Rheumatic Diseases In Pregnancy Research Articles

P004 Empowering the reproductive choices of patients with rheumatic disease: using the BSR 2022 pregnancy guidelines audit tool to evaluate pre-conception medication advice

Abstract Background/Aims For ideal pregnancy outcomes, patients with inflammatory rheumatic disease require targeted disease control with pregnancy compatible medications. A proactive approach is required given that people often won’t disclose plans for a pregnancy with healthcare professionals unless directly asked, and 45% of UK pregnancies are unplanned. The BSR 2022 guidelines on prescribing drugs in pregnancy and breastfeeding makes various recommendations on pre-pregnancy counselling for people with rheumatic disease with referral to specialists with relevant expertise as appropriate. Therefore, we used the linked BSR audit tool to evaluate documentation of pre-pregnancy counselling in rheumatology clinics lacking obstetric input at our hospital. Methods Inclusion criteria were all females, aged 15-45 years, attending a doctor-led Rheumatology clinic without obstetric input between 24/4/23 - 30/4/23 at University College London Hospital. Exclusion criteria were infertility and those seen as one-off clinic appointments and not commenced on medications. Clinic notes from all Rheumatology reviews over the preceding one year were assessed using the audit tool in the 2022 BSR pregnancy guidelines. People currently pregnant were audited for the year prior to the date of conception of their pregnancy. Results Among 50 clinics reviewed, 42 female subjects were eligible across 19 clinics, 64% of whom were aged 36-45 years and 36% were aged 21-35 years. Six subjects were pregnant. Diagnoses included: 24% systemic lupus erythematosus; 19.5% rheumatoid arthritis; 17% seronegative axial spondyloarthropathy; and the remaining 39% consisted of fibromyalgia, hypermobility, and other inflammatory arthritidies. 70% of people were screened for antibodies that could adversely impact pregnancy (i.e. anti-Ro or anti-phospholipid). Only 26% of subjects had documentation of being asked if they wished to conceive. In subjects who did not express a wish to conceive, only 21% were asked if they were using contraception. A total of 17% of the 42 subjects were referred to a specialist Obstetric-Rheumatology clinic for pre-pregnancy counselling during the study period. Of 35 subjects taking medications, only 22.8% had documentation of appropriate pre-pregnancy drug counselling within the last year. Of patients without documented pre-pregnancy advice, 46% were taking medications considered unsafe in pregnancy. Furthermore, no patients were signposted to sources of further information on drug therapy and/or rheumatic disease in pregnancy. Conclusion This audit highlights a lack of regular documented discussions around family planning and medication counselling in female subjects of childbearing age attending rheumatology clinics lacking obstetric input. Regular discussions are important for those who do and don’t wish to conceive, to appropriately counsel regarding pre-pregnancy measures or contraception. This audit using the BSR audit tool will be used as the baseline for a quality improvement project to support colleagues in providing regular, accurate reproductive health advice, supported by trusted online resources and referral to a specialist obstetric-rheumatology service as required. Disclosure A. Shirazi: None. B. Goulden: Grants/research support; Undertaking a PhD supported by Versus Arthritis (ref. 22975). I. Giles: Grants/research support; IG has received an unrestricted research grant, travel and speaker fees from UCB Pharma.

A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy

Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period. Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs. Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breastfed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections. Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.

P116 A systematic review of the safety of non-tumour necrosis factor inhibitor and targeted synthetic drugs in rheumatic disease in pregnancy

Abstract Background Despite increasing evidence to support safe use of tumour necrosis factor inhibitor (TNFi) drugs in pregnancy, there remains a paucity of evidence regarding non-TNFi and targeted synthetic disease modifying anti-rheumatic drugs (tsDMARDs) in pregnancy. Therefore, we conducted a systematic review to summarise use of these drugs in pregnancy and breastfeeding. Methods Systematic search of databases including; EMBASE, Pubmed (MEDLINE), and Cochrane up to December 2018 using keywords including; commonly prescribed non-TNFi and tsDMARDs, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection. Results From an initial screen of 700 papers, n = 92 full text papers were included in the final analysis. A summary of findings from known outcomes of pregnancy and breastfeeding exposures as well as long-term follow-up of infants where available are shown in Table 1. Overall, this data does not identify an increased risk of adverse pregnancy outcomes with these drugs in this population of patients. Conclusion These findings do not suggest an increased risk of non-TNFi and tsDMARDs in pregnancy. Given that the total number of exposures, however, remain limited these drugs should only be considered in pregnancy if the benefit of maintaining disease control in the mother justifies any potential risk to the fetus. This body of evidence will be useful when counselling women about the potential risks of using these types of drugs during pregnancy and breastfeeding period as well as following accidental exposure to drugs at conception. Disclosures H. Nguyen None. K. Ahmed None. J. Flint None. I. Giles None.

A systematic review of the safety of non-tumour necrosis factor inhibitor and targeted synthetic drugs in rheumatic disease in pregnancy

Despite increasing evidence to support safe use of tumour necrosis factor inhibitor (TNFi) drugs in pregnancy, there remains a paucity of evidence regarding non-TNFi and targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs) in pregnancy. Therefore, we conducted a systematic review to

Power in numbers

Collecting useful data on a sufficiently large cohort of pregnancies in women with rheumatic disease is a challenge. The original manuscripts that demonstrated the dangers of pregnancy in women with lupus were relatively small case series. As larger prospective cohorts were collected by university-based experts, however, greater safety was demonstrated and the current norms of treatment were determined. In recent years, larger administrative databases have been tapped to study pregnancies not managed within university clinics and to study the long-term impact of maternal rheumatic disease on the offspring. Each of these methods of study has both strengths and weaknesses, adding a unique piece of data to our overall knowledge. We will discuss a range of approaches to the study of rheumatic disease in pregnancy, covering the potential benefits that each brings as well as the biases that can impact study results. When the results of studies are viewed through these lenses, each can contribute to our larger understanding of the rheumatic diseases in pregnancy.

I110 Which Biologics are Safe to Treat Rheumatic Disease in Pregnancy and Breastfeeding?

I110 Which Biologics are Safe to Treat Rheumatic Disease in Pregnancy and Breastfeeding?

How to manage rheumatic diseases in pregnancy?

How to manage rheumatic diseases in pregnancy?

Use of biologic agents for rheumatic diseases in pregnancy

Use of biologic agents for rheumatic diseases in pregnancy

Prevalence and significance of previously undiagnosed rheumatic diseases in pregnancy

ObjectivesThe objective of this study was to evaluate the rates of previously undiagnosed rheumatic diseases during the first trimester of pregnancy and their impact on the pregnancy outcome.MethodsPregnant women in...

The management of rheumatic diseases in pregnancy

Pregnancy can create a challenge for physicians caring for women with rheumatic diseases. For many women with rheumatoid arthritis (RA), pregnancy can provide a reprieve from long-term joint pain and inflammation, but others will not experience remission and will continue to need medication. Systemic lupus erythematosus (SLE) may remain quiet in some women, but in others may become more aggressive during pregnancy, putting both mother and foetus at risk. Women with limited scleroderma can do remarkably well, but scleroderma renal crises can be difficult to manage. A third of pregnancies in women with antiphospholipid syndrome (APS) may be refractory to our best therapy. In general, active inflammation from rheumatic diseases poses a stronger threat to the well-being of both mother and foetus than many immunosuppressant medications. Therefore, continued immunosuppression with the least risky medications will allow for the most optimal pregnancy outcomes.

Treating rheumatic diseases in pregnancy: dos and don’ts

This paper presents a critical appraisal of the current evidence and recommendations regarding the use of pharmaceuticals and biologicals in pregnancy. Clinical experience is often at variance with published recommendations...

Disease-Modifying Antirheumatic Drugs in Pregnancy

Drug use during pregnancy is sometimes unavoidable, especially in chronic inflammatory diseases such as rheumatoid arthritis (RA). The use of disease-modifying antirheumatic drugs (DMARDs) often starts in the early stage of RA; therefore, women of reproductive age are at risk for exposure to a DMARD at time of conception as well as during pregnancy. The aim of this paper was to review recent literature about DMARDs used for rheumatic diseases in pregnancy and to describe the type of study designs and results reported.Twenty-nine studies; eight on hydroxychloroquine/chloroquine, thirteen on methotrexate, three on sulfasalazine and six on azathioprine were identified. With respect to hydroxychloroquine, most studies concluded that it could be safely used in systemic lupus erythematosus or RA. The same conclusions were drawn from the azathioprine studies, but the available evidence is scarce. Although the evidence regarding the safety of methotrexate during pregnancy is conflicting, a high rate of pregnancy losses indicates a risk to the fetus. For each individual case it must be decided whether the benefits outweigh the potential risks. No major teratogenic effects of sulfasalazine were seen although teratogenic effects still can not be excluded. For all other DMARDs, the information on their use in pregnancy was limited. This review underscores the gross absence of data on safety and risks of DMARD use during conception and pregnancy. While young women use these drugs in pregnancy, this review stresses the importance of good monitoring and further research.

Validity of a rheumatic disease diagnosis in the Medical Birth Registry of Norway.

In our population-based study of pregnancy outcome in women with rheumatic disease we based our assessment on the Medical Birth Registry of Norway (MBRN). We evaluated the MBRN as a source of data for such epidemiologic research by assessing the validity of a diagnosis of rheumatic disease in the MBRN against a gold standard. The validity may also be interpreted as a quality indicator, reflecting an obstetrician's attention to rheumatic diseases in pregnancy. Using the mother's national identification number the MBRN was linked with local hospital databases (gold standard), which contained data of mothers with rheumatic disease. The sensitivity of the MBRN was calculated as the proportion of all cases registered locally with a diagnosis of rheumatic disease notified to the MBRN. The correctness of type differentiation was calculated as the proportion of all cases notified to the MBRN that was correct with respect to the type of rheumatic disease. Among 169 mothers, 149 had a diagnosis in the MBRN, representing a sensitivity of 88.2%. Altogether, 97.3% of the diagnoses (145/149) were correct with respect to the type of rheumatic disease. Taken in to consideration the limitations of the study, namely the small numbers studied, we assume a rather high validity of rheumatic disease diagnoses in the MBRN, probably reflecting a high level of attention in the obstetric care for these patients.

Treatment options for rheumatic disease in pregnancy

Treatment options for rheumatic disease in pregnancy

Rheumatic diseases in pregnancy

Rheumatic diseases often present in women of childbearing age. Fortunately, most forms of inflammatory arthritis improve in pregnancy and maternal or fetal complications are rare. Drug therapy may need to be modified as most drugs cross the placenta but only a few are definitely teratogenic. Ankylosing spondylitis may not remit in pregnancy and can be difficult to manage as the high dose non-steroidal anti-inflammatory drugs usually taken by the patient must be discontinued. Providing that systemic lupus erythematosus is well-controlled at the onset of pregnancy, the prognosis for mother and baby is good. Neonatal lupus syndrome is uncommon. The outcome in the rarer systemic conditions such as scleroderma and vasculitis is less predictable and the risk of serious deterioration in the mother is greater. Close liaison between obstetricians and rheumatologists will ensure optimal management of these potentially complicated pregnancies.

First international conference on rheumatic diseases in pregnancy.

First international conference on rheumatic diseases in pregnancy.