Rheumatoid arthritis and pregnancy: issues for consideration in clinical management

Pregnancy outcomes and perinatal complications of Asian mothers with juvenile idiopathic arthritis - a case-control registry study

BACKGROUNDS

In order to provide juvenile idiopathic arthritis (JIA) patients with better pre-conceptional and prenatal counselling, we investigated the obstetrical and neonatal outcomes among women with Asian descent.

METHODS

Through the linkage of Taiwan National Health Insurance database and National Birth Registry, we established a population-based birth cohort in Taiwan between 2004 and 2014. In a case control study design, first children born to mothers with JIA are identified and matched with 5 non-JIA controls by maternal age and birth year. Conditional logistic regression was used to calculate odds ratios for maternal and neonatal outcomes crude and with adjustment.

RESULTS

Of the 2,100,143 newborn, 778 (0.037%) were born to JIA mothers. Among them, 549 first-born children were included in this research. Our result suggested that babies born to mothers with JIA were more likely to have low birth body weight, with an adjusted OR of 1.35(95% CI: 1.02 to 1.79) when compared to babies born to mothers without. No differences were observed in other perinatal complications between women with and without JIA including stillbirth, prematurity, or small for gestational age. The rate of adverse obstetrical outcomes such as caesarean delivery, preeclampsia, gestational diabetes, postpartum hemorrhage and mortality were also similar between the two.

CONCLUSIONS

Adverse obstetrical and neonatal outcomes were limited among Asian mothers with JIA. Intensive care may not be necessary for JIA mothers and their newborns.

Mothers with Arthritis, Child Care and Occupational Therapy: Insight through Case Studies

The role of occupational therapy in the treatment of mothers with arthritis has received little attention in the research literature to date. This study builds on previous work at the Psychosocial Research Centre at Coventry University on the theme of parenting in the context of arthritis. Qualitative case studies were undertaken with four mothers with arthritis and the two occupational therapists involved in their care. This involved the observation of occupational therapy sessions, interviews with mothers and occupational therapists and the use of field notes.

The data were analysed using the middle-order approach (Dey 1993). The middle-order categories that emerged were physical and psychosocial parenting problems, the level of support available to mothers and their experience of occupational therapy. The subcategories included items such as difficulty in carrying children and with physical play, guilt and anxiety about the ability to fulfil the parenting role, inadequate or too much support from partners and increased knowledge and confidence through occupational therapy. Broad, overarching themes evolving from these data included the significance of mothers' attitudes to parenting based on preconceived notions of motherhood, the psychological state of mothers and the nature of the support available from partners.

The implications for practice include the importance of nurturing a mother's own problem-solving strategies and balancing the physical and psychosocial aspects of intervention according to her needs.

Pregnancy outcomes in women with juvenile idiopathic arthritis: a population-based study

OBJECTIVE

The aim of this study is to describe pregnancy outcomes among women with JIA.

METHODS

Women who gave birth in New South Wales (NSW), Australia, were linked to hospital discharge records from 2000 to 2010. Women with an ICD-10-AM code of M08 or M09 in the hospital records were considered to have JIA. Logistic regression was used to calculate odds ratios for pregnancy outcomes and the lack of independence in study outcomes for multiple pregnancies in the same woman was taken into account using generalized estimating equations.

RESULTS

During the study period, 601,659 women had 941,496 births. Of these births, 78 births could be attributed to 50 women with JIA. Of 78 JIA pregnancies, 53 (68%) were delivered by either Caesarean section (n = 40, 51%) or instrumental delivery (n = 13, 17%); compared with other women, those with JIA had significantly higher rates of pre-eclampsia, postpartum haemorrhage and severe maternal morbidity. Compared with other infants, those with mothers with JIA were more likely to be born prematurely, but were not at increased risk of being small for gestational age, requiring neonatal intensive care, having a low Apgar score at 5 min or severe neonatal morbidity.

CONCLUSION

Infants of women with JIA did not have an increased risk of adverse neonatal outcomes. Intensive obstetric care might be required during pregnancy for women with JIA given the increased risk of maternal morbidity.

Th2 immune deviation induced by pregnancy: the two faces of autoimmune rheumatic diseases

One of the most important immunological modifications during pregnancy is the Th1/Th2 shift, due to the progressive increase of progesterone and estrogens during pregnancy, which reach their peak-level in the third trimester of gestation. At high levels, estrogens seem mainly to suppress Th1 cytokines and stimulate Th2-mediated immunological responses as well as antibody production. For this reason Th1-mediated diseases, like rheumatoid arthritis (RA), tend to improve and Th2-mediated disease, like systemic lupus erythematosus (SLE), tend to worsen during pregnancy. SLE is the autoimmune rheumatic disease in which pregnancy most frequently occurs because it predominantly affects young females in their childbearing age. Other autoimmune rheumatic diseases, including RA, are less frequently observed during pregnancy due to their low female-to-male ratio and peak onset after the age of 40. This review is focused on the disease course, gestational outcome and management of patients with SLE and RA during pregnancy.

Childbearing decisions and family size among women with rheumatoid arthritis

OBJECTIVE

To estimate childbearing trends relative to age and stage of family development and to report on childbearing decisions among women with rheumatoid arthritis (RA).

METHODS

Information about childbearing history and decisions was collected through structured telephone interviews with an existing cohort of married women with RA (n = 411), and was examined according to women's age at RA diagnosis and when RA was diagnosed relative to when children were born.

RESULTS

Almost all women (91.2%) reported at least 1 pregnancy; the majority (85.4%) reported at least 1 live birth. The odds of any pregnancy or a live birth were not significantly different according to age at diagnosis; however, women diagnosed at age < or =18 had fewer pregnancies and fewer children. Similarly, women diagnosed with RA prior to the birth of their first child had the fewest pregnancies and children. Few women (8%) reported being advised to limit family size, although approximately 20% reported that RA had affected their childbearing decisions. Being advised to limit family size was associated with fewer pregnancies and fewer children (P < 0.0001). Consideration of RA in childbearing decisions was more common among women diagnosed with RA at an early age. Women who reported that RA affected childbearing decisions were not less likely to have any pregnancy or any children, but had significantly fewer pregnancies and children.

CONCLUSION

Lower birth rates among women with RA may at least in part reflect choices by women to limit family sizes. Future research into the link between RA and fertility should take women's childbearing choices into account.

Being a parent or grandparent with back pain, ankylosing spondylitis or rheumatoid arthritis: a descriptive postal survey

Research that explores being a parent or grandparent with musculoskeletal problems has been fairly limited to date. The aim of this study was to describe the experience of parenting in the context of back pain (BP), ankylosing spondylitis (AS) and rheumatoid arthritis (RA), with a particular focus on the extent and nature of childcare experiences and to compare these experiences across the three groups. In addition, the possible reasons for these reported experiences, the availability of advice and support and the development of strategies for coping were explored using a cross-sectional descriptive survey. A total of 448 participants was recruited from relevant charitable organizations and the National Health Service (280 with BP, 106 with AS and 62 with RA). A combination of opportunistic and random sampling was used. Quantitative data were analysed with appropriate descriptive and inferential statistics using Statistical Package for the Social Sciences (SPSS version 10). Qualitative data were analysed using content analysis. Results indicate that a high proportion of all groups experienced a wide range of difficulties with parenting (81% BP, 77% AS, 97% RA). The most prevalent problems were similar for all three groups: lifting baby/child from the floor or cot, encouraging children/grandchildren to help with domestic chores and keeping up (in terms of energy) with children/grandchildren. However, the RA group reported having greater difficulties than the other two groups. Very little advice was offered to participants with parenting difficulties which may indicate a gap in service provision. However, a wide range of strategies for coping were described by respondents. The study highlighted a need for healthcare professionals to develop a greater awareness of parenting issues and to provide opportunities for these issues to be addressed.