Psoriatic Arthritis Linked to Increased Risk of Emergency Caesarean Sections

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A cohort analysis from Norway suggests women with active psoriatic arthritis or axial spondylitis are at greater risk of either elective or emergency delivery procedures.

Birth-giving women with either active axial spondylitis (axSpA) or psoriatic arthritis are more likely to undergo a caesarean section procedure than the general population, according to a new study.

What’s more, women with psoriatic arthritis are at an approximately 11% increased risk of an emergency caesarean section than the general population, while women with axSpA are about 4% more likely to undergo an elective procedure during child birth.

In new research from a team of Norway-based investigators, data suggest active rheumatic disease during at least the third trimester of pregnancy may increase the likelihood of a higher-risk delivery procedure. The findings emphasize the need for inactive disease target goals for expectant mothers with either psoriatic arthritis or axSpA, as well as improved guidance for pre-pregnancy disease management.

Led by Carina Skorpen, a postdoctoral fellow with the Department of Neuromedicine and Movement Science at the Norwegian University of Science and Technology (NTNU), investigators sought a possible link between active inflammatory disease and caesarean section rates among women with axSpA and psoriatic arthritis. They noted that caesarean section rates and globally increasing, and are generally associated with greater risk for maternal complications versus vaginal delivery.

Despite this issue, only one previous study among a European population has observed any link between spondyloarthropathies during pregnancy and rates of caesarean sections—despite a clear need to interpret the risk.

“In women with spondyloarthropathies, early mobilization after birth is important to counteract inflammatory pain and stiffness,” investigators wrote. “Often, there is a prompt need to introduce or restart immunosuppressive disease modifying medication. In cases with infection after CS, this may be delayed by several weeks.”

Skorpen and colleagues linked data from the Medical Birth Registry of Norway to a nationally-representative observational register that recruited women with inflammatory rheumatic diseases to derive the available cohort data and the associations therein. They collected 312 singleton births among women with axSpA and 121 among women with psoriatic arthritis between 2010 – 2019. Data from 575,798 singleton births excluding those inflammatory diseases from the same time period served as control.

Mean maternal age of the 3 cohorts was approximately 31 years old; a majority of patients were <35 years old and had ≥1 child.

Investigators observed a 43.6% increased rate of caesarean sections among women with active axSpA disease in the third trimester (22.4%) versus the control (15.6%). The rate was 96% greater among women with active psoriatic arthritis (30.6%) versus control.

Elective caesarean sections were greater among women with active axSpA versus the control population (risk difference, 4.4%; 95% CI, 1.5 – 8.2), but emergency procedures were not greater.

Emergency caesarean sections were indeed more common among women with psoriatic arthritis than the control population (risk difference, 10.6%; 95% CI, 4.4 – 18.7), but not elective caesarean section.

“Our findings indicate that active disease may be an important risk factor for emergency CS in PsA,” investigators wrote. “In addition, maternal age >35 years and obesity that are general risk factors for emergency caesarean section were more prevalent in psoriatic arthritis women compared with population controls. This is in accordance with earlier studies.”

The team observed little differences in treatment adherence or regimens among with active or inactive types of either inflammatory disease, though factors including fear of harming the fetus with disease-modifying antirheumatic drugs or tumor necrosis factor inhibitors were noted. Quality of life and burden of disease may also influence the outcome of birth delivery in these populations.

“A woman’s perception of poor physical function and general health as well as high levels of bodily pain and fatigue in the third trimester may contribute to a shared decision for elective caesarean section,” investigators wrote. “Low health-related quality of life may influence on the decision to perform elective or emergency caesarean section.”

Skorpen and colleagues concluded their multinational-relevant findings may help reinform counseling and disease management strategies for clinicians seeing expecting mothers with spondyloarthropathies.

“We have identified risk factors that need to be addressed before pregnancy, and especially in psoriatic arthritis maternal age and weight demands attention,” they concluded. “Perception of bodily pain and physical function should be discussed alongside with advice on possible lifestyle changes.”


  1. Götestam Skorpen C, Lydersen S, Salvesen KÅ, Koksvik HSS, Jakobsen B, Wallenius M. Caesarean section in women with axial spondyloarthritis and psoriatic arthritis: a population-based study. RMD Open. 2023;9(1):e002760. doi:10.1136/rmdopen-2022-002760