Themes and elements relating to specific conception and pregnancy information for women with rheumatoid arthritis and their families
| Saying: Information that should be discussed by health professionals | Doing: Actions that should be undertaken by health professionals |
|---|---|
| Review of current medications in relation to safety during conception and pregnancy (100%) | |
Prior to conception and pregnancy, review current medication(s) and discuss:
| Provide guidance as to where to obtain reliable information about safety of medicines in pregnancy |
Where current medication(s) is (are) contraindicated for conception/pregnancy the following should be discussed with the patient:
| |
| Discuss impact of RA pathology on pregnancy and pregnancy on RA (100%) | |
| There are different scenarios regarding RA disease activity during pregnancy (eg, possible remission/low disease activity) | Discuss: RA-related pain management options during pregnancy |
| Conception may take longer compared with women who do not have RA | |
| There is a need to balance disease control with maternal and fetal health and safety | |
| RA may affect pregnancy and pregnancy may affect RA, and there are possible adverse outcomes where risks are identified (eg, prematurity) | |
| There are significant risks associated with active or uncontrolled RA for the mother and baby, especially irreversible joint damage and functional impairment | |
| Pregnancy may change a patient’s health outlook in the future | |
| The size of the baby may be smaller than women without RA and may also be delivered pre-term | |
| Discuss important elements of preconception care relevant to patient (97.1%) | |
| It is important to achieve optimal disease control prior to considering pregnancy—planning conception is preferable after patients achieve and maintain low disease activity | Encourage and facilitate early discussions with all health practitioners involved in care about family planning to allow for adequate preparation |
| There is a critical need for a planned pregnancy rather than an unplanned pregnancy | Review prenatal nutrition, including need for dietary/vitamin supplements (ie, folic acid, calcium, vitamin D, iodine, iron) |
| History of previous attempts to conceive/pregnancies or pregnancy-related complications (eg, miscarriage) and other relevant patient history (such as smoking/illicit drug use history, family history of hereditary issues) may affect pregnancy | Undertake relevant health checks such as immunisation status (eg, rubella, varicella, pertussis), sexually transmitted disease screening, pap test, screening for other autoimmune disorders that may impact on pregnancy |
| Weight management and appropriate exercise are very important | Consider the need for review of diabetes or impaired glucose tolerance if risk factors are present (eg, on steroid medication or overweight/obese) |
| It is important to manage comorbid conditions, such as diabetes and hypertension | |
| Some women may need to avoid conception during a flare | |
| RA disease activity may or may not improve with pregnancy and there is a likelihood of postpartum flares | |
| Importance of maintaining optimistic outlook and providing positive messages (97.1%) | |
| Pregnancy and breast feeding success rates are near normal in women with mild to moderate RA nowadays (where appropriate for the patient's clinical status) | |
| RA is not a barrier to pregnancy | |
| Strategies to address anxiety, stress and depression (if relevant) are important, such as mindfulness meditation | |
| Need for close monitoring of a patient prior to and during pregnancy, where indicated (94.1%) | |
| It is importance to have a healthcare team with expertise in autoimmune disorders for some women with RA | Determine the need for high-level obstetric care during a pregnancy (where indicated), including the need for anaesthetic input |
| Some women require closer monitoring of their pregnancy and this is usually proportional to disease activity, comorbidities and maternal history | Assess the requirements for any extra treatment or monitoring prior to, or during, pregnancy |
| It is important to develop a pregnancy plan, which includes different options for management of RA and support for different scenarios | |
| Vaginal delivery may not always be possible, depending on condition of the patient's hips. There are other possible options for delivery and positions | |
| Outline practical considerations and planning requirements for the patient in relation to pregnancy and postdelivery (94.1%) | |
| Support networks are important during and after pregnancy (particularly in relation to postnatal flares) | Develop a plan as to how to manage a pregnancy based on physical function |
| There are different pain management options for RA disease if medications are withdrawn during pregnancy | Develop a plan for equipment and services required to care for an infant |
| It is important to establish a skilled, general practitioner-led multidisciplinary team | Develop a postpartum management plan for medicines and physical therapies |
| In some situations, clinical psychologists play an important role | Assess the need for physiotherapy and occupational therapy assessment/review and support in terms of managing physical tasks associated with caring for a baby |
| There is a need for contraception after delivery if taking medications that may be harmful to the fetus | Assess physical ability to manage pregnancy, motherhood and family life |
| Explore patient's wishes regarding a birth plan | |
| Explore patient's breast feeding wishes and potential considerations for immediately after birth (eg, initial attachment, establishing lactation) and during postnatal period (eg, ability to hold baby and feed comfortably) | |
Six themes are listed with their supporting elements for ‘saying’ and ‘doing’. The proportion of panellists who supported or strongly supported each theme is identified in parentheses.
NSAID, non-steroidal anti-inflammatory drug.