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 Pregnancy in Autoimmune DiseaseAbstract #678: Does Rheumatoid Arthritis Ameliorate During Pregnancy? Results from a Prospective Nationwide Cohort Study (the PARA-study)Authors: Y. A. de Man1, R. J. E. M. Dolhain2, F. E. van de Geijn2, T. Stijnen2, J. M. W. Hazes2. 1Erasmus MC, Dept of Rheumatology, Z 712, Rotterdam, The Netherlands; 2Erasmus Medical Center, Rotterdam, The Netherlands This is a prospective study of 78 pregnancies to women with Rheumatoid Arthritis in The Netherlands. The authors recorded medication usage, as well as a DAS28-CRP modified for pregnancy, prior to conception, in the 1st, 2nd, and 3rd trimesters, and 6 weeks, 12 weeks, and 26 weeks postpartum. The women in this study had a mean age of 31.6 years, and on average had had rheumatoid arthritis for 4 years prior to pregnancy. Only 65% of women had a positive rheumatoid factor, and only 62% had erosions on Xrays. All of the women were Caucasian. 8.1% of mothers with RA smoked cigarettes during pregnancy. A review of the mean DAS28-CRP scores demonstrates improvement between the 1st trimester (DAS 3.8) and the 3rd trimester (DAS 3.4, p<0.003). It also shows a worsening of RA symptoms 12 weeks (DAS 3.7), but not 6 weeks (DAS 3.3) postpartum. Using the EULAR response criteria to assess improvement in RA activity during pregnancy, the authors found that only 11% of women were “good responders,” 37% were “moderate responders,” and 45% were “non-responders.” Only one patient had a severe flare during pregnancy, but 33% had a moderate flare. After delivery, 4% had a severe flare, 14% had a moderate flare, and 67% remained stable. More than half (57%) of women in this study were on a disease modifying agent during pregnancy (sulfasalazine 30%, prednisone 36%, hydroxychloroquine 1%, and gold 1%). However, by 26 weeks postpartum, 82% were on a DMARD, most commonly methotrexate (44%). Editorial: The findings in this study contradict prior reports of the effect of pregnancy on rheumatoid arthritis, but may better reflect expectations in the setting of current DMARD therapy. Most of our patients have a lower level of disease activity than they did 10 years ago, as we have improved medications and higher expectations. Though not reported, I suspect that many of the women in this study were on DMARD therapy prior to pregnancy, thus giving them less room for improvement, and more of an opportunity to flare if they discontinued this medication, during pregnancy. Similarly, the lower rate of flares seen postpartum than reported in prior studies likely reflects more aggressive use of DMARD’s after delivery. I suspect that much of the expected disease activity was effectively, and appropriately, suppressed by these medications. Based on this study, pregnancy may not be the “cure-all” for RA we once thought. Prior studies demonstrated remission in over half of women during pregnancy, but in this study only 11% were good responders. It appears that the benefits of pregnancy may not counter-balance the effects of the discontinuation of effective medications. | |