Rheumatology-led pregnancy clinic: patient-centred approach

Changes in health related quality of life in mothers with inflammatory joint disease from year 2000 to 2020 - a comparative cross-sectional study

Objectives

More knowledge about health related quality of life (HRQoL) among mothers with inflammatory joint disease (IJD) is needed to understand the complex challenges for this group of patients. The overall aim of this study was to investigate changes in HRQoL among mothers with IJD from year 2000 to year 2020.

Methods

This study had a comparative cross-sectional design with two study groups 20 years apart, year 2000 (n = 77) and year 2020 (n = 197). Patients were identified from RevNatus, a Norwegian nationwide medical quality register (2020 cohort) and from a national centre for pregnancy and rheumatic disease (2000 cohort). Mothers with the diagnoses of rheumatoid arthritis, juvenile idiopathic arthritis, axial spondyloarthritis and psoriatic arthritis with children aged 0-6 were included. Data on HRQoL were self-reported and assessed by the RAND-36 (SF-36) questionnaire, along with data on educational status, number of children, months since last childbirth and eight questions on experienced motherhood limitations and experienced anxiety and distress for the children. Descriptive statistics were performed using the Mann-Whitney U-test, the Pearson chi-squared test and independent samples t-test. Multivariable linear regression were used to investigate changes and association between the RAND36 (SF-36) scores and the two study groups and possible confouders.

Results

The 2020 cohort had significantly higher scores on bodily pain (p < 0.001), physical function (p < 0.001), and role physical (p = 0.01) scales compared to the 2000 cohort, indicating better health. There were no significant differences between the two cohorts in the mental health (MH) (p = 0.81), vitality (p = 0.09), general health (p = 0.06), social function (p = 0.83), and role emotional (p = 0.93) scales. Compared to the calculated norm scores, the 2020 cohort had significantly lower scores on all scales (p < 0.01) except on the MH scale (p = 0.37).

Conclusion

Mothers with IJD were affected in most dimensions of RAND-36 (SF-36) both in year 2000 and year 2020. The findings emphasize the importance of understanding the intrusiveness of being a mother with IJD despite the improved medical treatment options over the last 20 years.

The Impact of Pregnancy Readiness on Lupus Activity, Maternal Mental Health, and Pregnancy Outcomes

OBJECTIVE

Among individuals with systemic lupus erythematosus (SLE) who became pregnant, we explored the impact of medical readiness for pregnancy and personal readiness for pregnancy on the following aspects of maternal health: (1) provider-reported disease activity, (2) patient-perceived disease activity, (3) mood symptoms, (4) pregnancy-related health behaviors, and (5) pregnancy outcomes.

METHODS

All study participants were enrolled in a prospective registry, met Systemic Lupus Collaborating Clinics (SLICC) criteria for SLE, and had at least one pregnancy. Patient-reported outcomes were collected at the first rheumatology visit during pregnancy. "Medically ready" for pregnancy was defined as (1) <1 g of proteinuria, (2) no rheumatic teratogens at conception, and (3) continuing pregnancy-compatible SLE medications after conception. "Personally ready" was defined as planned pregnancy based on a London Measure of Unplanned Pregnancy score ≥10. Multivariable logistic regression models estimated the association of pregnancy readiness with each outcome of interest.

RESULTS

Among the 111 individuals enrolled, lack of medical readiness for pregnancy was associated with significantly higher rates of active disease and worse pregnancy outcomes; however, these patients did not perceive themselves as having higher disease activity. Lack of personal readiness for pregnancy was associated with significantly higher patient-perceived disease activity. Although medical readiness did not impact depressive symptoms substantially, lack of personal readiness for pregnancy was associated with much higher maternal depressive symptoms.

CONCLUSION

To improve pregnancy outcomes among individuals with SLE, greater focus is needed on improving medical optimization before conception. For maternal mental health and quality of life, greater focus is needed on decreasing the incidence of unplanned pregnancy.

Family Planning in Fertile-Age Patients With Multiple Sclerosis (MS) (ConPlanEM Study): Delphi Consensus Statements

Family planning is essential for establishing Multiple Sclerosis (MS) prognosis, treatment decision, and disease monitoring. We aimed to generate an expert consensus addressing recommendations for family planning in MS patients of childbearing age. Initially, a committee comprising seven neurologists, experts in the MS field, identified the topics to be addressed. Then, the committee elaborated on different evidence-based preliminary statements. Next, using the Delphi methodology, a panel of neurologists manifested their level of agreement on the different statements using a Likert-type scale. Consensus was reached when ⩾70% of respondents expressed an agreement or disagreement using a five-point scale. Consensus was achieved on 47 out of 63 recommendations after three rounds of evaluations. The panel considered it essential to address family planning in all patients of childbearing age. There was also consensus that treatment should not be delayed due to the patient's desire for pregnancy. Additionally, in highly active patients, planning the pregnancy in the medium to long term using depletory drugs such as cladribine or alemtuzumab might represent a useful strategy. However, risks of adverse effects on the fetus due to drug-associated secondary autoimmunity should be addressed when alemtuzumab is considered. Moreover, the maintenance of natalizumab during pregnancy in very active patients reached expert consensus. Also, the panel supported the use of certain disease-modifying treatment (DMT) during lactation in selected cases. Our results identified specific areas of pregnancy planning in MS patients, where different treatment strategies might be considered to facilitate a safe and successful pregnancy while maintaining clinical and radiological stability.

Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data

OBJECTIVES

To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy.

DESIGN

A retrospective analysis of US claims data.

SETTING

Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database.

PARTICIPANTS

We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy.

PRIMARY OUTCOMES

Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims.

RESULTS

The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70).

CONCLUSION

Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.

Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy

Background

Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.

Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.

Results

An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.

Conclusion

These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.

Pregnancy Outcome in Women With APECED (APS-1): A Multicenter Study on 43 Females With 83 Pregnancies

CONTEXT

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED; also known as autoimmune polyendocrine syndrome type 1) has a severe, unpredictable course. Autoimmunity and disease components may affect fertility and predispose to maternal and fetal complications, but pregnancy outcomes remain unknown.

OBJECTIVE

To assess fetal and maternal outcomes and course of clinical APECED manifestations during pregnancy in women with APECED.

DESIGN AND SETTING

A multicenter registry-based study including 5 national patient cohorts.

PATIENTS

321 females with APECED.

MAIN OUTCOME MEASURE

Number of pregnancies, miscarriages, and deliveries.

RESULTS

Forty-three patients had altogether 83 pregnancies at median age of 27 years (range, 17-39). Sixty (72%) pregnancies led to a delivery, including 2 stillbirths (2.4%) and 5 (6.0%) preterm livebirths. Miscarriages, induced abortions, and ectopic pregnancies were observed in 14 (17%), 8 (10%), and 1 (1.2%) pregnancies, respectively. Ovum donation resulted in 5 (6.0%) pregnancies. High maternal age, premature ovarian insufficiency, primary adrenal insufficiency, or hypoparathyroidism did not associate with miscarriages. Women with livebirth had, on average, 4 APECED manifestations (range 0-10); 78% had hypoparathyroidism, and 36% had primary adrenal insufficiency. APECED manifestations remained mostly stable during pregnancy, but in 1 case, development of primary adrenal insufficiency led to adrenal crisis and stillbirth. Birth weights were normal in >80% and apart from 1 neonatal death of a preterm baby, no serious perinatal complications occurred.

CONCLUSIONS

Outcome of pregnancy in women with APECED was generally favorable. However, APECED warrants careful maternal multidisciplinary follow-up from preconceptual care until puerperium.