Patient Selection and Safety With TNF Inhibitors - Episode 29
Christopher Robinson, MD, MSCR, FACOG: I think when we look at autoimmune disease and its effects, it can have disabling effects—whether they’re outwardly visible effects, such as joint disease, or maybe inward effects, where a woman cannot go about normal daily life because of the complications of her disease, such as incontinence, diarrhea, and things of this nature. Our goal is really to maintain a stable disease state, such that the mother’s body is not affected over time by autoimmune disease. And so really the key here is, incrementally, over years, you have accumulation of potential impact to the body. Our goal, over the long term, is really to prevent disability and ensure that a person can enjoy a normal life where they can interact normally, be out in the workforce if they want to do that—to achieve whatever goals they have just the same as if they did not have disease whatsoever, and to achieve a longevity to that. By this I mean that the person has the ability to do that for the same duration as a person without disease. It is really about trying to normalize life for these women as if they did not have an autoimmune disease whatsoever.
When we look at the differential outcomes, the planned pregnancy that has made the effort to get control of the disease and has been able to achieve that prior to pregnancy has a very different outcome than one who has poor control in pregnancy. And so this has really led to a focus on reinforcing the importance of a healthy mother equals a healthy baby. That’s really, really important to understand. The mother is the vessel in which that baby is developing and is providing all the sustenance and support. By keeping the mother healthy, we avoid things like preterm birth, in some of these cases, and low birth weight. We avoid things like prematurity.
If we look at the 2 major contributors to adverse outcomes in infants, it’s prematurity, No. 1. When a baby has not completed its development in utero, it has to complete its development outside, which is not as optimal as it would be inside the mother. And then preeclampsia is the other. Both of those conditions remain our targets. By controlling autoimmune disease, we can improve those outcomes. And so a real goal of going back and asking ourselves, “Is it important to really treat the mother to keep her in remission,” has become very, very important. That has become a mainstay of autoimmune disease management—really focusing on the maternal health.
This is not a linear progression. It is not usual that a woman of childbearing age will become pregnant, complete the pregnancy, and then not potentially circle back into that process where she then decides to have another child. Maybe it’s a year later. Maybe it’s 3 years later. It’s important to have that plan, not just for the pregnancy but to persist through her reproductive years. And so you may continually reassess the plan during that time period but also in planning for the possibility of another pregnancy in the future, absolutely.
This AJMC® Insights program is very important for practitioners and for individuals who are seeking information about disease states that they may not feel comfortable going out and looking up, or if they may not have easy access to the information. I think 1 of the key things is dissemination of information. And especially surrounding pregnancy, it is often not as common. And so I think this is addressing a really significant gap in medical education for the majority of other practicing physicians who are not caring for pregnant women, so that they can begin making those plans prior to the onset of pregnancy and improve pregnancy outcomes.