Prescribing for pregnancy: inflammatory rheumatic disease

Inflammatory rheumatic disease during pregnancy requires careful management. Key factors for successful pregnancy outcome are disease remission at the time of conception and optimal disease control during pregnancy. This article forms part of a series on prescribing for pregnancy and discusses the impact of inflammatory arthritis on pregnancy and the influence pregnancy may have on inflammatory arthritis. It highlights the importance of prepregnancy care and collaborative working between obstetric and rheumatology specialties as well as focusing on prescribing before, during and after pregnancy.

Case report: Hereditary angioedema in pregnancy

Hereditary angioedema (HAE) is a rare genetic condition associated with episodic swelling due to dysfunction of bradykinin regulation pathways. This is most frequently caused by low level and/or function of the C1-esterase inhibitor protein (C1INH) which is known as hereditary angioedema with C1 inhibitor deficiency (C1INH-HAE). Pregnancy and labour can precipitate an attack, but the majority of women have an uncomplicated, spontaneous vaginal delivery. Intravenous C1INH is the first-line therapy in pregnancy and breastfeeding. It should be given if any obstetric intervention is planned. Routine prophylactic administration for uncomplicated vaginal birth is not mandatory but may be appropriate if symptoms recur frequently during the third trimester. Pregnant women with C1INH-HAE should deliver in a hospital with C1INH replacement, fiberoptic intubation and front-of-neck access equipment readily available. A documented treatment plan should be developed within a multi-disciplinary team to pre-empt complications. We describe a case of C1INH-HAE diagnosed in pregnancy.

Case series of COVID-19 infection in pregnancy complicated by ketoacidosis and symptomatic breathlessness

Background

The differential diagnosis of acute shortness of breath in a pregnant woman with COVID-19 is broad. Pregnancy is a ketosis-prone state, which can result in metabolic acidosis and tachypnoea.

Methods

We describe four pregnant women with COVID-19 and breathlessness where ketoacidosis was found to contribute to symptomatic tachypnoea.

Results

One patient did not have associated COVID-19 pneumonitis, but presented with severe tachypnoea and metabolic acidosis; three women had pneumonitis and metabolic acidosis. Corrective treatment for the metabolic abnormalities resulted in resolution of the ketoacidosis in all cases. No women had coexistent diabetes.

Conclusion

This is the first series of COVID-19 in pregnancy complicated by ketoacidosis and symptomatic tachypnoea. Ketoacidosis associated with COVID-19 is an important cause of tachypnoea requiring specific treatment, which should not be overlooked. Potential mechanisms for this are discussed with a framework for interpretation of blood gas results during pregnancy.

Sjögren's syndrome

This review discusses important aspects of the diagnosis and management of Sjögren's syndrome, covering clinical features, diagnosis and management, and summarizes recent developments in diagnosis, prognostication and treatment.

Sharing learning from hospital trusts on a journey of quality improvement

Background

Quality improvement (QI) has been shown to deliver better patient outcomes, and improved operational, organisational and financial performance when led effectively and supported by organisational systems and training. Surveys of staff and patient satisfaction also show positive effects. In many trusts that Care Quality Commission (CQC) has rated as outstanding, a culture of QI has been embedded throughout the organisation.

Objectives

We wanted to hear trusts’ experiences of using QI as a systematic approach to improving service quality, efficiency and morale, and share learning from these organisations to drive further improvement to quality of care.

Methods

Using CQC’s comprehensive inspection programme of all healthcare providers nationally, we identified 19 trusts for inclusion and carried out an in-depth review of their improvement journeys.

Results

We found that commitment from the board and senior leadership is crucial to ensuring success on the QI journey, modelling effective leadership behaviours that enable all staff to deliver improvement. These organisations have a systematic approach to QI, using a consistent model, anchored in a systems perspective, and often across a health system. The model of improvement requires leaders of all backgrounds and frontline staff to work together in improvement, and can help to break down barriers between managers and clinicians, and providers and patients, so there is a shared purpose to deliver better care to patients.

Conclusions

QI is not a magic bullet, but is an important factor in the evolution of an organisation from a traditional ‘command and control’ form of management towards higher performing approaches to the design and management of work.

A retrospective series of conditions and mortality associated with extreme hyperferritinaemia in adults

BACKGROUND

Serum ferritin is commonly used in the diagnosis of iron deficiency anaemia. However, extreme hyperferritinaemia suggests a significant illness, including the differential diagnosis of haemophagocytic lymphohistiocytosis (HLH), which is rare and associated with a high mortality, particularly if untreated. This series aims to identify the causes and associated mortality of severe hyperferritinaemia in patients seen at a teaching hospital in London, UK.

METHOD

Demographic and medical data were collected for all patients over 18 years of age with extreme hyperferritinaemia (defined as serum ferritin levels of ≥4000 mcg/L). Conditions associated with hyperferritinaemia and in-hospital mortality were identified from medical records, laboratory data and discharge and death notification.

RESULTS

One hundred and fifty-five cases of extreme hyperferritinaemia in adults were identified. Associated conditions included iron overload (35%), malignancy (24%), infectious disease (21%) and hepatocellular disease (12%). Autoimmune disease and HLH resulted in significantly higher median peak ferritin levels compared with all cases (10 616 mcg/L, P < .01 and 19 138 mcg/L, P < .05, respectively). Patients with confirmed HLH had the highest median peak ferritin. Uncommon infections were identified in this series, and included such as dengue, syphilis, HIV and murine typhus. HLH had been confirmed in seven patients (5%). In five patients (3%) no clear cause for raised ferritin was identified. Overall mortality in the whole cohort was 14% (n = 22), but there was a very high mortality of 80% in the group where no cause was found for the hyperferritinaemia, and these patients were significantly more likely to die during the index admission (P < .01).

CONCLUSION

Extreme hyperferritinaemia is associated with a broad differential diagnosis of significant medical conditions, including iron overload, infections, cancer and liver disease. Rare infectious causes were also identified, and this series reports a greater proportion of cases of HLH than has previously reported. Unexplained hyperferritinaemia was associated with significant mortality.