How do we manage difficult discussions about pregnancy in RA? Save

Most rheumatologists know that it is important to get pregnancy planning right for women of childbearing age living with rheumatic diseases. That is easier said than done, though: the details are difficult, it is overwhelming for the patient, and the conversations are hard.

We know that we need to communicate well with the patient and her whole team, so that details are not lost, but often that has been time-consuming at best and fraught at the worst. The upshot is that outcomes for these women and their babies have simply just not been as good as they could be - even at the best centers, only 39% of SLE patients have a healthy term, and RA patients do worse than the general population too. The pregnancy losses, the preterm births, the complicated pregnancies - they are some of the most stressful moments our patients will face, with long-lasting mental scars to add to the physical.

To have healthy mothers and babies, we need several things: good planning, pregnancy compatible medicines, and controlled rheumatic disease. Better processes will improve that preparation, and that’s one thing that Dr. Megan Clowse of Duke University has been working on. At the ACR Convergence 2023 Review Course in San Diego, she outlined some work being presented later in the conference that will support that, and shared some free new resources that she and her team have developed that can elevate all of our practice.

One of the biggest issues with pre-pregnancy counselling is that not everyone who gets pregnant had necessarily planned to get pregnant - and the patients who do not plan, do far worse. In data from Duke that will be presented in an oral abstract session on Monday (ABST1684), only 50% of pregnancies were both intended and medically optimized, and even after adjusting for marital status, low income, and Medicaid/Medicare status, those patients had three times fewer preterm births and preeclampsia.

Another related poster on Monday (ABST1354) shows that depression and quality of life suffer when patients get pregnant when they are not personally ready, and clinicians report higher disease activity when patients who are not medically ready get pregnant. For these reasons, patients need to be personally ready and medically ready, but how do we have these conversations when they may not be thinking about pregnancy at all?

A big part of the solution might be the discussion guides which Dr. Clowse and her team have developed for free use, which help to structure and document collaborative conversations efficiently - giving providers the right information at their fingertips, and give patients consistent information to take with them. New reproductive discussion guides have recently been released at reprorheum.duke.edu, and Dr. Clowse will discuss the process behind their development on Monday (ABST1683).

Alongside a plethora of other useful information, two discussion guides help providers talk with patients about the two sides of the coin: inflammatory arthritis and pregnancy for those who are ready, and birth control and rheumatic disease for those who are not. These guides not only are designed to structure effective conversations efficiently and to be easy to understand, they also provide consistent advice to distribute between other members of the treating team.

For women of childbearing age living with RA and other rheumatic diseases, these guides will help provide clarity in a space where ambiguity creates anxiety and poor medical outcomes. They also help support previous efforts from Dr. Clowse’s team from recent years, including the free HOP-STEP website released in 2021 (http://lupuspregnancy.org/), aimed at lupus patients to provide similar clarity and management steps for common situations for lupus and pregnancy.

Such efforts should be in every rheumatologist’s toolbox - because the quality of these conversations have just as big ramifications for our patients as any other part of their care.

REPRO Rheum Duke: https://reprorheum.duke.edu/