Friday, 16 Nov 2018

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Pregnancy and Contraception in Patients with Rheumatic Diseases

A number of abstracts at this year’s ACR in Chicago highlighted issues around pregnancy and contraception advice in routine clinical practice.

Azzouqah et al (Abstract 2653) examined the records of 131 women and found that 61% had contraceptive use documented in the medical records . Of patients taking teratogenic drugs, 67% had contraceptive use documented. Notably, more than 50% of patients taking potentially drug were not taking reliable contraception (abstinence, condoms) and 6% were using no contraception.

In a similar study, Payne et al (abstract 2418) surveyed 74 patients with a range of rheumatic diseases and overall, 39% reported consistent use of contraceptives. In currently sexually active women, 47% reported consistent contraceptive use. Of the remaining 53% not using any birth control, 59% were taking a potentially teratogenic drug. The investigators then randomised patients to an educational intervention and found that the intervention improved knowledge about medication effects on fertility, pregnancy and breastfeeding. An important point to make is that amongst health psychologists it is well recognised that educational interventions may improve knowledge, but that does not necessarily translate to altered behaviours. With that in mind, it will be important to follow these women to identify if clear behavioural changes occur.

There may also be barriers to the physician asking patients regularly about fertility and contraception issues. Janiak et al (abstract 2419) performed a needs assessment amongst rheumatologists regarding their current practice on fertility and contraceptive advice. In this survey, whilst most rheumatologist were confident to discuss such issues, major barriers included insufficient time in consultations, feeling that the topic was out of their scope and challenges around knowing where to refer patients. The investigators then implemented a “One Key Question” programme anchored on the question “Would you like to become pregnant in the next year?” This question was used as a lead-in to further education according to the patient responses. Initial application showed increased documentation of pregnancy advice on the record. This “One Key Question” provides a prompt that facilitates a more detailed conversation about this important topic.

 

There is no doubt therefore that in spite of the widespread use of potentially teratogenic drugs in rheumatology, as well as the potential risks of pregnancy amongst some rheumatic diseases such as lupus; pregnancy planning and contraceptive advice can vary considerably in routine practice. There is also a disconnect between what the physician understands they have told the patient and what the patients actually takes from the consultation. These abstracts attempted to address the physician and patient side of the consultation to reduce barriers to discussing these issues, and to educate patients better. What is extremely important is that these changes lead to real behavioural changes both from healthcare providers and patients to reduce the risks associated with unplanned pregnancy in rheumatology practice.

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