For clinicians

Takayasu arteritis

Takayasu, large-vessel vasculitis

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Bottom lineBottom line: pregnancy is often successful with planning, but obstetric complications, especially hypertension, pre-eclampsia, and IUGR, are notably increased. Blood pressure measurement is complicated by arterial stenoses, so measure in the least-affected limb. Assess vascular and cardiac status pre-conception and aim to conceive in remission.

By domain

Blood pressure (a special challenge) ●●●○moderate evidencestrong

Comarmond 2015 (French Takayasu Network, 240 pregnancies/96 patients, verified): hypertension drives outcomes. New-onset or worsening arterial hypertension occurred in 27% of pregnancies, and the authors note this is likely an UNDERESTIMATE because stenoses of all four extremity vessels or the abdominal aorta can produce misleadingly low limb blood-pressure recordings. Measure where the reading is reliable and manage hypertension aggressively. At TAK diagnosis, blood-pressure discrepancy >10 mm Hg was present in 51% and unequal or absent pulses in 51%.[4]

Pregnancy complications ●●●○moderate evidencestrong

Comarmond 2015 (verified): among 98 pregnancies concomitant with or after TAK diagnosis, obstetric complications occurred in 40% and maternal complications in 39%. Compared with 142 pregnancies before diagnosis, the odds of complications were 13-fold higher (OR 13, 95% CI 5-33). Obstetric complications were mainly pre-eclampsia/hypertension (21%), miscarriage (9%), premature delivery <=34 weeks (8%), and intrauterine fetal death or growth restriction (5%). Disease activity dominates: obstetric complications 64% with active disease (NIH >1) versus 24% with inactive disease (P<0.0001), and pre-eclampsia 46% versus 5%. On multivariate analysis, independent predictors were active disease (adjusted OR 28.7, 95% CI 7.89-104.7) and smoking (OR 6.15, 1.31-28.8). >5% of women developed a life-threatening TAK-specific maternal complication (aortic aneurysm, end-stage renal disease, stroke, TIA). No maternal deaths occurred; 14% of maternal complications were postpartum. Three neonatal deaths.[4]

Planning ahead ●●●○moderate evidencestrong

Comarmond 2015 (verified): control of disease activity and of arterial hypertension before conception and during pregnancy is critical to optimising maternal and fetal outcomes; pregnancies in TAK should be considered at risk and managed in close collaboration with obstetrics. Active disease (NIH >1) and smoking were the independent predictors of complications. Pre-conception vascular imaging and cardiac assessment; colour Doppler ultrasound is the imaging modality of choice in pregnancy, though it cannot image the entire aorta and may underreport progression.[1, 4]

Medicines ●●○○low evidenceconditional

Continue compatible immunosuppression (glucocorticoids, azathioprine); low-dose aspirin for pre-eclampsia risk; avoid methotrexate, mycophenolate, cyclophosphamide. For DMARD-refractory disease, Mekinian 2015 (49 patients, verified, NON-PREGNANCY cohort) found TNF-alpha antagonists and tocilizumab produced 75% complete and 83% overall response at 12 months, with 3-year relapse-free survival 90.9% versus 58.7% on DMARDs, a 50% reduction in daily prednisone by 12 months, and no efficacy difference between the two agents (adverse effects 21%; discontinuation 6.6%). That efficacy evidence is not pregnancy-derived, but both drug classes carry verified pregnancy positions: TNF inhibitors can be used throughout pregnancy (EULAR 2024, 2a/B), and IL-6 inhibitors may be used if needed to control maternal disease (EULAR 2024, 4/C; BSR advises reserving them for severe disease). The steroid-sparing effect is relevant in pregnancy, where corticosteroid exposure carries its own risks. Comarmond 2015 (verified) observed a trend toward fewer complications in patients receiving corticosteroid and immunosuppressive therapy during pregnancy, and suggests these treatments should be continued in TAK pregnancy; neither treatment during pregnancy nor abdominal aorta/renal artery involvement independently affected outcome in their model.[1, 2, 3, 4]

Key points

PointEvidence
Hypertension control and reliable blood-pressure measurement are central; stenoses can produce falsely low limb readings, underestimating true hypertension (Comarmond 2015, verified).[4]●●●○moderate evidencestrong

Key numbers

References

  1. Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in RMD. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
  2. Ruegg L, et al. EULAR recommendations for antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
  3. Mekinian A, Comarmond C, Resche-Rigon M, et al. Efficacy of biological-targeted treatments in Takayasu arteritis: multicenter, retrospective study of 49 patients. Circulation. 2015;132(18):1693-1700. https://doi.org/10.1161/CIRCULATIONAHA.114.014321
  4. Comarmond C, Mirault T, Biard L, et al. Takayasu arteritis and pregnancy. Arthritis Rheumatol. 2015;67(12):3262-3269. https://doi.org/10.1002/art.39335