Improving Care for Women of Childbearing Age With Psoriatic Disease

Aug 13, 2024

Photo Credit: Nature

Dr. Oseme Etomi discussed pregnancy and how care can be improved for patients with inflammatory diseases, with a focus on psoriasis and psoriatic arthritis.

Approximately two-thirds of women of childbearing age with rheumatic disease worry about family planning and up to half report receiving inconsistent advice from healthcare professionals¹. Dr. Oseme Etomi, CCT, from Guy’s and St Thomas’ Hospital, in the U.K., discussed pregnancy and how management can be improved for patients with inflammatory diseases².

Untreated inflammatory disease is associated with a delay in pregnancy. In a cohort of patients with rheumatoid arthritis, high disease activity was associated with not achieving pregnancy in 67% of participants and 30% of participants with inactive disease did not achieve pregnancy within the first 12 months³. Furthermore, untreated disease is associated with poor obstetric outcomes⁴.

Thus, there is an increased need for improving care for women of childbearing age, suffering from inflammatory conditions. “Firstly, we should consider all women as pre-pregnant, and not just the ones who indicate they missed their period or have a positive pregnancy test,” said Dr. Etomi. “Additionally, we need to be able to talk about sex, address comorbidities, offer long-acting reversible contraception, and pre-pregnancy counseling.”

Stopping medications at the time of conception can lead to disease flares. In patients with rheumatoid arthritis and axial spondyloarthritis, discontinuation of TNF inhibitors at the time of a positive pregnancy test led to a 3.0–3.3 relative increase in flares during the first trimester (P=0.001), while reintroduction of therapy could lead to improved disease control⁵. Good disease control is important. In a Toronto database of patients with psoriatic arthritis, 32% suffered from worsening or ongoing disease during pregnancy while 58% experienced a favorable disease course. The skin activity following pregnancy worsened in 43% of patients but was improved or mostly stable in most patients during pregnancy⁶.

Several anti-rheumatic medications can be used during pregnancy. Current guidelines from the British Society for Rheumatology consider corticosteroids such as prednisolone, azathioprine, ciclosporin, and anti-TNF medications as safe to use in all stages of pregnancy, while methotrexate should be stopped at least 1 month before conception⁷. A meta-analysis of patients with inflammatory bowel disease showed that adverse pregnancy outcomes following ustekinumab were similar to adverse outcomes in the general population⁸. Furthermore, long-term data from the PIANO registry enrolling patients with inflammatory bowel disease did not show increased congenital malformations, spontaneous abortions, preterm birth, or low birth weight following biologics⁹.

“To conclude, I think it’s clear that psoriasis and psoriatic arthritis affect a high proportion of women of childbearing age,” said Dr. Etomi. “Despite this, many pregnancies remain unplanned. Severe disease increases the adverse outcomes of the mom and baby, making it important to learn from what our colleagues are investigating and share the knowledge to improve the care for these patients.”