Rheumatoid arthritis

Tips for pregnancy in patients living with rheumatoid disease


Pregnancy can be a difficult time for any woman, but for those with rheumatoid disease, it can be even more complicated. We sat in on a webinar presented by Megan Clowse, Associate Professor of Medicine, Division of Rheumatology and Immunology at Duke University School of Medicine in Durham, North Carolina, to understand how to approach the topic of pregnancy planning and management in patients living with rheumatic disease.

The issue of the unplanned pregnancy

Unplanned pregnancies tend to suffer higher rates of complications compared to planned pregnancies,1–4 both in the general population and in women with rheumatic diseases. How do we help women with rheumatic diseases take the special care needed to plan their pregnancies for optimal outcomes?

Patients living with a rheumatic disease may not be aware of how much control they actually have over how to manage their reproduction for the best outcomes. They may assume, based on their lived experience with a systemic rheumatic condition, that the worst will automatically happen no matter what. But there are clear modifiable factors that can lead to pregnancy loss, for example, including medications that lead to birth defects, conceiving when the disease is highly active, uncontrolled hypertension and untreated phospholipid syndrome. Addressing these avoidable factors can help move a patient to a lower risk category for pregnancy loss.

Associate Prof. Clowse offered up her tips for “transforming pre-pregnancy communication to allow you to have honest and accurate conversations with your patients. When I say honest, I mean that your patient is able to be honest with you.”

Read on for A/Prof. Clowse’s advice throughout various stages of pregnancy.

Know her plans BEFORE she becomes pregnant

A/Prof. Clowse described making it part of the doctor’s routine to ask every single patient about her intentions regarding pregnancy. Asking every patient helps get over the implicit bias inherent in not asking people for whom you think it will be an uncomfortable conversation”. In practice, this could be:

  1. Asking open-ended questions about pregnancy, in a way in which the answer is not presumed;
    • e.g., instead of ‘You’re taking birth control, right?’ try ‘What are your thoughts on having children anytime soon?’
  2. Practicing asking about pregnancy in words that feel comfortable to you;
    • e.g., ‘Do you have any plans on becoming pregnant?’
  3. Thinking about where this conversation could take place;
    • An intake survey to which the questions could be added
    • Having a nurse or medical assistant ask whilst they are checking vital signs
    • Making it part of your review system – ‘Are you having chest pain or shortness of breath? Are you thinking of having children anytime in the next couple of years?
    • Signs or posters indicating you’re interested in talking about pregnancy

In short, think about putting the topic of pregnancy everywhere you can so that your patients know you are ready and open to the discussion.

What to do WHEN she is pregnant or plans to become pregnant

According to A/Prof. Clowse, Your main job with systemic vasculitis is to identify and mitigate risks… the goal is that the patient is as healthy as possible throughout pregnancy.” To achieve this goal, she recommends:

  1. Assess recent and current inflammation
    • Prior disease activity especially in the last 6 months
    • Monitor for active disease at least once per trimester
  2. Control hypertension
    • This is the realm of the obstetrics and gynaecology (OBGYN) team, but it’s good to keep an eye out just the same
  3. Check antiphospholipid antibodies at the start of pregnancy
    • If positive, give low dose aspirin daily
    • If the patient has antiphospholipid syndrome (a blood clot or major pregnancy complications), give aspirin plus a low molecular weight heparin
  4. Check for Ro/SSA and La/SSB antibodies

Medication management

As A/Prof. Clowse noted in her presentation The key to success in pretty much all pregnancies is to control the disease with pregnancy compatible medicines.” Her advice on medication management included:

  1. Try to replace prednisone with a pregnancy compatible medicine such as;
    • Hydroxychloroquine
    • Azathioprine, cyclosporine, tacrolimus and colchicine (for active disease)
    • Tumour necrosis factor (TNF)-inhibitors
  2. Start a prenatal vitamin when talking about planning a pregnancy
  3. Start low-dose aspirin by the end of the first trimester (as it decreases the risk of pre-eclampsia by about 20%)
  4. Give hydroxychloroquine to all women with lupus – recommended by the American College of Rheumatology.
Take home messages

A/Prof Clowse’s advice on transforming pre-pregnancy communication to help the patient stay as healthy as possible throughout pregnancy, despite living with a rheumatic disease, included:

  • How to introduce the topic before the patient becomes pregnant, by making her aware that you are open to and wanting to talk about her plans for the future
  • What to monitor during pregnancy, such as active disease and hypertension
  • Which medications to use, as well as special medication considerations, including replacing prednisone with hydroxychloroquine where possible, and ensuring commencement of low dose aspirin before the end of the first trimester.

By implementing these simple tips you can help your patients living with rheumatic disease move to a lower risk category for pregnancy.

This article was commissioned by Eli Lilly Australia Pty Ltd. The content is independent and based on studies and the author’s opinion. The views expressed do not necessarily reflect the views of Eli Lilly. Before prescribing please review the Olumiant® (link) and Taltz® (link) full product information via the TGA website. Treatment decisions based on these data are the responsibility of the prescribing physician.

References:

  1. Bearak J, et al. Lancet Glob Health 2020;8(9):e1152–e1161.
  2. Hall JA, et al. Maternal Child Health J 2017;21(3):670–704.
  3. Lindberg L, et al. Maternal Child Health J 2015;19(5):1087–1096.
  4. Rajendran A, et al. Lupus 2021;30(5):741–751.

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