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Pregnancy and Psoriatic Arthritis

Patient TS was a 30 year old woman who had been living with psoriatic arthritis for about 18 months. Her symptoms had started about 6 months after the birth of her first child with mild psoriasis in her scalp but increasing joint pain in her hands, wrists, elbows, knees, and ankles. She had dactylitis in several fingers that caused her extreme pain. She's seen by rheumatologist within about four months of symptom onset. Because she was trying to conceive again, she was never offered any immunosuppresant medications – that there were medications that could help her wasn’t even discussed. The patient lived in severe pain, unable to work and struggling to take care of her baby when her husband was at the office.

She eventually conceived again. Her rheumatologist said she didn’t need to return during pregnancy for visits.  She eventually found her way to my clinic half-way through pregnancy. I was horrified to see dramatic dactylitis in 3 fingers and pain, swelling, and limited range of motion in both wrists and elbows. She was limping with a very swollen knee and ankle. Through tears, she described her severe pain and the challenge of caring for her toddler at home. She was living with significant depression due to her belief that she was never going to be out of pain nor the mother that she had hoped to be.

That day I started her on a combination of prednisone, sulfasalazine and certolizumab. All of these are considered compatible with pregnancy and breastfeeding according to the American College of Rheumatology’s Reproductive Health Guidelines (LINK).  

She was already a new woman when she returned to clinic 6 weeks later. The synovitis and dactylitis was abating and she was living in less pain, better able to care for her child. This time she had tears of joy. She could see a brighter future - a life with less pain and the activities that she loved. 

She went on to have a beautiful baby, breastfeeding for a full year on sulfasalazine and certolizumab.

This should not happen. You no longer need to be afraid of prescribing medications during pregnancy.  

The American Colleges of Rheumatology’s Reproductive Health Guidelines provide important insight into the safety of medications. Table 3 provides clear guidance about medications that can be used prior to and during pregnancy and breastfeeding. The ACR’s Reproductive Health Initiative created terrific handouts to help guide your conversations about pregnancy prevention and planning with women who have PsA. Check them out and print a few to hand on your wall or keep in your clinic rooms. 

In the dark ages, which may be when you trained – or when the people who trained you were trained – the prevailing approach to pregnancy was to stop all medications and have women suffer through pregnancy “for the sake of the child.” We now know, however, that this was wrong. Women do not need to sacrifice their bodies in order to have healthy baby. Please help them.

ACR Reproductive Health Guidelines: 
2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

PsA Pregnancy Handout for Women
PowerPoint Presentation (acrreprohealthinitiative.com)

PsA Pregnancy Planning Handout for Men
psa-men_v5 (acrreprohealthinitiative.com)

Contraception Handout for Rheumatology:
PsA_BirthControlEffectivenessHandout_English.pdf (acrreprohealthinitiative.com)

 

Dr. Megan Clowse is an Associate Professor of Medicine in the Division of Rheumatology and Immunology.  Her clinical research focuses on the management of rheumatic diseases in pregnancy. She has cared for over 600 pregnancies in women with rheumatic disease, collecting information on these pregnancies initially in the Duke Autoimmunity in Pregnancy Registry and Repository, and now the MADRA (Maternal Autoimmune Disease Research Alliance) registry and repository.  She served on the Core Leadership Team for the inaugural American College of Rheumatology's Reproductive Health Guidelines, published January 2020.  Dr. Clowse created www.LupusPregnancy.org, a website dedicated to improving lupus pregnancy planning and management for patients and rheumatologists.

Rheumatologists’ Comments

Lode Dewulf MD

| Apr 21, 2022 4:55 am

Shocking to still read in 2022 this kind of medical negligence, wilful or not. Does our profession really only improve and come out of the dark ages when it is sued? In this case, I could clearly see good reason to.

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