Pregnancy and autoimmune diseases

Question 1

What two drugs used for SLE should be avoided in pregnancy?

Answer 1

Methotrexate and Mycophenolate are not compatible for pregnancy

Question 2

What two drugs used for RA should be avoided in pregnancy?

Answer 2

Pregnant women should not take Toficitinib/Baracitinib

Question 3

When is lupus more active in pregnancy?

Answer 3

Lupus becomes more active in later pregnancy. Half of women will experience some sort of disease activity in pregnancy. Risk is higher if not sorted before pregnancy.

Question 4

In what patients id the risk of maternal thrombosis high?

Answer 4

o Particularly in patients with antiphospholipid syndrome (procoagulant antibody that increases the risk of blood clots)
o Additive with traditional risk factors such as obesity
o Requires daily low-molecular weight heparin injections throughout pregnancy to reduce risk of thrombosis

Question 5

What are the Obstetric Complications in lupus?

Answer 5

• Foetal Loss (spontaneous abortion or intrauterine foetal death) (20%)
• Intrauterine Growth Retardation (15%)
• Pre-term birth (nearly 50%)
• Pre-eclampsia (15-20%)
• Obstetric complications are due to placental dysfunction
• Complex immune, neuroendocrine and coagulation factor play a role.
• Risks are higher in patients with active disease, nephritis, hypertension and antiphospholipid antibodies
• Aspirin (75mg/day) may have a protective role and is recommended for all lupus patients after 12 weeks’ gestation – risk of bleeding higher?
• Serial foetal monitoring and 38-week induction is common routine practice.

Question 6

What are the Obstetric Complications in RA?

Answer 6

• Placental function affected by maternal inflammatory milieu
• Low dose aspirin and careful monitoring required in patients with active disease.

Question 7

What drugs are safe to use in pregnancy for SLE?

Answer 7

• Hydroxychloroquine
• Azathioprine
• Ciclosporin/Tacrolimus

Question 8

What drugs are safe to use in pregnancy for RA?

Answer 8

• Hydroxychloroquine
• Sulfasalazine

Biologics for RA
o	Etanercept (TNF receptor/IgG fusion protein). Safe to 28 weeks of gestation
o	Adalimumab (Human anti-TNF monoclonal). Safe to 28 weeks gestation
o	Infliximab (Humanized mouse monoclonal). Safe to 16 weeks gestation
o	Certolizumab (PEGylated anti TNF Fab).
-	Theoretically and experimentally does not cross placenta so likely to be safe throughout pregnancy.
-	Received license for use in pregnancy in 2018.
o	Golimumab (long-acting human monoclonal). Safe to 14 weeks. – long half-life so patients don’t need many injections

Question 9

Which Biologics for RA should be avoided in pregnancy?

Answer 9

• Tocilizumab (anti IL6R monoclonal)
• Abatacept (CTLA-Fc fusion protein)
o should be stopped 3 months before conception.
• Rituximab (anti-CD20 monoclonal, used in rheumatoid arthritis and lupus).
o May cause neonatal B-cell depletion with late pregnancy exposure.
o Should be stopped 6 months prior to conception
• Belimumab (anti-BAFF monoclonal)
No data. Stop 3 months before conception

Question 10

information about other drugs

Answer 10

• Low dose steroids are safe in pregnancy (although may effect maternal blood pressure and risk of gestational diabetes).
• High dose steroids (>20mg/day Prednisolone) probably cross placenta. Specific risks are uncertain
• Analgesia
o Paracetemol. Low risk
o Opiates. Risk of neonatal withdrawal or sedation if used in high doses
o NSAIDs.
♣ Avoid early pregnancy (low risk of miscarriage and foetal malformation).
♣ Avoid in last trimester (Premature closure of ductus arteriosus)

Dihydrocodiene is safer than codeine