Women with Rheumatoid Arthritis have similar rates of postpartum maternal outcomes compared to women without autoimmune disease (2022)

Table of Contents
Seminars in Arthritis and Rheumatism Abstract Objective Methods Results Conclusion Introduction Section snippets The Synthetic Derivative Deliveries to control mothers Discussion Conclusions Declaration of Competing Interest Acknowledgements Financial Support References (37) Am J Obstet Gynecol J Allergy Clin Immunol Reprod Toxicol J Allergy Clin Immunol Semin Arthritis Rheum Am J Obstet Gynecol Rheumatoid arthritis in women. Incidence rates in group health cooperative, Seattle, Washington, 1987-1989 Arthritis Rheum Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study Arthritis Rheum Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: a nationwide cohort study Arthritis Rheumatol The new FDA labeling rule: impact on prescribing rheumatological medications during pregnancy Rheumatology (Oxford) Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis Arthritis Rheum High rate of preterm birth in pregnancies complicated by rheumatoid arthritis Am J Perinatol Pregnancy outcomes in women with rheumatoid arthritis: a retrospective population-based cohort study J Matern Fetal Neonatal Med Canadian pregnancy outcomes in rheumatoid arthritis and systemic lupus erythematosus Int J Rheumatol Patterns of prednisone use during pregnancy in women with rheumatoid arthritis: daily and cumulative dose Pharmacoepidemiol Drug Saf Development of a large-scale de-identified DNA biobank to enable personalized medicine Clin Pharmacol Ther MedEx: a medication information extraction system for clinical narratives J Am Med Inform Assoc Extracting and standardizing medication information in clinical text - the MedEx-UIMA system AMIA Jt Summits Transl Sci Proc Cited by (0) Recommended articles (6) Videos
ScienceDirect

Corporate sign inSign in / register

ViewPDF

  • Access throughyour institution

Seminars in Arthritis and Rheumatism

Volume 53,

April 2022

, 151975

Abstract

Objective

Limited data exist on the effect of rheumatoid arthritis (RA) on maternal postpartum outcomes. Using a real-world, electronic health record (EHR) cohort, we assessed maternal postpartum outcomes in RA.

Methods

In a large, de-identified EHR, we identified possible RA deliveries using ≥1 delivery ICD-9 or ICD-10-CM codes and a validated RA algorithm. RA cases were required to be diagnosed by a rheumatologist on chart review. Maternal postpartum outcomes included rates of blood transfusion, rates of infection up to 6 weeks postpartum defined by a clinician, and length of hospital stay. We also identified deliveries to women without autoimmune diseases.

Results

We identified 202 deliveries occurring after RA diagnosis and 596 deliveries to controls without autoimmune diseases. Postpartum infection rates were similar among RA patients and controls (8% vs. 4%, p=0.10), as were red blood cell transfusion rates (2% vs. 2%, p=1.00). RA case status was not significantly associated with postpartum infection (OR=2.10, 95% CI 0.88 – 4.98, p=0.09) but was significantly associated with preterm birth (OR=2.11, 95% CI 1.38 – 3.23, p=0.001). Corticosteroid use during pregnancy was common at 41%, while tumor necrosis factor inhibitor use was 13%. After adjusting for age at delivery and race, corticosteroid use at delivery was not associated with postpartum maternal infections but was associated with a significantly lower birthweight in RA cases.

Conclusion

Women with RA have an increased risk of adverse pregnancy outcomes, particularly preterm birth. Our study highlights, however, that maternal postpartum outcomes such as postpartum infection and blood transfusion are not significantly increased in RA patients.

(Video) DocTalks: Dr. Janet Pope - What you Need to Know About Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic, autoimmune disease commonly affecting females of child-bearing age [1]. Studies on birth outcomes to women with RA are limited and conflicting. Some studies indicate that women with well controlled RA have birth outcomes similar to the general population [2]. In contrast, other larger studies have noted higher rates of preterm birth, preeclampsia, eclampsia, and cesarean section [3], [4], [5], [6], [7]. There is a gap, however, in studies assessing maternal postpartum outcomes such as postpartum infections, rates of blood transfusion, and length of hospital stay in RA. One small study of 38 patients noted that infection rates in RA were no different than controls [8], but a larger administrative database study found an increased risk for wound complications and venous thromboembolism in women with RA [7].

Similarly, there is a lack of robust data on the effect of RA medications on maternal postpartum outcomes. Specifically, the effect of corticosteroid use on pregnancy outcomes in RA has been controversial. While historically prednisone use had been deemed relatively safe in pregnancy, recent studies show that prednisone use, even at low doses, may be associated with preterm birth [2,9]. Contemporary studies, however, have not investigated the effect of corticosteroid use on maternal postpartum infections.

Electronic health records (EHRs) provide an efficient and cost-effective method to study deliveries to RA patients. These methods can more quickly amass a larger sample compared to single-center, prospective cohort studies. Further, EHR-based studies have longitudinal, dense data that is more comprehensive than administrative database studies and allow for chart review for accurate phenotyping. Using a large, de-identified EHR and validated phenotypes for RA and deliveries, we assembled a cohort of RA deliveries. We assessed the impact of demographics, RA disease characteristics, and RA medications on maternal postpartum outcomes including infection, blood transfusions, and length of stay.

Section snippets

The Synthetic Derivative

Following approval from the Institutional Review Board of Vanderbilt University Medical Center (VUMC), we used a de-identified version of VUMC's electronic health record (EHR) called the Synthetic Derivative. The Synthetic Derivative contains clinical information on over 3.2 million unique patients since 1990 [10]. VUMC's patient population draws from a large area of the southern United States and is a key tertiary care center in the region. The Synthetic Derivative contains all available EHR

Deliveries to control mothers

We initially identified 250 control mothers and excluded 2 mothers with missing delivery data and 24 mothers with autoimmune diseases discovered on chart review resulting in 224 deliveries. A list of the autoimmune diseases in the controls is included in Supplemental Table 3 with the most common conditions being type 1 diabetes (n=9), ulcerative colitis (n=5), and Hashimoto's thyroiditis (n=3). We then analyzed 224 control mothers with 596 pregnancies. Mean age at delivery was 27±7

Discussion

In a large, real-world EHR study of RA and control deliveries, we examined maternal postpartum and delivery outcomes. Rates of maternal postpartum infection and blood transfusion were similar in RA compared to control deliveries, while mean but not median length of stay was significantly longer in RA deliveries. Limited data exists on maternal postpartum outcomes in RA. Our results provide reassuring data for certain postpartum outcomes and provides additional data on the risk of

Conclusions

In conclusion, women with RA have an increased risk of adverse fetal outcomes such as preterm birth, lower birthweight, and shorter gestational age. Our study, however, provides reassurance that maternal outcomes such as postpartum infection and blood transfusion may not be adversely affected. Corticosteroid use at time of delivery increased the risk of lower weight babies and postpartum infections in RA mothers, while TNF inhibitor use did not. Given this information, rheumatologists should

Declaration of Competing Interest

None.

Acknowledgements

None.

Financial Support

This work was supported by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (1K08 AR072757–01, Barnado); National Institutes of Health/National Center for Research Resources (UL1 RR024975, VUMC); National Institutes of Health/National Center for Advancing Translational Sciences (ULTR000445, VUMC); the Rheumatology Research Foundation (K Supplement Award, Barnado).

References (37)

  • E.F. Chakravarty et al.Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus

    Am J Obstet Gynecol

    (2005)

  • L.N. Bakhireva et al.Asthma medication use in pregnancy and fetal growth

    (Video) Pregnancy and Autoimmune Disease

    J Allergy Clin Immunol

    (2005)

  • C. Gur et al.Pregnancy outcome after first trimester exposure to corticosteroids: a prospective controlled study

    Reprod Toxicol

    (2004)

  • M. Schatz et al.The relationship of asthma medication use to perinatal outcomes

    J Allergy Clin Immunol

    (2004)

  • S. Kishore et al.Obstetric outcomes in women with rheumatoid arthritis: results from nationwide inpatient sample database 2003-2011

    Semin Arthritis Rheum

    (2019)

  • S. Yasmeen et al.Accuracy of obstetric diagnoses and procedures in hospital discharge data

    Am J Obstet Gynecol

    (2006)

  • C.E. Dugowson et al.

    Rheumatoid arthritis in women. Incidence rates in group health cooperative, Seattle, Washington, 1987-1989

    Arthritis Rheum

    (1991)

  • Y.A. de Man et al.

    Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study

    Arthritis Rheum

    (2009)

  • A.L. Rom et al.

    Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: a nationwide cohort study

    Arthritis Rheumatol

    (2014)

  • B.L. Bermas et al.

    The new FDA labeling rule: impact on prescribing rheumatological medications during pregnancy

    Rheumatology (Oxford)

    (2018)

  • E.F. Chakravarty et al.

    Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis

    Arthritis Rheum

    (2006)

  • E.S. Langen et al.

    High rate of preterm birth in pregnancies complicated by rheumatoid arthritis

    Am J Perinatol

    (2014)

  • H. Aljary et al.

    Pregnancy outcomes in women with rheumatoid arthritis: a retrospective population-based cohort study

    J Matern Fetal Neonatal Med

    (2020)

  • C. Barnabe et al.

    Canadian pregnancy outcomes in rheumatoid arthritis and systemic lupus erythematosus

    Int J Rheumatol

    (2011)

  • K. Palmsten et al.

    Patterns of prednisone use during pregnancy in women with rheumatoid arthritis: daily and cumulative dose

    Pharmacoepidemiol Drug Saf

    (2018)

    (Video) Rheumatoid Arthritis and Systemic Lupus Erythematosus Webinar

  • D.M. Roden et al.

    Development of a large-scale de-identified DNA biobank to enable personalized medicine

    Clin Pharmacol Ther

    (2008)

  • H. Xu et al.

    MedEx: a medication information extraction system for clinical narratives

    J Am Med Inform Assoc

    (2010)

  • M. Jiang et al.

    Extracting and standardizing medication information in clinical text - the MedEx-UIMA system

    AMIA Jt Summits Transl Sci Proc

    (2014)

  • Cited by (0)

    Recommended articles (6)

    • Research article

      Impact of the number of comorbidities on the outcome measures and on the retention rate of the first anti-TNF in patients with Ankylosing Spondylitis. Two-year follow-up in REGISPONSER-AS

      Seminars in Arthritis and Rheumatism, Volume 52, 2022, Article 151938

      To evaluate the impact of the number of comorbidities on the outcome measures after two years of follow-up in patients with Ankylosing Spondylitis (AS) and to determine whether the number of comorbidities influences the retention rate of the first anti-TNF.

      This was an observational and prospective study conducted during 2 years of follow-up in the REGISPONSER-AS registry. The patients were divided into three groups according to the number of comorbidities at baseline (0, 1 or ≥2). Linear regression models adjusted for disease duration, age, sex and smoking were constructed to evaluate the association between the number of comorbidities and the Patient Reported Outcomes (PRO) scores. The impact of the number of comorbidities on PROs over two years of follow-up was evaluated using mixed models for repeated measures adjusted for disease duration, age, sex and smoking. Finally, the retention rate of the first anti-TNF antibody across the three groups was evaluated using a log-rank test.

      Patients with two or more comorbidities showed higher scores at baseline and during the two years of follow-up for the Global VAS, BASDAI, ASDAS, and BASFI and worse scores for the physical component of the SF12. A higher probability of discontinuation of the first anti-TNF was found in patients with 2 or more comorbidities compared with the patients in the other groups (38.2% vs. 26.6% vs. 25.4% for ≥2 comorbidities, 0 and 1 comorbidity, respectively), although these differences were not significant (log-rank test: p-value=0.180).

      In patients with AS, the presence of 2 or more comorbidities was associated with worse scores on the outcome measures test after two years of follow-up and a greater tendency of discontinuation for the first anti-TNF.

    • Research article

      Macrophage activation syndrome in pediatric Sjögren's syndrome

      Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151977

    • Research article

      Comment on "Macrophage activation syndrome in pediatric Sjögren's syndrome”

      Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151976

      (Video) Let's Talk - How Autoimmune Diseases Affect Women and Men Differently
    • Research article

      Variations in Takayasu arteritis characteristics in a cohort of patients with different racial backgrounds

      Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151971

      We aimed to describe differences in disease characteristics and outcomes in Takayasu arteritis (TA) patients with different racial backgrounds.

      This was a retrospective cohort study consisting of TA patients seen at specialty vasculitis clinics from five academic hospitals across Canada. Disease features, treatments and outcomes were compared between White and non-White patients.

      The cohort included 113 patients, of which 51 were White. Over 50% of the non-White patients were Asian. Compared to non-White patients, White patients had higher CRP and ESR at diagnosis (33.6mg/l versus 9.4mg/l, p=0.033; and 51mm/h versus 24mm/h, p=0.047; respectively), and were less likely to have baseline cardiovascular comorbidities including dyslipidemia (11.8% versus 29%, p=0.037). There were no significant differences between racial groups for other disease characteristics or outcomes.

      Patient race did not appear to play a significant role in determining disease characteristics and outcomes when comparing TA patients from various racial backgrounds living in the same country.

    • Research article

      Effects of patient and disease characteristics on global functioning in patients with axial spondyloarthritis in routine care

      Seminars in Arthritis and Rheumatism, Volume 55, 2022, Article 152006

      The ASAS Health Index (ASAS HI) was developed to assess global functioning in patients with axial spondyloarthritis (axSpA). Influencing factors have not been studied to date, especially the influence of inflammation and structural changes in the spine has remained unclear to date.

      To find out whether and to what degree do axial inflammation, radiographic damage and other clinical features influence global functioning of patients with axSpA.

      Patient reported outcomes (ASAS HI, pain, BASDAI, BASFI, EQ-5D and SF-36) were assessed, spinal mobility by BASMI and depression by SF-36 scores. Axial inflammation was quantified using the MRI Berlin score and structural damage as detected by conventional radiographs by the modified Stokes AS Spinal Score (mSASSS). Correlation and regression analyses were performed to analyze the association between global functioning and other variables.

      A total of 191 axSpA patients with different degrees of global functioning and disease activity was included, 60.2% had r-axSpA. Syndesmophytes were found in 38.5% of patients - with a median mSASSS score of 3.8 (IQR 1.0-18.7) in r-axSpA and 0.0 (IQR 0.0-1.2) in nr-axSpA patients. The mean MRI score was 2.3 (IQR 0.5-7.6). ASAS HI values correlated significantly with BASMI, BASDAI, BASFI, BMI and MRI scores. However, no significant correlation was found for mSASSS and CRP. Regression analyses revealed that global functioning was significantly influenced by disease activity, physical function, obesity and depression but not by structural damage or spinal inflammation as detected MRI.

      Our study shows that global functioning is strongly associated with physical function, body weight and depression in patients with axSpA but not with spinal inflammation and structural damage. This may be explained by the relatively low mSASSS of these well treated patients.

    • Research article

      The incidence and risk factors for venous thromboembolic events in patients with psoriasis and psoriatic arthritis

      Seminars in Arthritis and Rheumatism, Volume 53, 2022, Article 151950

      (Video) 11/30/2016: Rheumatoid Arthritis: RA and Reproductive Health

    View full text

    © 2022 Elsevier Inc. All rights reserved.

    Videos

    1. Rheumatoid Arthritis and the Female Patient, Reproductive Health Considerations
    (Association of Reproductive Health Professionals)
    2. Rheumatoid Arthritis: Recent Concepts and New Trends in Therapy
    (RWCS)
    3. Interview with Cardiologist Dr. Monica Aggarwal: Rheumatoid Arthritis and Plant-based Diets
    (Vegan with Jenn)
    4. Reproductive Health in Myositis and Other Autoimmune Diseases 8 5 19
    (Myositis Association)
    5. RNL 2022: Rheumatoid Arthritis - Best Management
    (RheumNow)
    6. Women and girls with RHD and pre-pregnancy care planning for woman with RHD
    (RHDAustralia)

    You might also like

    Latest Posts

    Article information

    Author: Terrell Hackett

    Last Updated: 09/11/2022

    Views: 5543

    Rating: 4.1 / 5 (72 voted)

    Reviews: 95% of readers found this page helpful

    Author information

    Name: Terrell Hackett

    Birthday: 1992-03-17

    Address: Suite 453 459 Gibson Squares, East Adriane, AK 71925-5692

    Phone: +21811810803470

    Job: Chief Representative

    Hobby: Board games, Rock climbing, Ghost hunting, Origami, Kabaddi, Mushroom hunting, Gaming

    Introduction: My name is Terrell Hackett, I am a gleaming, brainy, courageous, helpful, healthy, cooperative, graceful person who loves writing and wants to share my knowledge and understanding with you.