Maternal and Neonatal Outcomes in Pregnant Women with Psoriasis and Psoriatic Arthritis: A Systematic Review and Meta-Analysis

Communication and Therapy Planning for Patients of Reproductive Age Under Immunomodulatory Treatments for Psoriasis or Psoriatic Arthritis-Survey of the German National Psoriasis Registry PsoBest

Background/Objective: During the systemic treatment of moderate to severe psoriasis in patients of reproductive age, contraindications and therapeutic peculiarities must be taken into account. Doctor-patient communication is crucial for therapy conduct and compliance. Methods: This survey among male and female patients from the German psoriasis registry, PsoBest, aims to provide real-world evidence on communication and patient needs for those of reproductive age (18-55). Result: In total, 404 patients were eligible for the analysis (254 m, 150 f), including 39 patients currently wishing to conceive (20 m, 19 f). Patients with and without the desire to have children received similar systemic therapy. In most cases, treatment was not adapted when patients expressed a desire to have children (85.9% m, 79.5% f). Only 38.3% of men and 49.9% of women had been informed about options for conception during or before systemic therapy, mainly by dermatologists (77.4% m, 84.6% f). The majority of patients retrieved additional information about the wish to conceive and medications from the internet and other media. This survey emphasizes the importance of open communication between patients and physicians regarding family planning and therapy options. Conclusions: Physicians need to broach the topic of family planning, conception and pregnancy with patients and support with evidence-based information to enable comprehensive medical decision making and safe therapy choices.

Psoriasis: analysis of comorbid pathology

Background. Chronic nature of course and presence of systemic inflammation in psoriasis are accompanied by the development of a great number of comorbid disorders, which not only lead to social maladjustment, but also directly affect patients’ survival. For clinicians, diagnostic search of co-occuring disorders in psoriasis during routine practice is often difficult due to their great diversity, different incidence and pronouncement of associations with the main disease. Objective. To study the structure of comorbid disorders in patients with psoriasis. Material and methods. A number of patients with the established diagnosis of «psoriasis» equal 509 was investigated from 2018 to 2021. All patients underwent examination with an assessment of the clinical course of psoriasis, the data of medical history were taken into account. The detection and analysis of comorbid disorders was carried out by patient’s clinical examination with further study of medical documentation. Results. Comorbid disorders have been noted in 224 (44%) patients. Psoriatic arthritis (143/63.8%), arterial hypertension (113/50.4%) and ischemic heart disease (27/12.5%) were the most common impairments. In addition, type II diabetes mellitus (17/7.6%), nephrolithiasis (16/7.1%), chronic glomerulonephritis (16/7.1%) and digestive system lesions with signs of chronic pancreatitis (23/10%) have been registered. Conclusion. The study and analysis of comorbid disorders in patients with psoriasis plays an important role in maintaining health and quality of life of patients. Clinicians should pay attention to the patient’s overall health status, in addition to the pathological process on the skin, with emphasis on possible lesions of the osteoarticular, cardiovascular and other systems.

Cardiovascular Complications During Delivery Hospitalization in Patients With Psoriasis

BACKGROUND

Psoriasis in pregnancy is associated with adverse maternal outcomes. However, there are limited data on this subject.

OBJECTIVES

The purpose of our study was to investigate the association between psoriasis and related cardiovascular complications during delivery.

METHODS

The National Inpatient Sample was used to identify hospitalizations for delivery from 2011 to 2020. Propensity score matching was performed to study the association of psoriasis with the primary outcomes of in-hospital medical and obstetric complications.

RESULTS

A total of 37,482,206 weighted delivery hospitalizations in women ≥18 years were identified; of which, 23,588 patients had psoriasis. Pregnant patients with psoriasis had a higher incidence of complications during delivery, including preeclampsia/eclampsia, acute kidney injury, pulmonary edema, cardiac arrhythmias, and venous thromboembolism compared to those without psoriasis. In propensity-matched analysis, psoriasis was significantly associated with a higher risk of preeclampsia/eclampsia (OR: 1.25, 95% CI: 1.08 to 1.43, P = 0.002) and cardiac arrhythmias (OR: 1.44, 95% CI: 1.08-1.93, P = 0.012), compared to patients without psoriasis.

CONCLUSIONS

Delivery hospitalizations in patients with psoriasis are associated with a higher risk of preeclampsia/eclampsia and cardiac arrhythmias.

Need for individualized counseling regarding psoriasis systemic therapy in women of childbearing age: analysis of the PsoFem study at the University Medical Center Hamburg

Background

For patients with moderate-to-severe psoriasis and current childbearing/pregnancy, the choice of therapy is limited.

Objectives

The present study compared the disease burden and treatment choices in women of childbearing age (WoCBA) with and without a current wish for pregnancy.

Methods

Female patients aged 18 to 45 years, with moderate-to-severe psoriasis vulgaris, were consecutively recruited. The patients reported on sociodemographic/reproductive characteristics and quality of life impairments. The physicians assessed disease severity, comorbidities, and current treatment(s). Both patients' and dermatologists' perceptions of shared decision-making for the current systemic treatment were surveyed.

Results

Participants were 145 WoCBA with psoriasis: 73 were pregnant or reported a desire to conceive (group CB+) and 72 reported no wish to have (more) children (group CB-). Patients without childbearing wishes were older and often had previous children; no significant differences in clinical features or quality of life impairments were found. A significantly higher proportion of patients in the CB+ group were prescribed tumor necrosis factor alpha blockers, particularly certolizumab pegol. This treatment option was associated with previous children and the desire to conceive, but not with disease variables. Family planning was more often discussed and considered in the clinical decision for the CB+ group, but patient-doctor agreement for shared decision-making was fair-to-moderate.

Limitations

The small sample size prevented comparative analyses between patients planning a pregnancy in the short- vs long-term future. In addition, specific variables related to the decision-making process for the current therapy need to be assessed and examined in more detail in further research.

Conclusion

For WoCBA with childbearing wishes, tumor necrosis factor alpha blockers were most frequently prescribed, in accordance with current guidelines/recommendations. Decision-making for continuing or changing systemic therapy during pregnancy must take into account medication specificities and the vulnerable stages in pregnancy, as well as the limited amount of pregnancy-compatible drugs.

Impact of Psoriasis on Pregnancy Desire and Possible Consequences on Fertility

INTRODUCTION

Approximately half of patients affected by psoriasis are women, and the management of female patients of childbearing age is an under-investigated topic. Some studies have shown a significant decrease in births in psoriatic patients due to intimacy and pregnancy avoidance and to potential birth complications.

OBJECTIVES

We sought to evaluate data on reproductive health in a cohort of female patients, to compare them with similar data in the general population and to assess the impact of psoriasis, especially genital psoriasis, on pregnancy desire and the prevalence of psoriasis in the children of patients with psoriasis.

METHODS

This retrospective observational study involved adult female patients with a diagnosis of psoriasis made during or before childbearing age. The enrolled patients were asked questions concerning fertility and previous pregnancies in relation to their dermatologic disease.

RESULTS

Of 100 women enrolled, 73 reported a history of pregnancy, for a total of 170 pregnancies. The average number of pregnancies to term and the average number of children per woman (1.2 ± 1) were lower than the national average. The percentage of miscarriages was 18.2%, higher than the national average; in particular, women with psoriatic arthritis had a greater percentage of miscarriages (27.4%). During the pregnancies, psoriasis was mainly stable (36.1%) or improved (29.2%), even though most patients (91.5%) did not follow any treatment.

CONCLUSIONS

Psoriasis impacts pregnancy desire and course. The management of psoriasis in women of childbearing age is crucial to minimize its burden on this vulnerable population.

Pregnancy Recommendations Solely Based on Preclinical Evidence Should Be Integrated with Real-World Evidence: A Disproportionality Analysis of Certolizumab and Other TNF-Alpha Inhibitors Used in Pregnant Patients with Psoriasis

Treatment for pregnant women with psoriasis is limited by the lack of information typically related to clinical trials. While anti-tumor necrosis factor (TNF) drugs offer therapeutic benefits, their safety during pregnancy is a concern. Notably, certolizumab is comparatively safer than adalimumab, etanercept, infliximab, and golimumab according to the current recommendations. Thus, this study aimed to conduct a pharmacovigilance comparative analysis of maternal and neonatal outcomes associated with certolizumab versus other anti-TNF drugs by using data from EudraVigilance. A descriptive analysis was performed of Individual Case Safety Reports (ICSRs) associated with an anti-TNF drug and related to the pregnant patients with psoriasis from 2009 and 2023, focusing our analysis on the specific pregnancy outcomes and fetal/neonatal disorders. The most common pregnancy-related adverse event was spontaneous abortion, predominantly related to adalimumab and certolizumab. Certolizumab was also reported in cases of caesarean section, gestational diabetes, abortion, fetal death, fetal distress syndrome, pre-eclampsia, and premature separation of placenta. Generally, the findings from our study depicted a safety profile that overlapped for each anti-TNF drug, both in maternal/neonatal outcomes and other adverse events, suggesting no substantial differences between treatments. We advocate for further investigations before making concrete recommendations.

Autoimmune diseases and adverse pregnancy outcomes: an umbrella review

BACKGROUND

There is a high prevalence of autoimmune conditions in women specially in the reproductive years; thus, the association with adverse pregnancy outcomes has been widely studied. However, few autoimmune conditions/adverse outcomes have been studied more than others, and this umbrella review aims to consolidate existing knowledge in this area with the aim to provide new knowledge and also identify gaps in this research area.

METHODS

Medline, Embase, and Cochrane databases were searched from inception to December 2023. Screening, data extraction, and quality appraisal (AMSTAR 2) were done by two independent reviewers. Data were synthesised narratively and quantitatively. Relative risks (RR)/odds ratio (OR) with 95% confidence intervals were reported.

RESULTS

Thirty-two reviews were included consisting of 709 primary studies. The review reported the association between 12 autoimmune conditions and 16 adverse pregnancy outcomes. Higher risk of miscarriage is reported in women with Sjögren's syndrome RR 8.85 (95% CI 3.10-25.26) and systemic lupus erythematosus (SLE) OR 4.90 (3.10-7.69). Pre-eclampsia was reported higher in women with type 1 diabetes mellitus (T1DM) OR 4.19 (3.08-5.71) and SLE OR 3.20 (2.54-4.20). Women reported higher risk of diabetes during pregnancy with inflammatory bowel disease (IBD) OR 2.96 (1.47-5.98). There was an increased risk of intrauterine growth restriction in women with systemic sclerosis OR 3.20 (2.21-4.53) and coeliac disease OR 1.71 (1.36-2.14). Preterm birth was associated with T1DM OR 4.36 (3.72-5.12) and SLE OR 2.79 (2.07-3.77). Low birth weight babies were reported in women with women with SLE or systemic sclerosis OR 5.95 (4.54-7.80) and OR 3.80 (2.16-6.56), respectively. There was a higher risk of stillbirth in women with T1DM OR 3.97 (3.44-4.58), IBD OR 1.57 (1.03-2.38), and coeliac disease OR 1.57 (1.17-2.10). T1DM in women was associated with 32% lower odds of small for gestational age baby OR 0.68 (0.56-0.83).

CONCLUSIONS

Pregnant women with autoimmune conditions are at a greater risk of developing adverse pregnancy outcomes. Further research is required to develop better preconception to postnatal care for women with autoimmune conditions.

Impact of maternal psoriasis on adverse maternal and neonatal outcomes: a systematic review and meta-analysis

BACKGROUND

There is a dearth of robust evidence regarding the correlation between psoriasis with maternal and neonatal outcomes, making it challenging to establish definitive recommendations for the management of these patients. This systematic review and meta-analysis aimed to review the evidence with regard to the impact of maternal psoriasis on maternal and neonatal outcomes.

METHODS

Following the PRISMA guideline, a systematic search of English articles using PubMed, Embase, Scopus, ScienceDirect, Web of Science, Google Scholar, and the Cochrane Library was conducted. The search was performed from inception to 22nd of May 2022.

RESULT

A significant association was observed between psoriasis and maternal outcomes, including cesarean delivery [OR = 1.25 (95% CI: 1.13-1.30, p-value = 0.001)], (pre)eclampsia [OR = 1.29 (95% CI: 1.15-1.44, p-value = 0.0001)], gestational diabetes [Odds Ratio (OR) = 1.23 (95% Confidence Intervals (CI): 1.15-1.30, p-value = 0.001)], gestational hypertension [OR = 1.31 (95% CI: 1.18-1.45, p-value = 0.001)] and preterm birth [OR = 1.22 (95% CI: 1.10-1.35, p-value = 0.001)]. Also, there was a significant association between psoriasis and neonatal outcomes, including small for gestational age [OR = 1.07 (95% CI: 1.02-1.11, p-value = 0.053)], low birth weight [OR = 1.19 (95% CI: 1.02-1.38, p-value = 0.001)] and stillbirth [OR = 1.27 (95% CI: 1.04-1.55, p-value = 0.023)].

CONCLUSION

Maternal psoriasis could negatively impact maternal and neonatal outcomes. Our results strengthen the importance of close monitoring of the mothers' psoriasis status before and during pregnancy.

Pregnancy & neonatal outcomes in spondyloarthritis

Limited research has been conducted on the impact of spondylitis (SpA) on fertility, but some studies suggest a higher risk of subfertility in women with SpA compared to the general population. Factors associated with impaired fertility in SpA include pain, fatigue, stiffness, functional disorders, depression, anxiety, negative body image, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) preconceptionally, while TNF alpha inhibitors may play a role in improving fertility in certain cases. There has been a recent increase in clinical research focused on pregnancy outcomes in SpA. However, clear trends in terms of risk of pregnancy and fetal complications have been slow to emerge and many questions remain for women with SpA planning a pregnancy. This article discusses the current evidence for risk of specific pregnancy and fetal complications in women with axial and psoriatic SpA.

Fetal and Neonatal Adverse Drug Reactions Associated with Biologics Taken During Pregnancy by Women with Autoimmune Diseases: Insights from an Analysis of the World Health Organization Pharmacovigilance Database (VigiBase®)

INTRODUCTION

Published data on the safety of biologics other than tumor necrosis factor (TNF) inhibitors during pregnancy are limited.

OBJECTIVE

The aim was to detect pharmacovigilance signals for fetal and neonatal adverse drug reactions (ADRs) to biologics taken by pregnant women with autoimmune diseases.

METHODS

We performed a disproportionality analysis of the World Health Organization's VigiBase^® pharmacovigilance database from 1968 to June 1, 2021. Data were collected in June 2021. By using terms for different hierarchical levels of the Medical Dictionary for Regulatory Activities, we selected the following fetal or neonatal ADRs: stillbirth, premature birth, low birth weight, small for gestational age, and congenital malformations. The frequency of all identified ADRs for biologics of interest (adalimumab, infliximab, golimumab, certolizumab, etanercept, anakinra, canakinumab, tocilizumab, sarilumab, ustekinumab, guselkumab, secukinumab, ixekizumab, belimumab, abatacept, and rituximab) was compared with that of all other reports for all other drugs and quoted as the reporting odds ratio (ROR) [95% confidence interval]. Reports with known concomitant use of teratogenic drugs were excluded from the main analysis. Other analyses included ROR stratifications by therapeutic indication in the periods 1968-2021 and 2001-2021, and an analysis after excluding reports with steroids.

RESULTS

In the main analysis, the RORs were particularly high for musculoskeletal malformations with anakinra (7.18 [3.50-14.73]), canakinumab (19.54 [12.82-29.79]), and abatacept (5.09 [2.77-9.33]), and for immune system disorders with canakinumab (347.88 [217.9-555.50]) and rituximab (9.27 [2.95-29.15]). After the exclusion of reports with steroids, the ROR was significant for neonatal infections with belimumab (28.49 [5.75-141.25]).

CONCLUSION

We identified possible associations with some adverse fetal and neonatal outcomes, suggesting that vigilance is required when prescribing certain biologics during pregnancy.

Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: a collaborative matched cohort study from Sweden and Denmark

Objective

To explore the risk of pre-eclampsia in rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA), focusing on the impact of treatment and disease activity.

Methods

We identified RA, AxSpA and PsA singleton pregnancies (2006–2018) by linking medical birth registers to Swedish (SRQ) and Danish (DANBIO) rheumatology registers. Control pregnancies from the medical birth registers were matched 1:10 on maternal age, parity and birth year.

We obtained information on antirheumatic treatment before and during pregnancy and disease activity during pregnancy. Risks of pre-eclampsia in RA, AxSpA and PsA pregnancies, compared with control pregnancies, were estimated overall and by antirheumatic treatment (conventional synthetic disease-modifying antirheumatic drug (DMARD)/biological DMARD/corticosteroids, as monotherapy or combination therapy) and disease load (Health Assessment Questionnaire≥1/C-reactive protein≥10/Disease Activity Score in 28 joints≥3.2) through logistic regression (adjusted ORs (aORs) with 95% CI).

Results

We observed 69, 34, and 26 pre-eclampsia events among RA (n=1739), AxSpA (n=819) and PsA (n=489), resulting in a risk of pre-eclampsia of, respectively, aOR 1.27 (95% CI 0.96 to 1.67), 1.17 (0.76 to 1.78) and 1.85 (1.10 to 3.12), compared with controls.

For RA, maternal combination therapy before and during pregnancy was associated with increased risk (1.59; 1.07 to 2.37 and 1.53; 0.97 to 2.39, respectively). For PsA, maternal monotherapy before pregnancy was associated with pre-eclampsia (2.72; 1.4 to 5.13). In RA pregnancies with available information (43%), high disease load was associated with doubled risk of pre-eclampsia (aOR 1.96; 1.26 to 3.04).

Conclusion

PsA pregnancies, but not AxSpA pregnancies, were at increased risk of pre-eclampsia. For RA, combination therapy (potentially a surrogate for high disease activity both before and during pregnancy) and high disease load during pregnancy might be a risk factor for pre-eclampsia.

Psoriasis and medical ramifications: A comprehensive analysis based on observational meta-analyses

Purpose

Based on a large number of systematic reviews and meta-analyses exploring the relationship between psoriasis and various health outcomes, we conducted an comprehensive analysis to assess the strength and evidence for the association between psoriasis and medical end-point ramifications in patients.

Methods

We searched related meta-analyses, investigating the links between psoriasis and medical ramifications from three databases. All summary effect sizes, 95% CIs, heterogeneity, and small-study effects in the included meta-analyses were recalculated. We assessed the methodological quality of included articles with the AMSTAR 2 tool and graded the epidemiological evidence. Subgroup analysis based on the severity of psoriasis and study design were also performed.

Results

A total of 38 articles comprising 85 unique meta-analyses were included in this study. Although 69 outcomes were statistically significant, only 8 outcomes (nonvascular dementia, ulcerative colitis, pediatric dyslipidemia, gestational diabetes, gestational hypertension, fracture, multiple sclerosis, and schizophrenia) showed a high quality of epidemiological evidence.

Conclusion

We found that psoriasis increased the risk of 69 health outcomes, and 8 outcomes were graded as high-quality evidence. No evidence was found that psoriasis was beneficial for any medical end point. However, to verify our results, more large-sample, multi-center prospective cohort studies are needed.

Sex- and gender-related differences in psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory musculoskeletal disease with a chronic, progressive course. Various aspects of PsA, including its clinical features, disease course and response to treatment, are influenced by sociodemographic characteristics of the patient. This includes patient sex, the biological attributes associated with being male or female, and gender, a sociocultural construct that comprises attitudes, traits and behaviours associated with being a man or a woman. An understanding of sex- and gender-related differences in PsA, as well as their underlying mechanisms, is therefore important for individualized care. In this narrative review, the influence of sex and gender on PsA manifestation and course, patient function and quality of life, and their association with comorbidities are described. Sex- and gender-related disparities in response to advanced therapies and their potential underlying mechanisms are delineated. Differences in pathophysiological mechanisms between male and female patients including genetics, immune and hormonal mechanisms are discussed. Finally, fertility and pregnancy outcomes in PsA are outlined. By adopting sex and gender lenses, this review is aimed at highlighting key differences between male and female patients with PsA and uncovering mechanisms underlying these differences, ultimately promoting individualized care of men and women with PsA and informing future research in this area.

Pregnancy, delivery, and neonatal outcomes among women with psoriatic arthritis, a population based study

OBJECTIVES

Many autoimmune diseases negatively affect pregnancies. Studies report conflicting data about the effects of psoriatic arthritis (PsA) in pregnancy. We sought to evaluate the pregnancy, delivery, and neonatal outcomes among women with PsA.

METHODS

We conducted a retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-HIS). Cases of PsA were identified using the ICD code 696.0. Pregnancies complicated with PsA were compared with the other pregnancies. A multivariate logistic regression was used to adjust for confounding variables.

RESULTS

A total of 9,096,369 control births and 419 with PsA occurred during the study period. Women with PsA were more likely to be older, Caucasian, obese, have a higher income, and private insurance (p-value <0.0001 all). Also, they were more likely to start their pregnancy with chronic hypertension, pregestational diabetes, thyroid disorders, inflammatory bowel disease, and depression. Rates of pregnancy induced hypertension (PIH) (aOR 1.58, 95% CI 1.13-2.21) and small for gestational age (SGA) (aOR 2.42, 95% CI 1.49-3.93) were higher in PsA. There were no differences in the rates of most outcomes including: preeclampsia, gestational diabetes, preterm delivery, preterm premature rupture of membranes (PPROM), placenta previa, abruption, modes of delivery, hemorrhage, deep vein thrombosis (DVT), pulmonary embolism (PE), chorioamnionitis, intrauterine fetal death, or congenital anomalies (p>0.05 all).

CONCLUSIONS

Women with PsA should be reassured about their pregnancy outcomes as only PIH and SGA were more common. Healthcare providers should take appropriate surveillance and preventive methods to mitigate the effect of these two complications in pregnancies complicated with PsA.

Epidemiology of Psoriasis and Comorbid Diseases: A Narrative Review

Psoriasis is a chronic autoimmune inflammatory disease that remains active for a long period, even for life in most patients. The impact of psoriasis on health is not only limited to the skin, but also influences multiple systems of the body, even mental health. With the increasing of literature on the association between psoriasis and extracutaneous systems, a better understanding of psoriasis as an autoimmune disease with systemic inflammation is created. Except for cardiometabolic diseases, gastrointestinal diseases, chronic kidney diseases, malignancy, and infections that have received much attention, the association between psoriasis and more systemic diseases, including the skin system, reproductive system, and oral and ocular systems has also been revealed, and mental health diseases draw more attention not just because of the negative mental and mood influence caused by skin lesions, but a common immune-inflammatory mechanism identified of the two systemic diseases. This review summarizes the epidemiological evidence supporting the association between psoriasis and important and/or newly reported systemic diseases in the past 5 years, and may help to comprehensively recognize the comorbidity burden related to psoriasis, further to improve the management of people with psoriasis.

Association of maternal psoriasis and small for gestational age or preterm birth: A nationwide matched cohort study in 69 080 singleton infants

BACKGROUND

Women with certain inflammatory diseases have increased risk of giving birth to infants who are small for gestational age (SGA) or preterm birth (PTB), with maternal disease activity being the most important risk factor. However, studies investigation psoriasis and SGA are scarce, and with conflicting results.

OBJECTIVE

To investigate the association between maternal psoriasis and risk of SGA infants and PTB, respectively, overall and according to psoriasis severity.

METHODS

This was a nationwide register-based matched cohort study of women with psoriasis matched 1:10 to women without psoriasis on age at delivery, body mass index and smoking status and their first singleton infant born 2004-2017. Odds ratios (OR) with 95% confidence intervals (CI) were calculated in conditional logistic regression models adjusted for known risk factors.

RESULTS

From 516 063 deliveries, we identified 6282 women with psoriasis and 62 798 matched women without psoriasis. The risk of SGA and PTB was similar in women with psoriasis and the matched controls, adjusted OR 1.07 (95% CI, 0.98-1.17) and adjusted OR 1.05 (95% CI, 0.93-1.19), respectively. The risk of term SGA was increased in women with psoriasis compared to matched controls, adjusted OR 1.11 (95% CI, 1.01-1.22).

CONCLUSION

Maternal psoriasis was not associated with increased risk of SGA or PTB. Risk of term SGA was slightly increased in women with a history of psoriasis compared to matched controls, however these are likely to be constitutionally small with no increased risk of perinatal morbidity and mortality.

Current Resources for Evidence-Based Practice, January 2022

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of breastfeeding while employed and commentaries on reviews focused on mammography test characteristics and sexual health for gynecologic cancer survivors. It also includes a quick update on a USPSTF review for aspirin as pre-eclampsia prophylaxis.

Pregnancy and neonatal outcomes in women with immune mediated inflammatory diseases exposed to anti-tumor necrosis factor-α during pregnancy: A systemic review and meta-analysis

BACKGROUND

Anti-TNFα is increasingly used as treatment for immune mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and psoriasis (PS). However, the impact of anti-TNFα during pregnancy on mother and newborn is under debate. This requires a sound knowledge of the effects of this treatment on pregnancy and neonatal outcomes.

OBJECTIVES

To assess pregnancy and neonatal outcomes after anti-TNFα therapy during pregnancy in women with IMID, specifically IBD, RA and PS.

METHODS

We performed a systematic review and meta-analysis of 39 studies assessing pregnancy and neonatal outcomes of women with IMID exposed to anti-TNFα agents during pregnancy. We used a random-effects model to determine pooled outcome measures.

RESULTS

An increased risk of preterm births (OR 1.45, 95% CI = 1.16 to 1.82, p = 0.001) and infections in newborns (OR 1.12, 95% CI = 1.00 to 1.27, p = 0.05)) was seen for women in the combined group of IMID exposed to anti-TNFα compared to diseased controls. Specifically for IBD patients exposed to anti-TNFα, the risk was increased for preterm birth (OR 1.66, 95% CI = 1.14 to 2.42, p = 0.009), and low birth weight (OR 1.49, 95% CI = 1.01 to 2.20, p = 0.047) compared to diseased controls. Combined data from studies of women with RA and PS, showed no increased risk for adverse pregnancy outcome after exposure to anti-TNFα. Most children of mothers with IMID received vaccination according to national vaccination schemes and only minor adverse events were reported.

CONCLUSION

Exposure to anti-TNFα agents during pregnancy is associated with increased risk of preterm birth and infections in newborns of women with IMID compared to diseased controls. The risk of preterm birth and low birth weight was increased in women with IBD specifically. The increased risk of infections in newborns underlines the importance of vaccination, which seems to be safe in children exposed to anti-TNFα. Delay of vaccination is therefore unnecessary in these children. These data may aid in balancing the continuing anti-TNFα therapy versus the risk of adverse pregnancy outcomes.