Interventions to enhance medication adherence in pregnancy- a systematic review.

BACKGROUND: Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. METHODS: Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. RESULTS: Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect  of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. CONCLUSIONS: There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.

The multidisciplinary care of a woman presenting with lymphoma in pregnancy whose delivery was also complicated by placenta accreta spectrum.

We report the case of a 44-year-old presenting with breathlessness in her second trimester of pregnancy diagnosed with pulmonary diffuse large B cell lymphoma (DLBCL) which was further complicated by a placenta accreta spectrum (PAS) disorder. In pregnancy, she was treated with rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin and prednisolone, which was associated with neutropenic sepsis requiring admissions to the intensive care unit with respiratory compromise. She safely delivered an infant at 31 weeks but required a hysterectomy at the time for PAS and seven days ventilation on the intensive care unit post-operatively. It is the first case report of DLBCL and PAS in pregnancy.

Acute presentation of the pregnant patient.

Three-quarters of maternal deaths are in women with coexisting medical complications. It can be challenging to differentiate symptoms of normal pregnancy from pathological symptomatology, and physicians need to be mindful of special considerations in assessing and managing acute medical problems in pregnancy. This article focuses on women presenting with shortness of breath, chest pain and palpitations.