A study published in JAAD International examined the association between psoriasis and adverse pregnancy outcomes (APOs) and found that providers should be on the lookout for ectopic pregnancies (EP) in this population.
Diseases like psoriasis cause systemic inflammation, which is not an optimal environment for a developing fetus. Inflammation can result in APOs. Cæcilie Bachdal Johansen, MD, of the department of dermatology and venereology and the department of clinical pharmacology at Bispebjerg and Frederiksberg Hospital in Copenhagen, Denmark, and colleagues conducted a study to see what APOs are linked with psoriasis. They also wanted to investigate if psoriasis disease severity resulted in differences in APOs.
In Denmark, residents are given a 10-digit number to identify them across healthcare registries. Johansen and colleagues used this nationwide registry to conduct a case-controlled study that collected data from 1973-2017. APOs (42,041 study participants/8.56%) were examined; diagnoses included stillbirth, intrauterine fetal death, EP, and spontaneous abortion in women with psoriasis. These were compared to 449,233 (91.44%) single live birth controls. Of these, 6426 (1.31%) pregnant people had psoriasis. For this group, 6225 (96.87%) had mild psoriasis and 201 (3.13%) had moderate-to-severe psoriasis.1
Psoriasis severity was defined based on psoriasis treatment any time before the index date via hierarchical approach, with moderate-to-severe overruling mild psoriasis,” researchers reported.1 Moderate-to-severe psoriasis was considered when pregnant people were treated with any systemic antipsoriatic drugs: acitretin, adalimumab, brodalumab, certolizumab pegol, cyclosporin, etanercept, guselkumab, infliximab, ixekizumab, methotrexate, secukinumab, and ustekinumab.
Researchers used adjusted logistic regression models for statistical analysis. Of all APOs, EP was the only statistically associated adverse outcome linked to psoriasis (odds ratio, 1.34; 95% CI, 1.06-1.68), Johansen and colleagues reported. The authors said this was highest for pregnant people with moderate to severe psoriasis (odds ratio, 2.77; 95% CI, 1.13-6.76). “The absolute risk of EP was 2.48% higher for women with moderate-to-severe psoriasis compared with women without psoriasis (3.98% vs 1.50%),” they wrote.1 While rare, EP is a life-threatening emergency that requires surgery, so providers should be aware of this increased risk due to psoriasis, researchers noted. The authors said there could be a number of reasons for this increase, but more data is needed to provide evidence. “Although embryo implantation and tolerance of pregnancy are extremely complex processes and not yet fully understood, the preexisting inflammatory load in women with severe psoriasis and psoriatic arthritis (PsA) may facilitate a microenvironment in the fallopian tubes permissive of embryo implantation, resulting in an increased risk of EP,” Johansen and colleagues said.1 They added that this idea may be reinforced “by psoriasis’ shared immunologic pathway with IBD, which also is associated with an increased risk of EP.”1
Women with psoriasis have more risk factors for APOs than women without the diagnosis, researchers reported. These include lower fertility rates, obesity, thyroid disease, smoking, preconception hypertension, gestational hypertension, diabetes, inflammatory bowel diseases, rheumatoid arthritis, low socioeconomic status, and use of nonsteroidal anti-inflammatory drugs.1
Johansen and colleagues stressed that EP is a major cause of maternal mortality and morbidity in the first trimester of pregnancy, so providers should be on the lookout for this complication in women with psoriasis, particularly those with moderate to severe form of the disease. Patients should be instructed to go to the ED for lower abdominal pain for an emergency gynecological evaluation, unplanned lack of menstrual bleeding, and concurrent light vaginal bleeding. Finally, researchers said more studies are needed to address the causal relationship between psoriasis and EP.