Rheumatoid arthritis and pregnancy: impediments to optimal management of both biologic use before, during and after pregnancy. Curr Opin Rheumatol. 2014;26:341-346. [PMID: 24663107 DOI: 10.1097/bor.0000000000000046]

A review of key terminology and definitions used for birth defects globally

Birth defects, also known as congenital disorders, are a significant health issue impacting at least five million births annually worldwide. For policymakers to mount a relevant healthcare response to care for those affected, the burden of disease of these conditions must be quantified. Estimates of the contribution of birth defects to under-5 child mortality and morbidity are generated by several groups globally. These estimates often differ, causing confusion for policymakers. While some differences may be attributed to the data sources and methods used, much is due to a lack of clarity in the terminology used for the group of disorders classed as "congenital". This study aimed to gain insight into the diversity of terms and definitions for birth defects, including those used routinely by relevant international/national organisations and in the peer-reviewed literature. This two-part study included (1) scoping review of peer-reviewed literature to identify terms and definitions in use for birth defects and (2) review of key websites and grey literature to identify terms and definitions used. The results of this study indicate a wide variety of terms being used, often interchangeably and undefined, in peer-reviewed publications, on institutional websites and related literature. This suggests a lack of clarity related to terminology and sets the scene for further discussion, recommending that the community of practice working on birth defects comes to a consensus on standard terminology and definitions for global uptake and implementation. Such standardisation will facilitate a common understanding of the burden of these disorders globally, regionally and within countries so that action can be taken to support affected children and their families.

Congenital anomalies in the offspring of women with total hip replacement: a nationwide register study in Finland

BACKGROUND

Few previous studies have analysed the possible teratogenic effect of maternal total hip replacement (THR) on congenital anomalies. The aim of this study was to estimate the risk of major congenital anomalies in the offspring of women with THR. Furthermore, we compared the risks based on type of implant (metal-on-metal [MoM]/non-MoM).

METHODS

The study population for this register-based cohort study was gathered from six Finnish national registers. All fertile-aged females who underwent THR from 1980 to 2007 and three reference females for each THR patient without THR were selected. THR operation day was the start of the follow-up for both groups. Information on pregnancies, induced abortions (IA) and congenital anomalies was gathered for the years 1987-2007 and the proportions of congenital anomalies were compared.

RESULTS

In the THR group, 2429 women had 256 pregnancies, 205 (80.1%) deliveries and 51 (19.9%) IAs. In the reference group, 7276 women had 1670 pregnancies, 1443 (86.4%) deliveries and 236 (13.6%) IAs. There was no difference in the incidence of major anomalies between the THR (3.5%, n = 9) and the reference group (3.6%, n = 60), p = 0.91. In the THR group, there was no difference in the risk of major anomalies between the patients with a MoM-THR (10.5%, 2/19) and those with a non-MoM (2.9%, 7/241) (OR 3.93, 95% confidence interval 0.76-20.2; p = 0.13).

CONCLUSIONS

Reassuringly, maternal THR does not appear to increase the risk of major congenital anomalies or pregnancies ending due to suspected foetal anomalies. Studies with larger study populations are needed to further assess the risk of anomalies in the offspring of women having MoM-THR.

Enhancing Patient Understanding of Medication Risks and Benefits

Objective

To evaluate the effectiveness of 2 interventions, including the DrugFactsBox format for presenting written medication information and the SMART (Strategic Memory Advanced Reasoning Training) program designed to enhance gist (i.e., “bottom‐line” meaning) reasoning ability.

Methods

We used a 2 × 2 factorial research design. A total of 286 patients with rheumatoid arthritis were randomly assigned to 1 of 4 groups, including DrugFactsBox with the SMART program, DrugFactsBox without the SMART program, other consumer medication information (CMI) with the SMART program, and other CMI without the SMART program. Data were collected via telephone interviews and online questionnaires at 4 time points, including baseline and 6‐week, 3‐month, and 6‐month time points following baseline. The primary outcome variable was informed decision‐making, which was defined as making a value‐consistent decision concerning use of disease‐modifying antirheumatic drugs based on adequate knowledge.

Results

We found no main effects for the 2 interventions, either alone or in combination. However, there was a significant interaction between assignment to the SMART/no SMART groups and informed decision‐making at baseline. Among participants in the SMART groups who did not meet the criteria for informed decision‐making at baseline, 42.5% met the criteria at the 6‐month follow‐up, compared to 23.6% of participants in the no SMART groups (mean difference 18.9 [95% confidence interval 5.6, 32.2]; P = 0.007). This difference was driven by increased knowledge in the SMART groups. Among participants who met the criteria for informed decision‐making at baseline, the difference between the SMART and no SMART groups was not statistically significant.

Conclusion

Participation in a theory‐driven program to enhance gist reasoning may have a beneficial effect on informed decision‐making among patients with inadequate knowledge concerning therapeutic options.

Peripartum issues in the inflammatory arthritis patient: A survey of the RAPPORT registry

Childbearing women with rheumatoid (RA) and psoriatic arthritis (PsA) have significant peripartum issues. A retrospective anonymous RedCAP survey of peripartum period in females with RA/PsA in the RAPPORT registry was performed. Completed analyses included descriptive statistics, Chi-square and Fisher’s exact test. 162 patients (133 RA/29 PsA) completed the survey (103 women having 234 pregnancies), 164 pregnancies occurring before and 70 pregnancies occurring after diagnosis. Pregnancy outcomes from 103 patients included: 96% live births, 1.9% stillbirths, 23% miscarriages, and 15% therapeutic abortions. A third of patients had fewer children than desired due to disease activity, medications and other reasons. For 63 pregnancies after diagnosis: (1) 49% of pregnancies received pre-conception counseling; (2) 65% described good disease control during pregnancy but 74% flared in the first 3 months postpartum; (3) 79% of pregnancies discontinued IA medications; (4) 35% of pregnancies occurred on biologic therapy at or prior to conception. Gestational age at time of delivery was 37–40 weeks in 58% (33/57) post-arthritis vs 66% (83/126) pre-arthritis pregnancies. No statistically significant differences occurred between pregnancies before or after RA/PsA diagnosis for: pregnancy planning, fertility treatment, pregnancy and labour/delivery complications, birth defect frequency or neonatal complications. Neonatal ICU admissions were significantly lower in pre- compared to post-arthritis pregnancies (3.2% vs 14.5%). No pregnancy complications were noted in 24/54 pregnancies on medications compared to 6/9 pregnancies not on medications. The impact of RA/PsA before, during and after pregnancy varied considerably in this cohort emphasizing the importance of informed-decision making at all stages.

Pregnancy and primary biliary cirrhosis: a case-control study

A very critical feature in women's health is the identification of risk factors for pregnancy and adverse fetal outcome. Primary biliary cirrhosis is an autoimmune disease of the liver that predominantly affects older women. However, the serologic onset of this disease appears to precede clinical manifestations by many years. The goal of this case controlled study was to analyze fertility in primary biliary cirrhosis (PBC) and investigate the outcome of pregnancy, and the influence of pregnancy on the course of the disease. The study included 233 consecutive female patients with PBC seen between 1987 and 2012. Among them, 186 had at least one conception and were matched for age with a 1:2 group of controls (367 healthy women with at least one conception in their life). PBC patients experienced 507 pregnancies as opposed to 700 pregnancies among controls (mean 1.91 vs 2.73, p < 0.05). The two groups' life history was similar in terms of miscarriages, voluntary interruptions of pregnancy, and term and preterm deliveries. The rates for one or more cesarean deliveries were lower for PBC patients (5.7 vs 11.7 %, p < 0.05). Pruritus during pregnancy was recorded in 15 pregnancies involving 13 PBC patients (3.0 %) and none of the controls. Perinatal and postnatal deaths and complications at childbirth were only recorded in the PBC patients, involving a total of 11 babies (2.7 %, p < 0.05). Eight pregnancies occurred after PBC was diagnosed in six patients, all of which had a favorable course at term, with no complications at childbirth. Ursodeoxycholic acid was continued during pregnancy and no exacerbation of the disease was observed. In conclusion, successful completion of pregnancy is a realistic expectation for PBC patients, though pregnancy and delivery must be monitored for the potentially higher than normal risk of childbirth complications.

The motherhood choices decision aid for women with rheumatoid arthritis increases knowledge and reduces decisional conflict: a randomized controlled trial

BACKGROUND

For many women with Rheumatoid Arthritis (RA) motherhood decisions are complicated by their condition and complex pharmacological treatments. Decisions about having children or expanding their family require relevant knowledge and consultation with their family and physician as conception and pregnancy has to be managed within the RA context. Relevant information is not readily available to women with RA. Therefore a randomized controlled study was conducted to evaluate the effectiveness of a new motherhood decision aid (DA) developed specifically for women with RA.

METHODS

One hundred and forty-four women were randomly allocated to either an intervention or control group. All women completed a battery of questionnaires at pre-intervention, including, the Pregnancy in Rheumatoid Arthritis Questionnaire (PiRAQ), the Decisional Conflict Scale (DCS), the Hospital Anxiety and Depression Scale (HADS), and the Arthritis Self-Efficacy Scale (ASES), and provided basic demographic information. Women in the DA group were sent an electronic version of the DA, and completed the battery of questionnaires for a second time post-intervention.

RESULTS

Women who received the DA had a 13 % increase in relevant knowledge (PiRAQ) scores and a 15 % decrease in scores on the decisional conflict (DCS), compared to the control group (1 %, 2 % respectively). No adverse psychological effects were detected as evident in unchanged levels of depression and anxiety symptoms.

CONCLUSIONS

The findings of this study suggest that this DA may be an effective tool in assisting women with RA when contemplating having children or more children.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, http://www.anzctr.org.au/ , ACTRN12615000523505.

Use of biologic agents for rheumatic diseases in pregnancy

Biologic agents have ushered a new era in the treatment of inflammatory rheumatic diseases. In recent years, several biologic agents have been approved by food and drug administration and have significantly improved outcomes for patients with immune mediated inflammatory disorders including rheumatic and inflammatory bowel diseases. The most common used biologic therapeutic agents are tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab), an interleukin (IL)-6 inhibitor (tocilizumab), an IL-1 receptor antagonist (anakinra), an anti-CD-20 antibody (rituximab), and a T cell co-stimulation modulator (abatacept). Their use during pregnancy has been controversial because of absence of controlled studies which have enrolled pregnant women. This brief overview provides published data on use of biologic agents for the treatment of rheumatic diseases in pregnancy.