Patients were examined within 6 months before conception, at each trimester (gestational weeks 10–12, 20–22, and 30–32) and 6–8 weeks postpartum. The study was approved by the ethics committee of the Canton of Bern, Switzerland, and patients were included after they provided written informed consent.
All patients with SpA also fulfilled the Assessment of SpondyloArthritis international Society (ASAS) criteria for axSpA for patients recruited before 2009, the ASAS criteria were applied in retrospect. Patients with spondyloarthritis (SpA) fulfilled the European Spondylarthropathy Study Group criteria for SpA. Patients with RA had to fulfill the revised 1987 American College of Rheumatology classification criteria for RA. In total, 136 pregnant patients with RA or axSpA were prospectively followed between 20 at the Center for Pregnancy in Rheumatic Diseases at the Department of Rheumatology of the Inselspital Bern, Switzerland. In addition, we analyzed the response to therapy in controlling disease activity after the occurrence of a flare in both diseases during pregnancy. The aim of this study was to analyze the frequency of flares during pregnancy in patients with RA and axSpA and to delineate risk factors for flares. This information would be of clinical importance, however, in the management of patients with RA and axSpA before and during pregnancy.
Up to now, it is unknown whether changes of treatment before conception or early in pregnancy have an influence on the disease course during pregnancy in patients with RA and axSpA. Active disease or flares during pregnancy in patients with rheumatic disease can harm maternal and fetal health and should therefore be avoided. Disease activity before conception seems to be an additional factor that influences the disease course during pregnancy in patients with RA because quiescent disease often remains stable throughout pregnancy. In RA, the positivity for or elevated level of rheumatoid factor or anticitrullinated antibodies is associated with more active disease during pregnancy. During pregnancy, active disease can be found in about 35% to 52% of patients with RA and in 60% to 80% of patients with axSpA. In patients wishing for children, pregnancy represents a challenge in the management of the disease because current disease activity, the influence of pregnancy on the disease, and the safety of antirheumatic drugs in pregnancy have to be taken into account. Rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) often affect women of childbearing age. On the basis of a risk-benefit analysis, to stabilize disease activity and to prevent a flare during pregnancy in patients with RA and axSpA, tailored medication including TNF inhibitors should be considered beyond conception. Patients with axSpA without TNFi in the preconception period showed persistent high disease activity from prepregnancy until the postpartum period. In spite of initiated TNFi or GC treatment in 62.5% of these patients, disease activity remained elevated throughout pregnancy.
The relative risk of flare in this group was 3.08 (95% CI 1.2–7.9). In patients with axSpA stopping TNFi, a disease aggravation at the second trimester could be observed. Of 61 patients with axSpA, 24 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. In comparison, patients with RA without TNFi in the preconception period, most of whom had used pregnancy-compatible antirheumatic drugs, showed mild and stable disease activity before and during pregnancy. Initiation of TNFi or glucocorticosteroid (GC) treatment in 60% of these patients resulted in disease improvement at the second and third trimesters. The relative risk of flare in patients with RA stopping TNFi was 3.33 (95% CI 1.8–6.1). After stopping TNFi, disease activity increased, which was reflected by peaking C-reactive protein levels at the first trimester. Of 75 patients with RA, 15 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. In both diseases, active disease and tumor necrosis factor inhibitor (TNFi) discontinuation in early pregnancy were identified as risk factors for disease flares during pregnancy. ResultsĪmong 136 pregnant patients, disease flares during pregnancy occurred in 29% of patients with RA and in 25% of patients with axSpA. Disease activity and flares of disease activity were analyzed in regard to medication.
Pregnant patients with RA and axSpA were prospectively followed before, during, and after pregnancy. The aim of this study was to identify possible risk factors of disease flares during pregnancy and to evaluate the effect of treatment in pregnant patients experiencing a flare. During pregnancy, patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) can experience active disease, which might be influenced by adjustment of treatment around conception.