Elevated cord levels of ustekinumab following its use in the treatment of Crohn's disease in pregnancy.

Ustekinumab (USK) was used in the treatment of two pregnant patients with Crohn's disease. It was given in the third trimester and restarted postnatally for both women. One woman remained on USK and in remission throughout pregnancy. The second woman, took a treatment break, flared, and then had remission induced with reintroduction of USK. Both women delivered healthy term infants. The interval from last dose to birth was 11 and 8 weeks respectively. Interestingly, USK levels in cord blood was observed in higher concentrations than in the maternal serum taken in third trimester. While no adverse effect in infants has been observed, clinicians should remain aware of fetal transfer when using USK in pregnancy. An evaluation of risk and benefit may favour continuing USK in pregnancy in patients with refractory disease.

Immunization status of children at kindergarten entry in Alberta, Canada.

OBJECTIVES: Little is known about immunization coverage among kindergarten-aged children in jurisdictions that do not require children's immunization records to be provided at school entry. Thus, we assessed immunization coverage and associated characteristics of a 2008 birth cohort of Alberta children at kindergarten entry as compared with at the end of grade one. METHODS: This retrospective cohort study used population-based administrative health data for childhood vaccines in Alberta, Canada. We categorized and compared immunization status of children as follows: (a) complete at kindergarten entry; (b) incomplete at kindergarten entry but complete at the end of grade one; and (c) still incomplete at the end of grade one. To assess factors associated with immunization status, we used multinomial logistic regression. RESULTS: Immunization coverage for the complete vaccine series for children (N = 41,515) at kindergarten entry was suboptimal (44.5%, 95% CI 44.0-45.0) and substantially lower than for children at the end of grade one (74.8%, 95% CI 74.3-75.2). Young maternal age, not living with a partner, and having > 1 child in a household were associated with incomplete immunization status at kindergarten entry. Midwife-assisted hospital and home delivery was strongly associated with incomplete immunization status at the end of grade one. CONCLUSION: Immunization coverage at kindergarten entry was strikingly low. Risk factors for incomplete immunization status were identified that require particular attention when addressing immunization coverage. The school-based catch-up immunization program in grade one seems to have substantially improved coverage among children, suggesting a potential benefit of shifting the catch-up program from grade one to kindergarten entry.

RéSUMé: OBJECTIFS: On en sait peu sur la couverture vaccinale des enfants de la maternelle dans les provinces et territoires qui n'exigent pas la présentation du dossier de vaccination de l'enfant à son entrée à l'école. Nous avons donc évalué la couverture vaccinale et les caractéristiques connexes d'une cohorte d'enfants de l'Alberta nés en 2008 à leur entrée à la maternelle et à la fin de la première année. MéTHODE: Cette étude de cohorte rétrospective a fait appel aux données administratives sur la santé de la population de l'Alberta, au Canada, axées sur les vaccins infantiles. Nous avons catégorisé et comparé le statut vaccinal des enfants comme suit : a) complet à l'entrée à la maternelle; b) incomplet à l'entrée à la maternelle, mais complet à la fin de la première année; et c) encore incomplet à la fin de la première année. Pour évaluer les facteurs associés au statut vaccinal, nous avons procédé par régression logistique multinomiale. RéSULTATS: La couverture vaccinale pour la série vaccinale complète chez les enfants (N = 41 515) à l'entrée à la maternelle était sous-optimale (44,5 %, IC de 95 % 44,0­45,0) et considérablement plus faible que chez les enfants à la fin de la première année (74,8 %, IC de 95 % 74,3­75,2). Le jeune âge maternel, le fait de vivre sans partenaire et le fait d'avoir > 1 enfant dans un ménage étaient associés avec un statut vaccinal incomplet à l'entrée à la maternelle. L'accouchement avec sage-femme à l'hôpital ou à la maison était fortement associé avec un statut vaccinal incomplet à la fin de la première année. CONCLUSION: La couverture vaccinale à l'entrée à la maternelle était étonnamment faible. Nous avons cerné des facteurs de risque de statut vaccinal incomplet qui méritent une attention particulière lorsqu'on aborde la couverture vaccinale. Le programme d'immunisation de rattrapage en milieu scolaire durant la première année d'école semble avoir considérablement amélioré la couverture chez les enfants; il pourrait donc être avantageux de l'offrir dès l'entrée à la maternelle plutôt que la première année d'école.

A multidisciplinary approach to reproductive healthcare in women with rheumatic disease.

INTRODUCTION: Rheumatic disease (RD) patients when family planning must consider fertility, disease activity, and management from preconception to lactation. A clear understanding is necessary, especially for those receiving disease-modifying antirheumatic medications. Previous studies have highlighted unmet needs in the care of women with RDs with reproductive healthcare needs. This study describes the first published standardized reproductive care pathway for women with RDs and the outcomes of this approach. MATERIAL AND METHODS: We developed the care pathway with multidisciplinary input from rheumatologists, rheumatology nurse specialists, obstetricians, midwives, maternal medicine specialists, and pharmacists. We identified patients' emotional and healthcare needs, ensured access to expert advice, maintenance of good disease control, and positive reproductive outcomes. We prospectively followed the patients and report the results of the service. RESULTS: Ninety-eight women with median age (range) of 35 years (19-48) were assessed. The majority had an inflammatory arthritis. Seventy-six babies were born to 62 mothers. There were 12 miscarriages and one perinatal death. Breastfeeding rates at 6 weeks were low (28%). CONCLUSION: We describe the first published evidence-based integrated multidisciplinary reproductive care pathway for women with RDs and the results of this approach. Seventy percent of women successful in trying to conceive delivered a healthy baby, and 90% of patients were 'very satisfied' with the service.

Updated pharmacological management of rheumatoid arthritis for women before, during, and after pregnancy, reflecting recent guidelines.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic immune-mediated inflammatory disease which can cause significant disability, morbidity, mortality, and impaired fertility. It commonly affects women of childbearing age. Managing rheumatoid arthritis (RA) in the perinatal period poses challenges. There is concern about the teratogenic effects of many traditional disease-modifying anti-rheumatic drugs (DMARDs) and an ever-growing list of new therapeutic options with limited data in pregnancy and breastfeeding. AIMS: We aimed to create a standardized approach to pharmacological management of RA patients seen in our newly established Rheumatology and Reproductive Health Service. METHODS: We reviewed relevant publications on the use of anti-rheumatic drugs in pregnancy. These include recent guidelines from The British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) and the European League Against Rheumatism (EULAR). RESULTS: After considering relevant publications, we developed a Saint Vincent's University Hospital/National Maternity Hospital consensus protocol for evidence-based medication in pregnancy in RA. CONCLUSIONS: RA tends to improve during pregnancy and flare postpartum. Several anti-rheumatic medication options during pregnancy and breastfeeding are now available including anti-tumor necrosis factor (anti-TNF) agents. Good disease control at all stages of reproduction is important to ensure best outcome for both mother and baby.