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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. Dr. John Cush

Belimumab in pregnancy? Dr. John Cush 🤰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

What are treatment options for obstetric APS? Dr. John Cush 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

Recent study on dosing of anticoagulation in pregnancy: Dr. John Cush 💉>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

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

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 Dr. John Cush 🤰< 20% experienced adverse pregnancy outcomes (improved from 69% with standard of care)

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

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

Neonatal vaccine schedule with in utero biologic exposure: Dr. John Cush 💉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

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

Conflicting data on risk of cleft palates with first trimester exposure to prednisone Dr. John Cush 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

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. Dr. John Cush

Will #lupus flare if taking oral contraceptive pills with estrogen? Dr. John Cush 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.

Is there a risk of thrombosis with estrogen containing birth control in patients with #lupus? Dr. John Cush 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

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 Dr. John Cush

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) Dr. John Cush Risk factors include: 💊cyclophosphamide ✋disease activity 🩸antibodies (RNP, LAC)

What immunologic shifts occur during menopause? Dr. John Cush ⬆️ IL-1, IL-6, IL-17a, TNF-alpha ⬇️ B cells ⬆️ Th1, NK activity

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. Dr. John Cush

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