Ep 53: Approaches to pregnancy in the rheumatology clinic

Aligning with International Women's Day, join host Jess Little in conversation with experts Dr Oseme Etomi & Dr Beth Goulden. This episode explores how to support women with inflammatory musculoskeletal (MSK) disease through pregnancy — from pre-conception counselling to postpartum care.

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Transcript

You're listening to the talking rheumatology spotlight podcast brought to you by the British Society for Rheumatology. 

Hello, and welcome to this special spotlight on women's health from the British Society of Rheumatology. I'm your host, Jessica Little, an MSK physiotherapist with an interest in women's health. And today we're focusing on a topic that sits at the heart of modern rheumatology care, supporting women with inflammatory MSK conditions throughout pregnancy. Pregnancy can be an exciting yet deeply complex time for women living with inflammatory MSK conditions. These are conditions that do not press pause during pregnancy. And for many women, navigating the toll medications, fertility, flare risk, the ins and outs of pregnancy itself, and then that postpartum recovery can feel really daunting. So in this episode, we'll be unpacking the key considerations across the entire reproductive journey from pre pregnancy planning and contraception to managing disease safely during pregnancy and to the realities of that postpartum period. When women often find themselves at their most vulnerable. Our aim is clarity, compassion and some evidence based guidance to an area where good information can make an enormous difference to outcomes. I am delighted to be joined by two fantastic experts in the field. Today we have Dr Oseme Etomi and Dr Beth Goulden, who brings specialist expertise in rheumatology, pregnancy and women's health. To get going, we're gonna hand over to our experts to do a little bit of an introduction to themselves.

00:01:52 [Speaker 2]

Bethan, can I get you to do it first for us?

00:01:55 [Speaker 2]

Okay.

00:01:56 [Speaker 3]

Of course hi there, so yeah I'm a Rheumatology Reg in London but I've also done the Perioperative Medicine Fellowship at UCLH years back.

00:02:03 [Speaker 2]

I'm currently doing my PhD on pregnancy and rheumatoid arthritis funded by Arthritis UK and I also lead a national study of HLH so hemophagocytic lymphohistiocytosis in the pregnancy and the postpartum. So pleased to be joining you.

00:02:19 [Speaker 2]

Amazing thank you so much and Oseme.

00:02:23 [Speaker 4]

Hello, my name is Oseme Etomi, I'm a consultant rheumatologist and an obstetric physician and I work, across South East London at Guy's and St Thomas's and also at the Queen Elizabeth's in Woolwich. I look after women through all the stages of pregnancy both in the rheumatology side and also in the obstetric side, and so excited to join in today.

Thank you both.

00:02:48 [Speaker 2]

Thought we'd kick off with that pre pregnancy phase. When a woman with an inflammatory and risky disease comes into clinic and says that she's thinking about pregnancy, what are the first things that you want her to know before she starts to try and conceive?

00:03:07 [Speaker 4]

I always try to start on a positive, so the first thing I always say to these patients is that it is possible, you know if that's your desire then this is possible, And the second thing I always want them to know is that their disease is only a barrier to pregnancy if it's not controlled, so it's really important as the first step that we get the disease under control and that then sort of allows me to sort of open up the conversation about medication saying that many of the medications that we prescribe are compatible and we just have a full think about, you know, how to get your disease under control with medications that are compatible.

00:03:47 [Speaker 4]

And we just need to do it together.

00:03:50 [Speaker 2]

That sounds good.

00:03:51 [Speaker 2]

Is there any stage in a woman's journey with her rheumatology condition that this will be brought up? Is it always waiting until the patient brings it up or is this something that would be discussed with a female if she if she got that diagnosis?

00:04:06 [Speaker 4]

Yes.

00:04:07 [Speaker 4]

So I think it's really important right from diagnosis to open that conversation up because what that allows is there's this open door because a lot of ladies when I when I talk about family planning they look at me and they think I'm crazy, you know, they're in the throes of life, they're young and that's the last thing on their mind, but as long as you can signpost that at some point your plans might change, then this door is always open and as long as we have these conversations then it is safe, it is possible, and it is.

00:04:44 [Speaker 4]

I think the other thing to say is that even if you're not planning a family, if you're sexually active then that is possible, and so even if it's not in your life plans and you want to talk about it, if you're sexually active potentially you might become pregnant at some point, so again even if it's not in someone's life plan I think it's important to have that conversation so that they're aware of how to avoid an unplanned pregnancy.

00:05:11 [Speaker 2]

Definitely.

00:05:12 [Speaker 2]

Bethan, is there things that females will come in around fertility or around some misconceptions that they've maybe heard before or anything that they want clarity on?

00:05:27 [Speaker 3]

I think that the common misconception is the assumption that medications are going to be unsafe and I think that partly comes from when they've had these conversations. For many women the only time that pregnancy is brought up with them is in the context of this is a medication where you shouldn't get pregnant, so I personally have lots of positive messaging, exactly as Oseme says when I see women I will always just touch base on where they are in terms of thinking about pregnancy and if it's just a quick glance then there's to say well what you're on currently is safe, your disease is well controlled so that's a really good place and that reiteration of well controlled disease and pregnancy compatible therapies throughout their disease course means that having the conversation with them when they're pregnant is so much easier. And I think exactly as Oseme said that, obviously, as common, UK government data would suggest that forty five percent of UK pregnancies are unplanned or associated with feelings of ambivalence.

00:06:27 [Speaker 3]

And as such we can't just put this message forward to the women who approached us wanting pregnancy and certainly in our own units the way that we are trying to tackle that currently is to just have pregnancy information evenings. We run them three times a year, we do that via Teams, we have representation from rheumatology, rheumatology nurses, experts, and we just talk them through what pregnancy might look like and I think it's really helpful both for those women who are actively thinking about a pregnancy and also for those who just want to know what the future might look like.

Oh that's amazing and is there any like kind of national resources available for women that they can tap into and have a look at?

00:07:08 [Speaker 3]

And there's lots of good information out there but I think that can be a real problem when it comes to pregnancy, particularly around medication safety as most package inserts that they're going to look at will not say that the medication is safe to use.

00:07:22 [Speaker 3]

In terms of, I think, good starting websites, that it's actually not a UK website, but in terms of there's an American website for a university called Duke, there's one called ReproRoom and they also do one called Lupus Pregnancy and these both have excellent resources both for patients and for clinicians including decision aids and almost cheat sheets on contraception and safe pregnancy and medication use, which I think are excellent starting points and of course the BSR pregnancy and prescribing is a fantastic starting point and I think with with a bit of orientation actually it can also be something that could be useful for patients themselves to have a look at as well as websites such as Arthritis UK which also touch on pregnancy.

00:08:07 [Speaker 3]

I don't know if you have any others Oseme

00:08:09 [Speaker 4]

I think those are the main ones actually.

00:08:11 [Speaker 2]

Amazing that's fantastic.

00:08:13 [Speaker 2]

So if we move from that phase with a woman considering this or maybe thinking about her longer term plans to a patient who is now in clinic, they have become pregnant.

00:08:26 [Speaker 2]

What do you see as like the biggest myths among clinicians or patients about managing rheumatology disease safely during pregnancy?

00:08:35 [Speaker 2]

Beth let's come to you.

00:08:37 [Speaker 3]

I think once again it's often around medication use and safety.

00:08:41 [Speaker 3]

Many medicines are safe to use in pregnancy, cornerstone medications for us in our clinic would be hydroxychloroquine, sulfasalazine, azathioprine and the TNF inhibitor biologics, but actually many of the non TNF biologics can also be used with appropriate counselling and even for drugs that we might conventionally think of that shouldn't be using in pregnancy and I think the obvious one here is Cyclophosphamide, the reality is that the control of disease is absolutely vital and so if somebody is critically unwell with life or organ threatening disease, it's to just remember that actually often nothing is off the table at that point, and that in the context of multidisciplinary team discussions around the timing of delivery, alternative therapies, but, actually, there is an evidence base for the use of medicines such as Cyclophosphamide in the second or third trimester.

00:09:36 [Speaker 3]

And there is also a range of and tests that we can still run, in these individuals. So drawing in expertise from others, and don't don't assume that you can't do things or can't prescribe things in pregnancy. So that real MDT approach to to the more complex patient and is there anything within clinic that would be discussed with the female herself around flare management and reassurance, like wider than medication?

00:10:04 [Speaker 2]

So different things that they could maybe do and different approaches that they could take.

00:10:10 [Speaker 4]

I think obstetric medicine or obstetric rheumatology is not a black and white field. There is a lot of grey in what we do, and a big part of what we do is balancing and managing risk. So the most important principle for and it can be really scary because sometimes we are up against, sort of having to make treatment decisions without good evidence base, but I think the main principle that we choose is that disease control is key, and if you can optimize the woman's health, if you can optimize her disease, then overall, the outcomes are much better.

00:10:56 [Speaker 4]

So sometimes we are faced with minimal information, about the drug, you know, their newer and newer drugs that are coming out, but where, the disease is, affecting major organs, whereas is, life threatening, then we have to say that actually the use of certain treatments is more beneficial than not giving any treatments because that often makes poor outcomes for the woman and the, the foetus. So we try to have, balanced conversations with our patients and honest conversations with our patients and sort of and as Beth said in a multidisciplinary supported environment, to make some of these more difficult decisions.

So, Oseme, are there specific considerations and specific diseases during pregnancy that women or consultants looking after women should be thinking about?

00:11:56 [Speaker 4]

Yeah so when I'm thinking about women who are pregnant I I ask, you know, three main questions around their disease. Firstly, is their disease active or inactive? Secondly, what organs have been affected by their disease? And there's certain organs that would increase their risks in the pregnancy, so for example if they've had renal involvement, if they have a preexisting diagnosis of hypertension, then that can increase their pregnancy risks and certainly their risk of preeclampsia. The other thing I always think about is about their antibody profile, thinking about the risk of foetal heart block, so, two percent of patients with the antibody are at risk of developing foetal heart block, and we need to know that as a woman goes into the pregnancy because it guides how we manage them or monitor them. If you have those antibodies then we offer extra, scans, so we do foetal echoes, somewhere between twenty and twenty eight weeks, we repeat that, and you can then institute feeding listening for the foetal heart rate because that can be the first signs that something is wrong, and when the baby is born you have to remind the patients with the antibodies that five percent of them, so one in twenty, their children will develop a rash, and it can be quite widespread, it can be quite alarming, but the one thing is to remember that those antibodies might be the cause of that, so then these babies are not over investigated, And that they are and and so they can signpost to their clinician saying my rheumatologist told me that I have these antibodies and it might cause a problem with my baby. It's also really important to reassure them that the rash is outgrown and doesn't cause any scarring, and I met a lady who had the antibody rash, and she came to clinic and her skin was perfect, so you know it's good to remind your patients of that.And then the second group of antibodies are the antiphospholipid antibodies, which can be associated with, sort of recurrent miscarriages, recurrent early miscarriages, they can be associated with, lessees or, placental, syndromes, and they can be associated with early onset preeclampsia.

And it's important to know about those antibodies as woman goes into the pregnancy because it allows you to risk stratify, and it allows you to consider certain medications like aspirin, you know, with, heparin sometimes in order to help mitigate some of those risks.I don't know if there's anything else I'd miss Beth.

Yeah no I completely agree, I think other issues about any established organ damage, so pregnancy requires huge physiological adaptation to cope with the increased blood volume for example, and the result of that is that if the woman does have underlying issues with her kidneys, heart or lungs in particular then these may be poorly tolerated in pregnancy.

00:15:26 [Speaker 3]

So, for example, if she has existing kidney disease, we know that there is an increased chance of her developing preeclampsia in pregnancy. So she understands what preeclampsia is, but she understands the signs and symptoms of it.

00:15:40 [Speaker 3]

So any ones that have headache, nausea, vomiting, abdominal pain, swelling, particularly in the later half of pregnancy, alongside, educating her on regularly checking her blood pressure, particularly as the pregnancy progresses and understanding how she seeks help, if her blood pressure is going over 140 over 90, I think is very important. And then particularly for those individuals with existing cardiac, impairments or particularly pulmonary hypertension, ensuring that they really do get early pre-emptive pre pregnancy counselling, because particularly for pulmonary hypertension and those with severe cardiomyopathy, these are some of the incredibly rare situations where we may recommend against pregnancy, and that isn't something that we do often anymore. But those conditions, such as having an ejection fraction of less than thirty percent of primary hypertension, in use sadly to carry a very high maternal mortality and a poor pregnancy outcome, so considering other routes to motherhood early on is I think is a is a good is a good step in that woman's care so that she is informed at an early point.

So following up on the discussion we've had around unplanned pregnancy, What has some practical advice for rheumatologists or nurses that might have a patient come into to clinic? If they are pregnant, It's been unplanned, and there's a lot of fear. What sort of messages, what support could you put out there for clinicians to say the right thing and to be supportive?

00:17:24 [Speaker 3]

So I tried to establish the details, what has she been taking, has she been taking it, when did she last take it, I try to establish when her last menstrual period was.

00:17:35 [Speaker 3]

I try to establish when the positive pregnancy test is so that we can try to get a feel of where she is and how big the risk is if she has conceived on a potentially transgenic medication for example.

00:17:49 [Speaker 3]

If this is a pregnancy that she is even contemplating continuing with then I would recommend that she stops any transgenic or potentially transgenic medications.

00:18:01 [Speaker 3]

So for us the key ones are going to be mycophenolate, methotrexate and leflunomide, and I would then ensure that she is urgently referred to counselling and I think where that might be will differ in different centers.

00:18:17 [Speaker 3]

So it may be through your local maternal medicine network, but it should be getting her through to an obstetrician with maternal foetal medicine expertise, ideally being seen in a joint clinic with an obstetrician, obstetric and the obstetric physician as well who can give them that nuance.

00:18:35 [Speaker 3]

Whilst waiting for that, I would start her on any relevant supportive therapies.

00:18:40 [Speaker 3]

So that would be folic acid, vitamin d.

00:18:43 [Speaker 3]

You can see you've got leflunomide it would be prescribing the cholestyramine washout, the dose and regimen is in the DNF so it's nice and easy to find. I would consider her need for low molecular heparin prophylaxis, I'd have a think about what are the swine's thrombotic risk factors, is her disease very active, does she have comorbidity as a result of that active disease, and are there other risk factors such as heavy proteinuria, it's worth getting that started quickly.

00:19:15 [Speaker 3]

Eyesight disease activity, so particularly if you are stopping treatments because of that potential strategy then can you add something else in now? It takes often weeks if not months for our treatments to become established so if you can get her started on that now all the better. And finally I would think about screening her for any existing organ damage, particularly in those who have multisystem disorders. You know, has she had an up to date set of bloods? Do you know what her renal function is? What's her proteinuria at the moment? Up to date echo. And I think just remembering that whilst we put all this time into trying to get these women to plan a pregnancy beyond pregnancy safe treatments, and whilst we talk about medications being stratogenic, they are not 100% stratogenic.

00:20:06 [Speaker 3]

And that is particularly true of course if they haven't been taking the medications as prescribed or they've missed doses, and it depends a lot also on the duration of exposure during the pregnancy. So I think you know even a medication like Mycophenolate, we say that that increases your risk of pregnancy loss two to threefold and that among those ongoing pregnancy one in four babies will be born with a birth defect, but I have looked after pregnancies in women who have accidentally conceived on mycophenolate who have gone on to have, live births without congenital defects. So I think it's not about, you know, getting these women incredibly frightened, you know, there is the chance that the pregnancy could continue as normal and that requires dedicated risk counselling to help her navigate the right decision for her going forward and I think also there can be a lot of guilt associated with these pregnancies and you know, I think there's always a degree of risk in any pregnancy even a perfectly planned pregnancy, you know, I think I'm always struck that national figures would suggest that anywhere, it depends on your age, but around one in five pregnancies in women in their 30s can end in miscarriage, that figure's a little bit higher if you're over the age of 40 it's a little bit less if you're in your 20s.

00:21:25 [Speaker 3]

One in forty five pregnancies in The UK end with a baby with a birth defect, that's common, I think, than many people realize, and actually one in two fifty pregnancies in The UK end in stillbirth and this is, you know, just the general population figures that we have. So we can never promise women, a perfect outcome and so it's just about helping her and that none of these risks with medications are absolute so it's helping navigate often very difficult waters, but yeah do the basics right at the beginning and I think it often makes the job easier for everyone who sees her after that.

00:22:00 [Speaker 2]

Amazing Oseme, anything you want to add to that?

00:22:04 [Speaker 4]

Yeah I think very well said Beth, and I think the one thing to remember is that when when these women present to our services this is an opportunity to engage them in terms of their care, in terms of their understanding about their disease, and their motivation to take treatment. And I've often seen, patients who have recurrent DNAs, poor compliance of medication, be so motivated by, a pregnancy even if it was unplanned, and we can really, improve the way that we engage with these patients and use that to springboard onto sort of better, health, better control disease, so it's important to remember to keep those relationships and navigate these difficult times because it can be an opportunity, to sort of improve their long term outcomes and how they engage with rheumatology services.

00:23:00 [Speaker 2]

That's really insightful.

00:23:03 [Speaker 2]

Let's have a think about after pregnancy now.

00:23:06 [Speaker 2]

And with that postpartum period, which can obviously be a very vulnerable period for a, any woman experiencing pregnancy. What should the rheumatology team be planning for before birth to support that woman in the weeks and months after delivery?

So I think in terms of planning once again that should be done as part of a multi disciplinary team, particularly with the obstetricians. I suppose in terms of another myth for bust is, the idea that c section is a safer delivery, we seem to come across that a lot that women have been told by rheumatologists or other physicians that they should have a caesarean section and I think it's important that whilst we can offer advice as rheumatologists on their disease and its management and optimizing control that actually that is a decision to be made by the obstetricians with knowing what's happening with the baby and what other risks are present in the pregnancy and actually that many of our women can deliver, sorry, vaginally.

00:24:12 [Speaker 3]

However, we will, of course, always support women to deliver how it feels right for them, and as I said alongside the obstetricians' advice as to whether there is an indication to deliver via c section. It's useful to reiterate that if a medication has been safe to use in pregnancy, if it's going to be safe to use in lactation, so in breastfeeding, and so we would support that. And I think having contact details for what they should do if they do flare, you know we know that there is an increased risk of flare ups and that risk is reduced by maintaining well controlled disease in pregnancy by continuing pregnancy safe therapies pre pregnancy into the postpartum but look it can still happen And so I usually ensure that the women have a route by which to contact our team so that they can rapidly access their treatment and that they know what treatments they can take, start taking even at home. So, you know for example signposting them if they are breastfeeding to a website called the breastfeeding network that has an excellent information leaflet on just simple analgesia and non steroid anti inflammatory drugs whilst breastfeeding which can be really helpful just in the hours or days they might be waiting to hear back from us.

Amazing and anything for you Oseme to add?

00:25:26 [Speaker 4]

Yeah I think we often call the postpartum phase the fourth trimester and it is often a neglected area, you know, the women have had all this antenatal care, they've had regular contact, and then they're no longer pregnant, so you know the obstetricians don't want to know, they can't go back to the midwives, and sometimes patients can be found in a very vulnerable position without knowing who to turn to. I think many of the disease we look after might well have this risk of a postpartum flare, you know, as the pregnancy, stops and your immune system is starting to sort of, reconstitute back to normal, then, you know, many diseases are at risk of flare. And so what I always say is that it's useful to have a touch base with your patient because you know them, your specialist nurses know them, and what I'll try to do is leave a telephone appointment for six weeks after they've delivered for after they delivered because it's a quick conversation. How are you? How are your joints? How are you getting on with you know breastfeeding and all of these issues, do you have any concerns, because they have so much going on at that time and I think it's just really useful to book a touch in and you can do that over a telephone conversation and it often just takes five minutes.

00:26:50 [Speaker 2]

And Bethan?

00:26:51 [Speaker 3]

I think the other thing as rheumatologists is to understand what a woman's experience of pregnancy, about her future health, so just thinking about that postnatal review. I often find that colleagues might comment that she's just had a lovely baby and that she might be breastfeeding or not but often there's very little detail in the letter about actually what happened in that pregnancy, how big was that baby, did the mother develop preeclampsia, did she develop gestational diabetes because whilst those obstetric syndromes, a greater restricted baby, a diagnosis of gestational diabetes or a diagnosis of preeclampsia way once that baby is delivered actually it's told you something about that woman's physiology so pregnancy is the ultimate physiological stress test for a woman, any underlying vulnerabilities can be unmasked by pregnancy in the form of gestational diabetes and preeclampsia and so we know that if a woman is diagnosed with gestational diabetes she can have a tenfold increase in her lifetime risk of type two diabetes and that pre-eclampsia is associated with a quadrupling in her risk of developing hypertensive and I just think you know we spend so often in rheumatology conferences talking about the fact that cardiovascular risk is often underestimated on our populations and part of that reason is because our populations are predominantly female and we know that lots of traditional risk algorithms actually don't incorporate pregnancy complications into them and often underestimate risk in females, but I think they can be really useful ways for you as a rheumatologist to understand what this woman's cardiometabolic risk profile might be going forward even if you're seeing her in clinic that day, she doesn't have diabetes, her blood pressure is normal but actually her pregnancy experience has told you something about what may happen in the next ten years. 

I think that was really useful and like nice to think as you say Oseme on that fourth trimester and the importance of that postpartum period and how that's going to form as any clinician working with females and to their population health, I suppose, their long term health and management of disease. Probably takes us quite nicely to thinking about across rheumatology services in The UK. What do you guys see as systemic barriers or do you think limit women's access to that safe specialist pregnancy care? And what do you think the practical steps could be for clinicians or services, out there and to try and help close these equity gaps or these training gaps? Beth, we'll come to you first.

00:29:34 [Speaker 3]

So I think both it's great it's worth saying that both Oseme and I obviously work in London and for the last few years England has had the maternal medicine networks which is really trying to deliver that parity of access in terms of, an ability for every pregnant woman to access specialist care if she has a new or existing medical complication in pregnancy. So I think first of all as a rheumatologist in England making sure that you understand how you do access that local service, Idan's and your local obstetrician should know if you don't, and unfortunately though that that is still not present within the devolved nations, which I think is a huge shame. And I think otherwise there is some really, stark information provided to us by the embrace reports, which are The UK confidential inquiry into maternal deaths which publish annually and their work has shown very clearly the impact of ethnicity and disadvantage and when they say multiple disadvantaged they mean those individuals who come to pregnancy not just with an existing medical problem or a new medical problem but who have other things happening in their lives including substance misuse, domestic violence, recently arrived in The UK, refugee or asylum seeker status, all of these things intersect and put women at much greater risk of dying in pregnancy. Now that risk is clearly across the board very rare in The UK, we have fewer than one hundred and twelve deaths annually but there is also UK data to suggest that for every woman who dies one hundred more come to significant, experience a significant outcome or event, and so I think thinking about how we support the most vulnerable women within our services is going to be particularly important that this isn't just about good medical care, it's about linking in with all of these other services that can support them and Embrace in particular talks about bridging the gap, so sharing information with other services within obviously the rights to do so, urgent referral pathways to get help, and good information and discharge summaries if you have ended up admitting a pregnant woman or you've seen her in clinic.

And also Oseme, anything from yourself to add?

Yeah.

00:31:58 [Speaker 4]

I think that, it is clear that the care of women of childbearing age around sort of fertility, pregnancy, and postpartum care, I think there is a growing interest. I think patients are really it's a really important topic for a lot of women of childbearing age and clinicians are wanting to wanting to do better and provide better care for their patients. And, you know, I think the first BSR conference I ever attended was in 2011, and at that time, you know, professor Nelson Pearcy was a keynote speaker talking about pregnancy and rheumatic disease, and the appetite for, knowledge is increasing. And I think that is reflected in, you know, you get more and more obstetric rheumatologists, like myself or Bethan, but also around the country, I think there are clinicians who've always had an interest in in pregnancy, whether that's in a formalized setting or not. And in your local area, I think it's useful to know who that person is that is interested in reproductive health, in women's health, in sort of obstetric rheumatology, and develop those links locally. Because in truth, it's a rapidly evolving landscape. You know? Convulsar medications that we had five years ago have changed. You know, information about vaccinations has changed, and I think it's useful to link in and develop specialist interests within your local areas where you have a good obstetrician who, knows about your patients, comfortable with your medications, and you have these pockets of MDTs and expertise that are coming up around the country. I think, the BSR pregnancy group is a really good, this interest group where you can get support and clinical information. I think there are obstetric medicine conferences that you can attend, there's the rumourpreg, which happens every other year, and, you know yeah I think what other resources do we have available Beth? Your newsletter. Yeah there's also the Macdonald Obstetric Medicine Society also does webinars quite often throughout the year which are free to join, and not all topics open to all rheumatologists but there's a lot of overlap there but I think many rheumatologists interested in this field would benefit from hearing and joining.

00:34:40 [Speaker 2]

Amazing that is loads of good resource and and loads of great insight to this. We're getting to our towards the end of our podcast recording and I want to finish by asking both of you if there was one piece of clinical wisdom that you'd love the listeners to hold on to after the episode finishes. What would it be? And, Oseme, we'll come to you first.

00:35:06 [Speaker 4]

It's really important to ask yourself what would you do if she was not pregnant, and I think that is a really important principle to think about when you're looking after these women, so making sure that you're not withholding treatment, you're not withholding appropriate investigations, because of the fear of harm, and that you treat these women as you would anyone else. One of we didn't talk about sorry, earlier on is historically, you know clinicians would tell rheumatologists would tell their patients that autoimmune disease gets better in pregnancy, so they didn't have to stop, you know, they could stop their medications, they didn't need to take these medications because it would get better, and I think one of the most important things that I say now is that it's more important about whether your disease is well controlled or not going into the pregnancy rather than whether you have this condition or not. So not, diseases will get better. Many patients will need medication to control their disease, but, ultimately, if they have good control then they're likely to have good outcomes.

00:36:16 [Speaker 2]

Fantastic and Beth?

00:36:18 [Speaker 3]

Yeah we often talk about the four d's, so first one is discuss, so talk to women about this and if they don't want pregnancy get them on good contraception, if they do then continue on. We think about disease, that's your autoantibodies, your anti ro-, anti lar-, anti phospholipid antibodies and also telos.

00:36:36 [Speaker 3]

I think drilled home at many points in this podcast get it well controlled. Then to think about damage so we think so much about drugs and worry so much about drugs but actually existing organ damage so kidney damage, existing cardiomyopathy, pulmonary hypertension, many of these things particularly in their established forms have a far greater impact on pregnancy outcome than actually the vast majority of medications. So making making sure you are clear what her organ damage currently sits at and making sure that she has early pre pregnancy counselling if she has existing significant existing damage, and then final D is D for drugs and that is thinking about your pregnancy compatible therapies as per the BSR guideline, so yeah four D's.

00:37:26 [Speaker 2]

So we've had a bit of review about the barriers and looking at how we can overcome that and look at training gaps. Is there any advice or information out there for people working in rheumatology who might be interested in getting more learning around obstetrics or or training in that area?

00:37:46 [Speaker 2]

Beth, we'll come to you.

00:37:48 [Speaker 3]

Yeah. There's now a training program available by the Royal College of Physicians. This is primarily geared towards, higher trainees, so ST five and above. It is now advertised nationally, so you apply through a national application process which opens, once a year, and there are multiple training centers across The UK. The there are fully funded places for trainees who are based in England, but, the 12 nations can also reach out to the RTP to discuss their own training needs individually, as there are also roots in, that way. So I think, yes there is formal training for those who want to go down the route of obstetric medicine more formally, and that will end up being a year at a dedicated centre working with consultant obstetric physicians, midwives, substitutions across a broad range of specialties. If you are looking for something more within the realms of rheumatology then yes please join the Pregnancy and Rheumatic Disease Interest group for the BSR and I would encourage you to attend events from the MacDonald obstetric medicine society through their website, and that website also has a lot more information around other obstetric medicine meetings that are around and other teaching that's available.

00:39:09 [Speaker 4]

I think there are also a handful of post CCT schemes, so I have had rheumatologists for example reach out because they do have an interest and they would like to deepen their in training specifically around obstetric rheumatology for example, I think those are less formalized, but you can always reach out to people like myself or Bethanne, Ian Giles, and other obstetric rheumatologists within country, to sort of talk about further training and and those sorts of things.

00:39:46 [Speaker 2]

Fantastic. Hopefully, we are encouraging some people to get involved after they're listening to this. A massive thank you to you. This has been, honestly, for me, really interesting, really insightful, and there's definitely some takeaways. So a huge thank you from BSR.

00:40:07 [Speaker 3]

Thank you.

00:40:07 [Speaker 3]

Thank you.