Lower Fertility Rates, Higher Risk of Pregnancy Loss in Patients With Moderate to Severe Psoriasis

Patients with moderate to severe psoriasis have a lower fertility rate and a higher risk of pregnancy loss compared with individuals without psoriasis, new results of a cohort study show.

Findings were published in JAMA Dermatology.

“Future research should identify the mechanism of increased risk of pregnancy loss among patients with psoriasis,” the authors wrote.

Around half of patients with psoriasis are women who are diagnosed with the condition before the age of 40 years. As this diagnosis can coincide with a woman’s peak reproductive period, psoriasis may affect childbearing potential, researchers explained. Previous research has also shown that inflammatory and autoimmune diseases are linked with negative pregnancy outcomes.

However, research that has assessed fertility and pregnancy outcomes in women with psoriasis has yielded conflicting findings, and most studies had small sample sizes.

In an effort to better understand fertility and obstetric outcomes in these individuals, investigators carried out a cohort study using population-based electronic health records.

Data were gleaned from a large primary care database in the United Kingdom, the Clinical Practice Research Datalink (CPRD) GOLD, from 1998 to 2019. Researchers also linked this information to the pregnancy register, Hospital Episode Statistics (HES), and an area-level measure of deprivation.

A total of 63,681 patients with psoriasis and 318,405 comparators were included in the analysis. At the index date, median age was 30 (IQR, 22-37) years. In addition, patients were followed up with for a median of 4.1 (1.7-7.9) years. Just over 5% of patients had moderate to severe psoriasis in the follow-up period.

Analyses revealed the following:

• Lower fertility rates (rate ratio, 0.75; 95% CI, 0.69-0.83) were found in patients with moderate to severe psoriasis.
• Compared with matched comparators without psoriasis, pregnancies in patients with psoriasis had a higher risk of loss (odds ratio, 1.06; 95% CI, 1.03-1.10).
• Pregnancy loss occurred in about 1 in 5 pregnancies in patients with psoriasis, and approximately 95% of these occurred in the first trimester.
• There was no increase in the risks of antenatal hemorrhage, preeclampsia, or gestational diabetes in patients with psoriasis.

“Higher fertility rates were found in patients with psoriasis, especially among those aged between 15 and 29 years, but lower fertility rates were found in patients who had moderate to severe psoriasis,” authors wrote.

“Overall, the fertility rates of patients with psoriasis followed the national fertility trends,” they added.

The statistically significant association between psoriasis and pregnancy loss reported in the current study is similar to a previous case-control study.

Although the mechanism behind a higher risk of pregnancy loss among women with psoriasis is not clear, one potential explanation could be that the proinflammatory cytokines IL-17, IL-23, and tumor necrosis factor α could negatively affect the placenta and result in impaired fetal growth, researchers explained.

To the authors’ knowledge, the current study is one of the largest to investigate fertility and obstetric outcomes in patients with psoriasis.

Researchers used surrogates for moderate to severe psoriasis due to the lack of direct measures of disease severity, marking a limitation to the investigation.

“To avoid miscarriage and its adverse consequences, further studies should evaluate the effects of better management of psoriasis and close monitoring during pregnancy on pregnancy loss,” authors wrote.

“In particular, patients with psoriasis were more likely to have comorbidities that may be related to poor pregnancy outcomes, and hence increased emphasis of managing comorbidities as part of the routine management plan is also warranted,” they concluded.

Reference

Chen TC, Iskandar IYK, Parisi R, et al. Fertility trends and adverse pregnancy outcomes in female patients with psoriasis in the UK. JAMA Dermatol. Published online June 7, 2023. doi:10.1001/jamadermatol.2023.1400