A Multidisciplinary Care Pathway for a Rheumatology and Reproductive Health Service
K Murray, L Moore, C O’Brien, A Clohessy, C Brophy, O FitzGerald, E Molloy, AB Mongey, S Higgins, MF Higgins, P Minnock, FM McAuliffe and D Veale
Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin Rheumatology Department, University College Dublin and St. Vincent’s University Hospital, Dublin UCD Perinatal Research Centre, Obstetrics and Gynaecology, School of Medicine, University College Dublin National Maternity Hospital, Dublin
A multidisciplinary team (MDT) approach to pregnancy in women with rheumatic and musculoskeletal diseases (RMD) ensures best outcomes for mother and baby. RMD patients have previously expressed dissatisfaction about the information and care received. No standardised or national care pathway has been developed to guide clinicians with respect to RMD in pregnancy in general.
We developed and report initial results (2013-2016) of standardised reproductive care pathway .
This is a prospective observational study. 98 female RMD patients with reproductive health needs were assessed for age, diagnosis, medications, use of assisted reproductive technology and pregnancy outcomes. Through a literature review and our initial experience, an evidence based reproductive care pathway for women with RMD was established outlining management at each step of the patients’ journey from pregnancy planning to breastfeeding.
Ninety-eight patients were seen. Their diagnoses were rheumatoid arthritis (n=41), psoriatic arthritis (16), ankylosing spondylitis (8), SLE (7), JIA (5), fibromyalgia (5), granulomatosis with polyangitis (3), reactive arthritis (2), Behcet’s disease (2), Sicca syndrome (2), Takayasu’s arteritis (2), sarcoidosis (1), mixed connective tissue disease (1), systemic sclerosis (1).
88 of 98 women decided to have a baby. 76 babies were born to 62 mothers, three of whom used assisted reproductive technology. 49 women had one birth and 27 gave birth twice, including one set of twins. There were 12 miscarriages (11-1st trimester and 1-2nd trimester losses) and one perinatal death due to renal aplasia diagnosed in utero. There was one fourth degree vaginal tear.
24 women were on biologic DMARD therapy at conception. 10 discontinued in the first semester and 5 in the second trimester. 9 continued throughout pregnancy. At six weeks, breastfeeding rates were 28%.
These data show high levels of successful pregnancy outcomes. 70% of women who tried to conceive had a baby. 38% of patients on biologic DMARDS continued throughout pregnancy. There were comparable miscarriage rates with the general population (14% versus 20%) but lower breastfeeding rates (28% versus 55%).