Pregnancy management for RMD patients

Obstetric care for women with rheumatic musculoskeletal disease (RMD) was the key theme of this year’s Irish Society for Rheumatology (ISR) Spring Meeting, which took place in Malahide, Co Dublin, on 11-12 April.

RMD patients must carefully consider fertility, disease activity and management from pre-conception to lactation when they are planning a family. Active RMD in pregnancy is potentially associated with adverse outcomes for both mother and baby, such as low birth weight, pre-term delivery, and pre-eclampsia, according to Prof Fionnuala McAuliffe. Prof McAuliffe is Consultant Obstetrician and Gynaecologist, National Maternity Hospital, Holles Street, Dublin, and co-author of the HSE National Clinical Practice Guideline on the management of rheumatic diseases in the preconception, antenatal, and postnatal periods.

To better meet the needs of this patient group and to create an evidence-based national care pathway, the NMH, in conjunction with St Vincent’s University Hospital’s rheumatology department, established a dedicated rheumatology obstetric service for women with RMD, known as the ROSE Clinic. The clinic, which was formed in 2017, is co-led by Prof McAuliffe.

Addressing the ISR Spring Meeting, she stressed the importance of good disease control at each stage of reproduction in women with RMD, and taking a multidisciplinary approach, to ensure the best outcomes possible for both mother and baby.

Inflammatory arthritis in remission does not in general affect fertility, she noted, adding that sub/infertility in this cohort may be related to immunological mechanisms. However, RMD may affect women’s decisions on how many children to have due to concerns about being able to cope because of the burden of the disease.

Prof McAuliffe gave an overview of medication safety in RMD during pregnancy, including the agents to continue, and which to avoid. This information can be obtained from the HSE guidelines. Drug therapy should be reviewed prior to conception and during pregnancy and again during breastfeeding. The risks and benefits of drug treatment to the woman and foetus should be discussed and documented by all healthcare professionals involved in the woman’s care.

Prof McAuliffe also noted the importance of assessing these women for anti-Ro or anti-La antibodies and ACA status, and managing those risks accordingly. Women with lupus have higher risks of many pregnancy complications. The ROSE service sees about 10 women with lupus a year. Complications include lupus nephritis, pre-eclampsia, pre-term labour, and foetal growth restrictions, as well as a higher rate of Caesarean section. In relation to antiphospholipid syndrome, she outlined the advised dosages of aspirin and/or heparin for the various subtypes.

For women with rheumatoid arthritis (RA), while about half see an improvement in their disease during pregnancy, Prof McAuliffe stressed the importance of them going back on biological medicines as soon as possible after delivery, due to the risk of post-partum flare. Women with axial spondyloarthritis are less likely to improve during pregnancy and are more likely to relapse post-partum than those with RA, she noted.

Prof McAuliffe also noted the risk of flare during pregnancy in RMD if the woman’s disease is not well managed. Getting it back under control can take six-to-eight weeks and has risks to the pregnancy. 

She also stressed the importance and benefits of breastfeeding, and supporting women with RMD to do so where possible. Speaking to the Medical Independent, Prof McAuliffe said the majority of women with RMD have good outcomes in pregnancy with modern management approaches. She added that while those referred to the ROSE clinic continue to be cared for by their usual rheumatologist and obstetric team, attending the clinic for one or two visits can provide expertise and reassurance on their optimal management.

ROSE service

A more detailed overview of the ROSE service and its results to date were outlined at the second day of the ISR Spring Meeting by Dr Áine Gorman, Consultant Rheumatologist, Midland Regional Hospital Tullamore. Dr Gorman also discussed the recently launched HSE National Clinical Practice Guideline on the management of rheumatic diseases in the preconception, antenatal, and postnatal periods (2023), which she co-authored.

The ROSE clinic has a comprehensive multidisciplinary team including a rheumatologist and rheumatology nurse specialist, obstetric and midwifery, maternal medicine, anaesthesia, and pharmacy support. It identifies patients’ emotional and healthcare needs, provides expert advice, and aims to achieve maintenance of good disease control and positive reproductive outcomes, Dr Gorman explained.

Between January 2018 and July 2022, 150 patients were seen in the ROSE clinic. The majority of patients (63 per cent) had inflammatory arthritis and a minority had connective tissue disease, vasculitis or other diagnosis. The majority (89 per cent) had stable disease over pregnancy, with 17 (11 per cent) experiencing a deterioration of their disease.

Discussing the new national guideline, she said it outlines evidenced-based considerations for the assessment, management, and care of women with RMD before, during, and after pregnancy (up to six weeks postnatal).

The key 11 best practice recommendations in the guidance are as follows:

1. Risk stratification and pregnancy planning are vital to assisting individuals with RMD to have successful pregnancy outcome while minimising pregnancy complications.

2. Disease activity should be assessed pre-pregnancy and be optimised prior to pregnancy with appropriate medication, which is compatible with pregnancy.

3. All women and their healthcare providers should have access to pre-pregnancy advice and counselling with input from rheumatology and obstetrics services.

4. All women with RMD should have the following baseline blood tests prior to pregnancy or in early pregnancy: Anti-extractable nuclear antibodies for anti-Ro and anti-La antibodies; antiphospholipid antibody syndrome screening; full blood count; renal and liver function; erythrocyte sedimentation rate; and c-reactive protein.

5. All women should be monitored for disease activity during pregnancy.

6. Optimal care should include at least one rheumatology review during the pregnancy.

7. Antenatal care should include regular assessment of blood pressure, urinalysis, and assessment of foetal wellbeing. Consideration should be given to low-dose aspirin 75-to-150mg to reduce pre-eclampsia risk in women deemed to have risk factors.

8. Individual obstetric factors should guide the timing/mode of birth.

9. Information and/or counselling should be provided to women on the safety of medication in pregnancy and breastfeeding to support informed shared decision-making.

10. To optimise the health of women and infants, postpartum care, and support with input from rheumatology, midwifery, and obstetrics services, should be tailored to each woman’s individual needs.

11. Drug therapy should be reviewed prior to conception and during pregnancy and again during breastfeeding. The risks and benefits of drug treatment to the woman and foetus should be discussed and documented by all healthcare professionals involved in the woman’s care. A review of medication by a specialist pharmacist should be undertaken where available.

The full guidelines can be accessed at: www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/ncpg-rheumatic-disease-guideline.pdf

One key difference between the Irish and the British Society for Rheumatology (BSR) guidelines are that the BSR recommend stopping methotrexate one month before conception, while the HSE recommends stopping three months before conception, Dr Gorman noted.

Antiphospholipid syndrome care

Also speaking during this session was Prof Fionnuala Ní Áinle, Consultant Haematologist, Mater Misericordiae University Hospital and Rotunda Hospital, Dublin, who discussed obstetric antiphospholipid syndrome (APS), a rare autoimmune disease that can lead to serious thrombotic or obstetric complications including miscarriage and pre-eclampsia.

She said that diagnosis can be challenging and advocated joint decision-making in challenging scenarios. She also pointed to new ACR/EULAR 2023 classification criteria for APS (for research purposes), and the 2019 EULAR APS treatment guidelines (eg, heparin, aspirin, etc).

Prof Ní Áinle stressed the “crucial” importance of carrying out further high-quality research in APS in pregnancy and encouraged the audience to consider participating in the HYPATIA trial. This is a prospective randomised controlled trial of HYdroxychloroquine to improve Pregnancy outcome in women with AnTIphospholipid Antibodies. 

“Multidisciplinary care for those with antiphospholipid syndrome and shared decision-making with the patient, where our evidence is less than perfection, is also key,” she told the Medical Independent.

Pregnancy and axSpA

Discussing pregnancy in women with axial spondyloarthritis (axSpA), Dr Sinead Maguire, Toronto Western Hospital, Canada, who has carried out significant research in this population, said these women face a high prevalence of complications overall.

Pre-term birth,  pre-eclampsia and low birth weight are more prevalent in axSpA pregnancies than the general population. Increased disease activity during pregnancy and postpartum is also common for women with axSpA, as confirmed by data from the Ankylosing Spondylitis Registry of Ireland and other registries and studies, she noted, while breastfeeding rates appear to be lower.

Dr Maguire stressed the importance of careful pregnancy planning in women with axSpA and continuation of pregnancy-compatible medications. The aim of care in pregnancy in these patients is keeping their disease in remission, limiting the risk of obstetric complications, preventing disease progression, and avoiding foetal exposure to harmful medication, she said.

There is a need for more research in this patient population, as well as specific measurement scales akin to what exists for RA (DAS-28, etc), Dr Maguire added. “Ongoing national data collection is essential to inform evidence-based clinical practice.”