Reachout Orthopedics - Issue 2

Kieran E. Murray 1,2 , Louise Moore 1 , Celine O’Brien 3 , Anne Clohessy 3 , Caroline Brophy 3 , Patricia Minnock 1 , Oliver FitzGerald 1,2 , Eamonn S. Molloy 1,2 , Anne-Barbara Mongey 1,2 , Shane Higgins 3 , Mary F. Higgins 3 , Fionnuala M. Mc Auliffe 3 , Douglas J. Veale 1,2 Kieran E. Murray kemurray@hotmail.com 1  Rheumatic Musculoskeletal Disease Unit, Our Lady’s Hospice an Dublin d Care Services, Harold’s Cross, Ireland 2  Rheumatology Department, University College Dublin and St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland 3  UCD Perinatal Research Centre, Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland Rheumatoid arthritis (RA) tends to improve during pregnancy and flare postpartum. Several anti-rheumatic medication options during pregnancy and breastfeeding are now available including anti-tumor necrosis factor (anti-TNF) agents. Good disease control at all stages of reproduction is important to ensure best outcome for both mother and baby. R heumatoid arthritis (RA) is a chronic immune-mediated inflammatory disease which can cause significant disabil- ity, morbidity, and mortality. RA affects women three times more often than men, commonly in their childbearing years [1]. There are concerns about the tera- togenic effects of many traditional disease- modifying anti-rheumatic drugs (DMARDs) and an ever-growing list of new therapeutic options with limited data in pregnancy and breastfeeding. Active RA in pregnancy is associated with a number of negative outcomes for both mother and baby. These include increased incidence of low birth weight, pre-term de- livery, cesarean section, and pre-eclampsia [2, 3]. But, thankfully, outcomes for women with well-controlled RA are comparable to the general population [4]. Before pregnancy, a key aim is to establish the RA patient in remission on medications that are relatively safe in pregnancy; this is usually achieved by the judicious use of synthetic and biological DMARDs. A specific withdrawal period is required for teratogenic medications such as methotrexate and leflunomide. Clinicians should be encouraged to enquire about family planning at the first consultation and each review thereafter, to allow all patients opportunity to discuss any concerns they may have. Pre-conceptual risk assessment and counseling should be ideally performed in every woman with systemic autoimmune diseases before attempting pregnancy [5]. This is an opportune time to alter medication management if required and to refer for a pre- conceptual review with maternal medicine if available. This facilitates access to numerous specialities. Complex patients may benefit from a multidisciplinary approach from obstetrics, hematology, rheumatology, and respiratory or other specialties. This may be possible in a combined clinic. Pregnancy itself may reduce the activity of RA [6]. In 1938, Hench suggested that remission rates during pregnancywere greater than 70% [7]. Later studies suggest that this rate is lower, with a recent prospective study giving a remission rate of 48% [3]. The exact mechanism of this improved disease control is unclear; one theory is downregulation of the maternal immune system with the presence of the fetus. It can be tempting to withdraw anti-rheumatic medications and treat symptomatically with steroids during pregnancy. Recent data would suggest that this may not be the best approach [8]. The postpartum period can be a diffi- cult for the patient, the baby, and the treat- ing healthcare providers. It is important to explain this to patients, their partners, and/ or family. There is an increased rate of disease flare. A 2008 study showed a deterioration in RA control in 39% of patients postpartum [3]. One should also consider the additional strain of caring for an infant. It may be difficult to differentiate what is normal postpartum from a disease flare, par- ticularly for first time mothers. Breastfeeding and medication safety is another consid- eration. Postpartum complications such as wound infection may delay re-institution of RA medications. Methods Upon commencement of a multidisciplinary Rheumatology and Reproductive Health Service, a systematic approach to prescribing anti-rheumatic drugs in women of childbear- ing age was required. Thus, the published UPDATED PHARMACOLOGICAL MANAGEMENT OF RHEUMATOID ARTHRITIS FOR WOMEN BEFORE, DURING, AND AFTER PREGNANCY, REFLECTING RECENT GUIDELINES 10