Optimal RA management reduces risk for adverse pregnancy outcomes
Patients with rheumatoid arthritis who follow the ideal clinical pathway have a reduced risk for overall adverse pregnancy outcomes, according to data published in Arthritis Care & Research.
“With the improvement in the management of RA, patients with severe disease have been able to reach remission more frequently and live normal lives, including starting a family,” Alessandra Bortoluzzi, MD, PhD, of the University of Ferrara, in Italy, and colleagues wrote. “As a consequence, the paradigm that ‘RA spontaneously improves during pregnancy’ has been defied over years, as nearly half of RA pregnant patients can have disease flares. Therefore, it has become critical to provide a tool for risk stratification and develop uniform management plans to improve favorable pregnancy outcomes among women with RA.”
According to Bortoluzzi and colleagues, preconception counseling should include evaluation of maternal disease activity, modification of treatment and assessment of general obstetric risk factors as performed in routine obstetric care.
“Patients should be informed about specific washout periods for teratogenic medications such as methotrexate (MTX) and leflunomide (LFN) and, conversely, about the fact that several anti-rheumatic drugs are appropriate for use during pregnancy and lactation,” they added. “This approach to women of childbearing age with RA could be considered as an ‘ideal’ management pathway, however, in the literature, neither data explored the impact of this pathway on pregnancy outcomes nor guidelines specifically aimed at pregnancy management in RA.”
To analyze the impact of optimal pregnancy management among patients with RA on miscarriage and complicated birth, Bortoluzzi and colleagues conducted a retrospective observational examination of data extracted from the Record-linkage on Rheumatic Diseases study. According to the researchers, this study included information from health care databases in the Lombardy region of Italy from 2004 to 2013. For their analysis, Bortoluzzi and colleagues included 443 women with RA, identified through copayment exemption code, and 6,097 control individuals from the general population aged 18 to 50 years.
The researchers constructed and summarized seven health care quality indicators within three pathways — diagnostic, therapeutic and prenatal follow-up. Adverse pregnancy outcomes were defined based on miscarriage, perinatal death or complicated birth. The relationship between health care quality indicators and adverse pregnancy outcomes were evaluated using logistic models.
According to the researchers, among those with RA, patients who followed the ideal pathway demonstrated a reduced risk for overall adverse pregnancy outcomes (OR = 0.6; 95% CI, 0.39-0.94) and for miscarriage and perinatal death (OR = 0.4; 95% CI, 0.24-0.69), compared with those who did not. Patients with RA who met all health care quality indicators during pregnancy demonstrated a risk for adverse pregnancy outcomes (OR = 0.92; 95% CI, 0.61-1.38) and miscarriage or perinatal death with an (OR = 0.77; 95% CI, 0.47-1.29), compared with control individuals in the general population.
“The concept of preconception counselling and risk stratification, and multidisciplinary management during pregnancy has gained greater importance in the field of rheumatology though to date many women struggle to find adequate counselling on reproductive issues to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition,” Bortoluzzi and colleagues wrote. “Our findings suggest the adherence to an ideal clinical pathway should be strived for as much as possible in order to offer the best possible chances for a successful pregnancy to women with RA.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.