Management of Pregnancy with Ankylosing Spondylitis

Fertility and pregnancy outcomes in women with spondyloarthritis: a systematic review and meta-analysis

OBJECTIVE

To determine the impact of spondyloarthritis (SpA) and its treatments on fertility and pregnancy outcomes, as well as the impact of pregnancy on disease activity.

METHODS

A systematic review and meta-analyses were performed, including studies in women with SpA (axial (axSpA) and peripheral SpA, including psoriatic arthritis (PsA)). The heterogeneity between studies was quantified (I2), and in case of substantial heterogeneity, the results were reported in a narrative review.

RESULTS

Within 4397 eligible studies, 21 articles were included, assessing overall 3566 patients and 3718 pregnancies compared to 42264 controls. Fertility suffers from a lack of data in the literature. We found an increased risk of preterm birth (pooled OR 1,64 [1,15-2,33], I2 =24% in axSpA and 1,62 [1,23-2,15], I2 =0,0% in PsA), small for gestational age (pooled OR 2,05, [1,09-3,89], I2 =5,8% in axSpA), preeclampsia (pooled OR 1,59, [1,11-2,27], I2 =0% in axSpA) and caesarean section (pooled OR 1,70 [1,44-2,00], I2 =19,9% in axSpA and 1,71 [1,14-2,55], I2 =74,3% in PsA), without any other unfavourable pregnancy outcome. Further analysis showed a significant higher risk for elective caesarean (pooled OR 2,64, [1,92-3,62], I2 =0,0% in axSpA and 1,47, [1,15-1,88], I2 =0,0% in PsA), without increased risk for emergency caesarean in PsA. During pregnancy, there appears to be a tendency for unchanged or worsened disease activity in axSpA and unchanged or improved disease activity in PsA. Both conditions tend to flare in postpartum period.

CONCLUSION

SpA seems to be associated with an increased risk of preterm birth, small for gestational age, preeclampsia, and caesarean section.

Pregnancy outcomes in Korean women with ankylosing spondylitis

BACKGROUND/AIMS

Because ankylosing spondylitis (AS) mainly affects sacroiliac joints, special attention should be given to normal labour and pregnancy outcomes. Here, we investigate pregnancy outcomes in Korean women with AS.

METHODS

Based on data from the Korean Health Insurance Review and Assessment Service claims database since July 2007, maternal complications were compared between women with AS and 1:10 matched general population by maternal age and year of delivery. Additionally, the 27 deliveries from 21 patients with AS who were seen at a tertiary hospital were retrospectively evaluated using 1:4 matched control group by maternal and gestational age.

RESULTS

In the population-based cohort, there were 1,293 deliveries in 996 patients with AS. Higher maternal age and more comorbidities were reported than in the general population. However, compared to age and delivery-year matched population, only the rate of Caesarean section (CS) was higher in women with AS (odds ratio, 1.52; 95% confidence interval, 1.36 to 1.70). Incidence of other maternal complications was comparable between women with AS and control subjects. In the hospital-based cohort, the CS rate was higher in women with AS (44.4% vs. 20.4%, p = 0.002). Causes of CS was not different in both groups, including previous uterine surgery. There were no significant differences in foetal outcomes, including growth restriction, foetal malformations and Apgar score.

CONCLUSION

CS deliveries were performed more often in women with AS. However, other maternal complications and offspring complications were similar between women with AS and healthy control subjects.

Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review

In this scoping review, we sought to summarize the types of outcomes collected in pregnant patients with ankylosing spondylitis (AS), and to identify some methodological limitations related to pregnancy research in these patients. A comprehensive search was done to identify relevant articles in MEDLINE and Embase. We included 21 studies assessing pregnancy outcomes in AS. Most studies reported disease flare during pregnancy, and few reported improved disease activity or stable disease. Disease flare occurred in 25-80% of patients during pregnancy and in 30-100% during the postpartum. There was no increased risk of pre-eclampsia across all studies. Based on two case-control studies, there was an increased risk for prematurity and small for gestational age in AS pregnancies, pooled odds ratio (95% confidence interval) 1.99 (1.30-3.05) and 2.41 (1.22-4.77), respectively. The etiologies of cesarean section were not related to joint issues from AS but were related to other causes like pre-eclampsia and prematurity. Some key methodological issues were related to the study design, selection of study participants, disease classification, choice of control participants, and outcome measures. Based on the current literature review, some key areas for future research should evaluate the disease state at conception, effects of pharmacological treatment for AS during pregnancy, and long-term outcomes of children born to women with AS. The use of pregnancy registers and validated measurement tools in pregnancy will help to improve the state and quality of evidence in this field. Key Points • Disease flare during pregnancy in patients with ankylosing spondylitis (AS) occurred in 25-80% of the cases in the various studies, and in 30-100% of the cases during the postpartum period. • There was an increased risk for prematurity, and no increased risk of pre-eclampsia or small for gestational age. Etiologies of cesarean section were not related to the hip or sacroiliac joint affection of the disease but to other causes like pre-eclampsia and prematurity. • This study provides a comprehensive overview of issues related to research on pregnant women with ankylosing spondylitis (AS). We addressed methodological issues related to the study design, selection of study participants, disease classification, control choice, assessment of outcomes measures, and statistical analysis. • The use of pregnancy registers and validated disease activity measurement tools for pregnancy can enhance pregnancy research in women with AS.

Pregnancy in axial spondyloarthropathy: A systematic review & meta-analysis

BACKGROUND

Axial spondyloarthropathy (axSpA) is an inflammatory arthritis which affects the sacroiliac joints and the spine. Many females affected are of childbearing age. Studies on effects of pregnancy on axSpA disease activity and medication use have been limited, with divergent conclusions.

OBJECTIVE

To review literature on axSpA in pregnancy to determine the effect of disease on pregnancy outcomes.

METHODS

A systematic review of case-control trials, observational studies, cross sectional studies and case series (n>5) on axSpA in pregnancy. EMBASE, Medline (OVID), CINAHL, Maternity and Infant Care (MIDIRS online), and Web of Science were searched for keywords. Two reviewers reviewed articles to determine suitability for inclusion. The Newcastle Ottawa Scale was used to assess risk of bias. Data extraction was performed using a standardized template to streamline data to allow comparison and meta-analysis.

RESULTS

Search strategy returned 884 records, 130 full text articles were assessed for eligibility. Eighteen studies with a total of 3,166 axSpA participants were eligible for inclusion. There was an increased prevalence of pre-eclampsia (OR 1.3, 95% CI 0.92-1.82) and IUGR (OR 1.17, 95% CI 0.26-5.17) and a statistically significant increase in cesarean sections (OR 1.85, 95% CI 1.46-2.30) in axSpA females, with an especially high prevalence of elective cesarean sections (OR 2.26, 95% CI 1.74, 2.93). There was a trend towards increased prevalence of fetal complications in axSpA pregnancies (LBW OR 1.47, 95% CI 0.98-2.21; SGA OR1.66, 95% CI 0.93-2.95; congenital abnormalities OR 1.34, 95% CI0.63-1.24; NICU admissions OR 1.55, 95% CI 0.96-2.51) which did not reach significance.

CONCLUSION

AxSpA females have an increased prevalence of cesarean sections compared to the general population. There is a trend towards increased prevalence of pre-eclampsia, IUGR and certain fetal complications. Ongoing development of national registries could help to better understand axSpA in pregnancy.

Retrospective evaluation of pregnancies with ankylosing spondylitis in a tertiary center in Turkey

BACKGROUND

To evaluate obstetrical and perinatal outcomes of pregnancies with ankylosing spondylitis (AS).

METHODS

This was a retrospective study evaluating obstetric outcomes of 52 patients with AS who were followed up at our institution between 2006 and 2019. Patients were classified as having disease greater than or less than 5 years, and according to disease-related medical treatment during pregnancy, as drug free, single medication or multiple medication.

RESULTS

Overall rates of preterm delivery, intrauterine growth retardation and preeclampsia were 17.3%, 13.4% and 7.7%, respectively. Thirty-three of the patients were followed up without any medication, while 19 patients used drugs during pregnancy. Seven patients used a single drug and 12 patients had multiple drugs. There was no significant difference in terms of obstetrical and neonatal outcomes. However, a higher rate of neonatal intensive care unit (NICU) admission was observed in the group using medication for AS, despite a lack of statistical significance (31.5% vs 15%, P = .162). On the other hand, patients having disease more than 5 years had higher rates of Apgar scores less than <7 and admission to the NICU despite a lack of statistical significance (4% vs 7.4% and 16% vs 26%; P = .267 and P = .297, respectively).

CONCLUSION

In conclusion, pregnancies of patients with AS must be considered as high risk due to increased rates of adverse outcomes such as preterm delivery, intrauterine growth retardation or preeclampsia.

A Population-level Analysis of the Differing Effects of Rheumatoid Arthritis and Spondyloarthritis on Peripartum Outcomes

OBJECTIVE

The effects of rheumatoid arthritis (RA) and spondyloarthritis (SpA) on maternal and neonatal outcomes at a population level have not previously been well compared.

METHODS

A contemporary pregnancy cohort of 312,081 women and corresponding birth events was assembled for the province of Alberta from the random selection of 1 live birth event per woman. We identified 3 groups: (1) no inflammatory arthritis (no IA, n = 308,989), (2) RA (n = 631), and (3) SpA (n = 2461). We compared maternal and neonatal outcomes, comorbid conditions, and medication use among the 3 groups. Multivariable logistic regression models evaluated the independent association between RA and SpA, relative to no IA, and the outcomes of small for gestation age (SGA) and hypertensive disorders during pregnancy.

RESULTS

Pregnant women with RA were significantly more likely to have preterm delivery (13.5%), cesarean delivery (33.9%), hypertensive disorders in pregnancy (10.5%), and SGA babies (15.6%), compared to pregnant women with either SpA or no IA. Nonsteroidal antiinflammatory drugs and corticosteroid use were significantly higher in pregnant women with RA compared to the other groups. Women with RA were significantly more likely to have an SGA baby (OR 1.51, 95% CI 1.21-1.88; p < 0.01), and hypertensive disorder in pregnancy (OR 1.51, 95% CI 1.16-1.97; p < 0.01), compared to women with no IA, while no difference was found between women with SpA and those with no IA.

CONCLUSION

Women with RA have a higher risk of worse maternal and neonatal outcomes, whereas the risk of these events is similar between women with and without SpA.