emergency procedures (aOR, 1.42; 95% CI, 1.10-1.84).

No differences in risk were observed in psoriasis pregnancies compared with non-psoriasis pregnancies for incidence of pre-eclampsia, gestational diabetes or hypertension, and neonate born small for gestational age or large for gestational age.

Regarding anti-rheumatic drugs, adverse pregnancy risks were shown to differ with presence, timing, and type of treatment. Notably, the most increased risks were observed in women with psoriasis pregnancies who underwent anti-rheumatic treatment during pregnancy, especially those treated with biologics:

• Risk of preterm birth in women undergoing anti-rheumatic treatment during pregnancy compared with non-psoriasis pregnancies (aOR, 2.30; 95% CI, 1.49-3.56)
• Risk of elective/emergency Cesarean delivery in women undergoing anti-rheumatic treatment during pregnancy compared with non-psoriasis pregnancies (elective; aOR, 2.11; 95% CI, 1.47-3.03; emergency; aOR, 1.74; 95% CI, 1.14-2.67)
• Risk of preterm birth in women undergoing biologic treatment during pregnancy compared with non-psoriasis pregnancies (aOR, 4.49; 95% CI, 2.60-7.79)

Furthermore, a statistically significant increased risk in all analyses of preterm birth was found in women with psoriasis undergoing their first pregnancy, compared with matched first-pregnancy controls, particularly those treated with anti-rheumatic treatment during pregnancy (aOR, 3.95; 95% CI, 1.43-10.95).

No difference in risk of preterm birth was observed in analyses of subsequent pregnancies comparing psoriasis with non-psoriasis pregnancies.

Speaking on the study findings, researchers concluded that all women with psoriasis, regardless of anti-rheumatic treatment, should be counseled about pregnancy outcomes and receive individualized monitoring during pregnancy.

Reference

Remaeus K, Johansson K, Granath F, Stephansson O, Hellgren K. Pregnancy outcomes in women with psoriatic arthritis with respect to presence and timing of antirheumatic treatment. Arthritis Rheumatol. Published online October 20, 2021. doi:10.1002/art.41985