With regard to safety, in 2013, the ACR put out a news release about research showing that medications used to treat RA may affect abortion rates in women. The European League Against Rheumatism considers the use of steroids to be relatively safe during pregnancy.2 Additional research suggests that corticosteroids, hydroxychloroquine and azathioprine are safe to use in pregnancy and are not associated with adverse fetal effects.3
One topic that Dr. Desai would like to see investigated further is the effect of uncontrolled disease activity during pregnancy on various maternal and fetal outcomes. Some research suggests that RA may improve during pregnancy, although postpartum flare-ups are likely.4 Another study demonstrated “widespread variability in disease response” among 140 pregnant women with RA.5 In this study, 16% of women were in complete remission, having no joints with active disease and no therapy, but there was a statistically significant increase in the mean number of inflamed joints in the postpartum period compared with the findings during pregnancy.
An earlier study also showed symptom improvements in pregnant women with RA and psoriatic arthritis (PsA), but researchers noted that it was rare to see improvement in patients with ankylosing spondylitis (AS) during pregnancy.6 The study also indicated that fetal outcomes were not adversely affected by AS, PsA or juvenile RA, but postpartum flares in disease activity were seen in 90% of AS pregnancies, 70% of PsA pregnancies and 50% of juvenile RA pregnancies.
A literature review showed an increase in SLE activity during pregnancy, which they noted raises the risk of poor pregnancy outcomes (e.g., stillbirth, preterm birth, low birth weight, preeclamspsia).7 Another review that included 37 studies with 1,842 patients and 2,751 pregnancies showed the following maternal complications: lupus flare (25.6%), hypertension (16.3%), nephritis (16.1%), pre-eclampsia (7.6%) and eclampsia (0.8%).8 Fetal complications included spontaneous abortion (16.0%), stillbirth (3.6%), neonatal deaths (2.5%) and intrauterine growth retardation (12.7%). Further, the unsuccessful pregnancy rate was 23.4%, and the premature birth rate was 39.4%.
Study Overview
Because a small amount of empirical data exists on the patterns of use for immunomodulatory agents during pregnancy, Dr. Desai and his team designed their study to examine treatment changes at various stages of pregnancy. They included 2,645 pregnant women with SLE, RA, PsA or AS who were being treated with immunomodulatory agents prior to their pregnancies. Additional evaluation was performed to determine secular trends in the use of these agents during pregnancy in the cohort between 2001 and 2012.
