RA and Pregnancy. What are the risks?

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From: The Rheumatologist, April 2015

Rheumatoid Arthritis and Pregnancy
by Richard Quinn

New research from a team in Denmark shows patients of reproductive age with rheumatoid arthritis (RA) require special attention—beyond the routine check for medication contraindications—during the prenatal process.

The first-of-its-kind research, published online in December in Arthritis & Rheumatology, looked at nearly 2 million children born in Denmark between 1977 and 2008, and found more than 13,000 children exposed to either maternal RA or maternal preclinical RA.1 Children exposed to maternal RA (n=2,101) were at approximately 50% higher risk of preterm birth; those exposed to maternal preclinical RA were at approximately 30% increased risk of preterm birth. Researchers found no association with paternal RA, and found only small differences in fetal biometry.

“Preterm birth is a well-known risk factor for a variety of adverse health outcomes in children, both short and long term,” says lead author Ane Rom, MPH, a reproductive epidemiologist in the Women’s and Children’s Health research unit at Copenhagen University Hospital. “Whether these children are at increased risk of adverse health outcomes later in life due to reduced fetal growth, we do not know.

“For women with RA who are—or hope to become—pregnant, our research underlines the importance of attending prenatal care with the overall aim to prevent preterm birth.”

Background
RA afflicts approximately 1% of the adult population worldwide, and the CDC estimates 1.5 million Americans have RA.2,3 Past studies, according to Ms. Rom, have associated rheumatic diseases with a number of pregnancy complications. This study is the first to look specifically at mothers diagnosed with RA. Data from the ACR show women are three times as likely to have RA as men.4

Although no evidence suggests babies born to mothers with RA will be any less healthy, rheumatologists now have research to back up what they have been telling their patients for decades.

Ms. Rom
Ms. Rom
“A lot of patients get better clinically during pregnancy, which is probably related to a hormone or hormones they produce during this time. Because many of the patients have less disease activity and are off RA medications, we tend to see these patients less often,” says Scott Zashin, MD, a private practice rheumatologist in Dallas and clinical professor of medicine at the University of Texas Southwestern Medical School.5 “Many patients are on medications and are doing well. But now, if they ask questions—such as ‘Is it safe for me to get pregnant?’—now we can tell them they might have a higher risk of preterm delivery.

“I don’t think it’s anything that is earth shattering, or that patients need to do anything different. But I do think pregnant [RA] patients should let their obstetricians know that they have RA and that this is a possibility.”

Tell Your Patients
The new information is something high-risk obstetrician Jeff Ecker, MD, wants his patients to communicate. He says the research confirms “a notion that had been supported by some data previously,” and is a step in the right direction for patients, rheumatologists and obstetricians.

“We recognize that whenever there is inflammation in the body, whether it stems from an infection or lupus or RA, that there is a cascade that starts that can sometimes provoke preterm labor and delivery,” says Dr. Ecker, director of the maternal fetal medicine fellowship at Massachusetts General Hospital in Boston, and chair of the American College of Obstetrics and Gynecologists’ Committee on Obstetric Practice. “I think this information is very important. The more we can do to start out with a healthy mom, the better.”

Ms. Ecker
Ms. Ecker
Dr. Ecker says that although the study results do not seem overly concerning, he notes that some women with RA may find the increased risks alarming. He says, for that reason, rheumatologists should add this information to their “normal” conversations with women of reproductive age.

“For women with RA who want to become pregnant, a visit in advance of pregnancy to consider these risks, and to consider their course and medications they are taking, is ideal,” he says. “These risks do not seem enormous to me, but there might be some out there that say, ‘Oh my, I’m at this higher risk for preterm labor and delivery. Nope, I’m not going to get pregnant.’ It’s better for them to understand that in advance than for me to be seeing them at 15 weeks and the patient saying, ‘Oh, I wish I had known that.’”

What it all comes down to is a better-informed patient, he adds.

“For women [who] don’t want to become pregnant, because their RA is active or their meds are not great to use in pregnancy, or they just don’t want to be pregnant because of these risks, rheumatologists need to be certain that women of reproductive age, who don’t want to be pregnant, particularly if they have active disease, are using appropriate birth control,” he adds. “We should avoid the, ‘Oh, I really didn’t want you to get pregnant because I am treating you with this drug or your disease is really active, and, oops, now you are pregnant.’”

Future Implications
More importantly, this study gives rheumatologists a starting point to “look further into the health of babies of RA patients,” according to Dr. Zashin.

“Let’s follow these kids over time and see if they have an increased risk of problems compared to those that weren’t premature,” he says. “That is the more important study.”

Ms. Rom says her research team is working on a follow-up study examining morbidity among the same cohort of children, “since little is known about the impact of maternal RA on long-term health among the children.”

“We still need to investigate whether children of mothers with RA are at increased risk of adverse health later in life,” she says. “This is only possible to examine in large-scale, epidemiological studies where children are followed for many years.”

Richard Quinn is a freelance writer in New Jersey.

References
Rom AL, Wu CS, Olsen J, et al. Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: A nationwide cohort study. Arthritis Rheumatol. 2014 Dec;66(12):3265–3273.
Markenson JA. Worldwide trends in the socioeconomic impact and long-term prognosis of rheumatoid arthritis. Semin Arthritis Rheum. 1991 Oct;21(2 Suppl 1):4–12.
Centers for Disease Control and Prevention. Arthritis-related statistics. Updated March 17, 2014. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm#1
The American College of Rheumatology. Rheumatoid Arthritis. http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.
Hazes J, Coulie P, Geenen V, et al. Rheumatoid arthritis and pregnancy: Evolution of disease activity and pathophysiological considerations for drug use. Rheumatology (Oxford). 2011 Nov;50(11):1955–1968.
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