Cassy Sims, MD

Register your #pregnant #vasculitis patients in VPREG! #ACR22 📍Women with vasculitis report a prior miscarriage rate double that of women without autoimmune disease 📍 Rheumatologists should engage women in family planning discussions at EVERY clinic visit

Lupus Unlocked: Antiphospholipid Syndrome x.com/i/broadcasts/1…

There is overlap in symptoms between #menopause and #lupus disease activity This is an opportunity for rheumatologists to assess lupus disease measures (labs, imaging, exam) to help distinguish from menopause related symptoms. @RheumNow

What immunologic shifts occur during menopause? @RheumNow ⬆️ IL-1, IL-6, IL-17a, TNF-alpha ⬇️ B cells ⬆️ Th1, NK activity

Women with #lupus are at increased risk of premature ovarian failure with a mean age of menopause at 47 years (compared to 51 y/o in gen pop) @RheumNow Risk factors include: 💊cyclophosphamide ✋disease activity 🩸antibodies (RNP, LAC)

There is no increased risk of IUD associated pelvic inflammatory disease in patients with HIV or solid organ transplants. This can be extrapolated to women with rheumatic conditions. No need to hold or stop immunosuppression with patients with IUD @RheumNow

Is there a risk of thrombosis with estrogen containing birth control in patients with #lupus? @RheumNow There is a baseline risk for thrombosis in all SLE patients (even without aPL) 🩸increased risk if aPL positive or active disease 🩸less risk if no aPL and quiet disease

Will #lupus flare if taking oral contraceptive pills with estrogen? @RheumNow If patients with SLE take combined oral contraceptives during quiet disease there is no evidence of flare risk. The ACR recommends against estrogen contraceptives in women with very active lupus.

A large study of neonates exposed to TNFi in utero (n=5,750) had no significant increase in diarrheal illness after receiving their first rotavirus vaccination in the first 6 months of life. This data supports the 2022 ACR vaccination guidelines. @RheumNow

Conflicting data on risk of cleft palates with first trimester exposure to prednisone @RheumNow Prevalence of cleft palates is 1/700-1k. The window of development is 7-11 weeks gestation The 2025 EULAR and 2020 ACR reproductive guidelines don’t list prednisone as a teratogen

Pregnant patients exposed to vitamin K antagonists (warfarin) are at increased risk for: @RheumNow 👶 fetal warfarin syndrome (facial/vertebral abnormalities) 🤰spontaneous abortion 👶 embryopathy Patients can be switched to LMWH or unfractionated heparin, ASA in pregnancy

Neonatal vaccine schedule with in utero biologic exposure: @RheumNow 💉Rotavirus: exposed to TNFi, can administer vaccine per recommendations. Exposed to Rituximab, avoid vaccine in first 6m. 💉BCG vaccine: if exposed to TNFi after 20-32w, except certulizumab, delay for 6m

NSAIDs can cause unruptured follicle syndrome, delayed/disrupted ovulation leading to subfertility. @RheumNow 💊If there are concerns for subfertility, consider discontinuing NSAIDs

In addition to checking anti-Ro/neonatal SLE, what are other causes of neonatal heart block? @RheumNow 🫀genetic cardiac disease 🫀anatomic heart malformation 🦠viruses (parvo, lyme, coxsackie) 💊medications 🤰hypothyroidism, low vitamin D, iodine deficiency

The IMPACT study assessed the role of certulizumab (in addition to LMWH and ASA) in preventing fetal death > 10w and preeclampsia in patients with clinical APS and LAC @RheumNow 🤰< 20% experienced adverse pregnancy outcomes (improved from 69% with standard of care)

Does LMWH increase live birth rates in women with history of recurrent pregnancy loss? @RheumNow 💉n=428 with >/= 2 pregnancy losses and thrombophilia 💉LMWH did not result in higher live birth rates

Recent study on dosing of anticoagulation in pregnancy: @RheumNow 💉>1k pregnant women with history of VTE treated with weight based vs. fixed LMWH; no difference in VTE risk during pregnancy; weight based decrease postpartum VTE risk

What are treatment options for obstetric APS? @RheumNow 1st line: ASA & LMWH (70-80% live births) What are options for the 20-30% that fail 1st line therapies? prednisone, IVIG, pravastatin, HCQ, RTX, belimumab, TNFi

Belimumab in pregnancy? @RheumNow 🤰Most available data (n=80 pregnancies) stopped belimumab before the 2nd trimester with no safety signals with this data. 🤰In a case series (n=14) pregnancy outcomes were better in women who continued belimumab throughout pregnancy

There is a lack of data for drug safety studies in obstetrics research. The incidence of congenital malformations globally is 3% meaning very large studies are needed to establish causality of drug exposure and birth defects. @RheumNow

Starting today’s agenda with bioethics of pregnant women in research. Lack of clinical data on pregnant patients puts this vulnerable population at higher risk of poor clinic outcomes. A real world example was the COVID-19 pandemic and lack of vaccine data in pregnancy.