How Are Pregnant Women Affected by PsA?

Half of all people with psoriatic arthritis (PsA) are women, and most are diagnosed during their childbearing years. PsA does not generally affect the reproductive system. However, women who are or become pregnant need to take special precautions to protect their health and the health of their unborn child.1,2

One recent study estimates that up to 107,000 deliveries are performed annually in women with psoriasis, and a percentage of those women also have PsA. Women who are dealing with PsA during pregnancy have additional considerations compared to women without arthritis. Some women, approximately 55%, experience an improvement in the severity of their PsA symptoms during pregnancy. Others find their symptoms are the same (21%), and 23% of women report their symptoms worsen with pregnancy. In addition, between 40-90% of people with PsA report a worsening of their symptoms after the child is born, during the postpartum period.1-3

Symptoms during pregnancy

Pregnant women who have PsA may experience an increase in the severity of their symptoms. Joint pain and swelling may be exacerbated by the additional weight of a developing child. PsA in the spine, spondylitis, and between the spine and the pelvis, sacroiliitis, may also worsen with the changes of a growing belly during pregnancy. Fatigue, a common symptom of PsA, is also commonly experienced during pregnancy, and women with PsA may experience significant tiredness. 3

Research on infliximab and adalimumab during pregnancy

A review of the clinical data published between 2010 and 2012 confirmed that the use of infliximab (Remicade) and adalimumab (Humira) during pregnancy does not increase the risk of birth defects. Several case reports did not detect any adverse effects on the mother or fetus with the use of adalimumab during pregnancy, and larger studies are available on the use of infliximab. The largest evaluated 96 pregnancies, and the rates of adverse events were similar to those of the general population. Another review of the published scientific literature in 2011 analyzed 156 pregnancies exposed to infliximab and 106 to adalimumuab, 70-90% of which were exposed to these treatments during the first trimester. Birth defects were identified in 8 of the pregnancies that were exposed to infliximab and in 8 with adalimumab. The abnormalities usually occurred in isolated cases. However, despite these positive results, the routine use of PsA treatments during pregnancy is still questioned.1

Research on etanercept and certolizumab during pregnancy

Etanercept (Enbrel) and certolizumab (Cimzia) differ from other TNF-alpha inhibitors, the class of biologic drugs that target tumor necrosis factor, known for its role in the inflammatory response. Both etanercept and certolizumab show limited transfer across the placental barrier. Most case reports on etanercept conclude that there are no birth defects or prematurity patterns association with the treatment, although there have been rare cases of some malformations that are difficult to conclusively prove causality.1

Biologics and miscarriage

One study by the British Registry documented 130 pregnancies in 118 women. The pregnancies were divided into three groups: 1) women exposed to TNF-alpha inhibitors at conception, 2) women exposed to TNF-alpha inhibitors in the past, and 3) women who were not exposed to these medications. The rate of miscarriage was highest in the group exposed to TNF-alpha inhibitors at conception (24%). Miscarriage in the second group, those exposed to TNF-alpha inhibitors in the past, was 17%.1

Treatment of PsA during pregnancy

The treatment of PsA during pregnancy, as well as prior to conception and during breastfeeding, must be tailored to meet both the needs of the woman and her developing child. The National Psoriasis Foundation released treatment guidelines in 2012 for women who are pregnant or breastfeeding, concluding that systemic and biologic drugs should be avoided during pregnancy and while breastfeeding unless there is a clear medical need, as some medications have a link to birth defects and/or miscarriage. However, the Arthritis Foundation notes that while there is no research that demonstrates the safety of biologics during human pregnancy – including adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) – there are numerous case reports and animal studies that suggest they are safe.2,3

In all cases, women who are pregnant or plan to become pregnant should discuss with their rheumatologist and obstetrician to determine what is best for their particular case.2,3

Resources

Women who become pregnant while on a medication can contact MothertoBaby.org, a service of the non-profit Organization of Teratology Information Specialists, to contribute to ongoing research on treatments for PsA.4

Written by: Emily Downward | Last reviewed: October 2016.
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