Pregnancy management for RMD patients

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

All reports Priscilla Lynch

Rheumatic musculoskeletal disease (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, 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 evidenced-based national care pathway, the National Maternity Hospital, Holles St, in conjunction with St Vincent’s University Hospital Rheumatology Department, established a dedicated rheumatology obstetric service for women with RMD, known as the ROSE Clinic, in 2017, which is co-led by Prof McAuliffe.

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

In relation to rheumatoid arthritis, Prof McAuliffe stressed the importance of women going back on their biological medicines as soon as possible after delivery, due to post-partum flare risk.

An overview of the ROSE service and its results to date were outlined at the ISR 2024 Spring Meeting by Dr Áine Gorman, Consultant Rheumatologist, Midland Hospital Group Tullamore. Dr Gorman also discussed the recently-launched HSE National Clinical Practice Guideline (2023) – which she co-authored – on the management of rheumatic diseases in the preconception, antenatal, and postnatal periods.

The ROSE clinic has a comprehensive multidisciplinary team including a rheumatologist and rheumatology nurse specialist, obstetric and midwifery maternal medicine, anaesthesia, and pharmacy. 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. Most patients (63 per cent) had inflammatory arthritis and a minority 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.

Discussing the new national guideline launched last year, Dr Gorman 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:

1. Risk stratification and pregnancy planning are vital to assisting individuals with RMD to have successful pregnancy outcomes whilst 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 (ENA) for anti-RO and anti-LA antibodies; antiphospholipid antibody syndrome screening; full blood count; renal and liver function; erythrocyte sedimentation rate (ESR); and C-reactive protein (CRP).

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 preeclampsia 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, 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.

Also speaking was Prof Fionnuala Ní Áinle, Consultant Haematologist, Mater 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 advocated joint decision-making in challenging scenarios. She also pointed to new ACR/EULAR 2023 classification criteria for APS (for research purposes), and 2019 EULAR APS treatment guidelines (eg, heparin, aspirin, etc). Prof Ní Áinle stressed the importance of carrying out further high-quality research in APS in pregnancy, and encouraged the audience to consider participating in the HYPATIA trial, a prospective randomised controlled trial of hydroxychloroquine to improve pregnancy outcomes in women with anti-phospholipid antibodies.

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.

Dr Maguire stressed the importance of pregnancy planning in women with axSpA and continuation of pregnancy-compatible medications. The goals 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 rheumatoid arthritis (DAS-28, etc), Dr Maguire added. “Ongoing national data collection is essential to inform evidence-based clinical practice.”

AI in healthcare is here to stay

Artificial intelligence (AI) is here to stay and is well on its way to transforming how healthcare is delivered for both healthcare workers and patients, the ISR 2024 Spring Meeting heard.

Prof Erwin Loh from the Monash Centre for Health Research and Implementation, Monash University, Australia, a renowned international expert on the role of AI in medicine, who lectures and writes books and articles on the topic – including a commentary in the BMJ Leader on ChatGPT and medicine – gave a tour de force lecture on the rise of AI in medicine.

While accountability and regulation are key, and countries need to catch up rapidly on this, AI has multiple potential positive consequences for the field of medicine, across drug discovery, disease prediction, screening, diagnosis, and treatment guidance, he noted.

AI has already proven to be as good as doctors and sometimes better in comparative studies of its use in diagnosing disease/abnormalities in cancer screening and retinal diseases. It has also been studied in psychiatry in relation to its potential as a suicide prediction tool, with promising results to date. It is also being increasingly incorporated into surgical and procedure tools, for example in endoscopy and robotic surgical systems, Prof Loh reported.

However, he cautioned: “The AI model is only as good as the data it is learning from, and, unfortunately, the internet has a lot of sources that may have data that is skewed or focused on a population that cannot be generalised.”