Ideal Clinical Pathway Improves Pregnancy Outcomes in RA

By Reuters Staff

January 22, 2020

NEW YORK (Reuters Health) - Women with rheumatoid arthritis (RA) who adhere to an ideal clinical pathway have similar pregnancy outcomes as women in the general population, new findings show.

Less adherent RA patients had worse pregnancy outcomes, Dr. Carlo Alberto Scire of the University of Ferrara in Cona, Italy, and colleagues found. "Our findings suggest the adherence to an ideal clinical pathway should be strived for as much as possible in order to offer the best possible chances for a successful pregnancy to women with RA," they conclude in their report in Arthritis Care & Research.

A growing number of women with RA are achieving remission and starting families, Dr. Scire and his team note, but almost half will have disease flares during pregnancy.

"Therefore, it has become critical to provide a tool for risk stratification and develop uniform management plans to improve favorable pregnancy outcomes among women with RA," they write. "Preconception counseling should include evaluation of maternal disease activity, modification of treatment, and assessment of general obstetric risk factors as performed in routine obstetric care."

Dr. Scire and his team developed a set of seven healthcare quality indicators (HCQI) for pregnancy in RA, based in part on guidance for other rheumatic diseases. They grouped the indicators into three pathways: diagnostic (blood lab tests, musculoskeletal imaging, antiphospholipid antibody testing, antinuclear antibody or anti-ENA testing); therapeutic (no exposure or washout of methotrexate/leflunomide, no exposure to biological disease modifying antirheumatic drugs); and prenatal follow-up (at least one rheumatological visit).

They analyzed HCQI for first pregnancies in 443 RA patients (including 141 who received care that adhered to the clinical pathway), and 6,097 general population controls.

There were 157 cases with adverse pregnancy outcomes among women with RA and 1,809 in the general population, and 115 and 1,360 cases of miscarriage and perinatal death, respectively.

The most adherent patients were less likely to receive no treatment (39.7% vs. 65.9%), and more likely to be on glucocorticoids (40.4% vs. 20.2%) or hydroxychloroquine (41.1% vs. 14.6%).

Being on the ideal clinical pathway was associated with a 40% lower adjusted risk of overall adverse pregnancy outcomes and a 60% lower risk of miscarriage and perinatal death.

Compared to the general population, the most adherent RA patients had similar risks of adverse outcomes (OR 0.92) and miscarriage or perinatal death (OR 0.77).

"The significant association between the ideal therapeutic pathway with the outcomes of the study suggests that the women who were not adherent were also not properly treated for their RA," Dr. Scire and colleagues write. "This reinforces the importance of adjustment of therapy for RA before conception and throughout pregnancy, because medication use could affect pregnancy course not only influencing maternal disease activity but also the gestational outcome."

The study was supported by the Italian Society for Rheumatology.

Dr. Scire did not respond to an interview request by press time.

SOURCE: Arthritis Care & Research, online January 7, 2019.