Sammaritano makes recommendations for pregnant women with rheumatologic disease

DESTIN, Fla. — At the Congress of Clinical Rheumatology Annual Meeting, Lisa R. Sammaritano, MD, from Weil Cornell Medical College and Hospital for Special Surgery, reviewed the risks for women with rheumatic disease and who are pregnant or who are planning to become pregnant and made recommendations based on recently published literature.

Lisa R. Sammaritano

For patients with antiphospholipid syndrome, Sammaritano mentioned increased risks for pre-eclampsia and eclampsia for the mother. For the child, there are increased risks for premature birth, as well as growth restrictions.

For patients with lupus, Sammaritano discussed a study that showed hypertension medication and lupus anticoagulant positivity during screening, as well as flares and low C3 count during the second and third trimester, were risk factors for adverse pregnancy outcomes. In the study, 19% of patients with lupus had an adverse pregnancy outcome; however, if no risk factors were present, the adverse event risk dropped to 7.6%.

For patients with rheumatoid arthritis (RA), she noted a slightly increased risk for lower birth weight and preterm delivery, as well as more frequent cesarean delivery, and prednisone use can increase the risk for pre-term delivery; but overall, the RA outcome is similar to that of the general population. To prepare for post-partum flare, Sammaritano said rheumatologists should assess for C-spine stability and hip range of motion before delivery.

For patients with Sjögren’s syndrome, there are increased risks for neonatal lupus and complete heart block, for which the mortality rate is 20%, and between 60% and 80% of patients require pacemakers.

For patients with systemic sclerosis, according to an Italian multicenter study of 109 pregnancies published in 2012, there are increased risks for preterm deliveries (25% vs. 12% in general population), severe preterm deliveries (10% vs. 5% in general population), intrauterine growth restriction (6% vs. 1% in general population), low birth weight of less than 1,500 grams (5% vs. 1% in general population) and cesarean section (52% vs. 31% in general population).

For patients with myositis, the maternal outcome if often good and rarely there is mortality. In addition, pregnancy complications are more frequent in patients with polymyositis vs. dermatomyositis. For both, patients with joint involvement and anti-Jo1 positivity had increased risk for adverse pregnancy outcomes. However, recent onset of disease has a fetal survival rate between 38% and 50%; whereas, remission of disease had an 80% fetal survival rate and a 25% occurrence of flare.

For patients with vasculitis, there are also increased risks for miscarriage and preterm birth; however, there are a limited number of reported cases.

As for medications during pregnancy, Sammaritano said hydroxychloroquine, azathioprine, sulfasalazine, cyclosporine, NSAIDs, tacrolimus, prednisone and intravenous immunoglobulin have low to moderate risk during pregnancy; whereas, cyclophosphamide, methotrexate, mycophenolate mofetil and leflunomide carry greater risk and should be avoided. In addition, novel small molecules, such as Janus kinase inhibitors and non-tumor necrosis factor (TNF) biologics, should be avoided due to lack of data. With the exception of a few case reports, TNF inhibitors (TNFis) have not had any observed increases in congenital abnormalities. Sammaritano recommends to continue TNFis until pregnancy diagnosis at least and through the second trimester if necessary.

For breastfeeding, Sammaritano said it depends on the medication. For TNFis, there is no significant transfer into the breast, so the infant is likely to not absorb the drug. For azathioprine, the WHO recommends against breastfeeding while on this drug due to concerns of bone marrow suppression and susceptibility to infection and pancreatitis in the infant; however, there are case reports that support safety of the drug during breastfeeding. In addition, case reports support tacrolimus as safe in breastfeeding. For non-TNF biologics, there is not enough data, so Sammaritano recommended against breastfeeding while on a non-TNF.

To help develop a plan for patients, Sammaritano said rheumatologists should teach patients about the need for safe and effective contraception. In addition, rheumatologists should rule out any serious underlying disease-related damage. Sammaritano mentioned the best maternal and fetal outcomes occur with quiescent disease in the 4-month to 6-month period leading up to conception. However, rheumatologists should still review medications before, during and after pregnancy and should change to more compatible medications and observe these for 3 months to 6 months before conception. In addition, rheumatologists should counsel couples about the patient’s risk according to disease damage, activity, medications and autoantibody status and rheumatologists should closely monitor the patient with other specialists. – by Kristine Houck, MA, ELS and Will A. Offit

Reference:

Sammaritano LR. Pregnancy and medication use in pregnancy in rheumatic diseases; April 27-20, 2017; Destin, Fla.

Disclosure: Sammaritano reports no relevant financial disclosures.