Spring 2024 (Volume 34, Number 1)
Top Takeaways from the
12th International Conference on Reproduction, Pregnancy and Rheumatic Diseases
By Stephanie Keeling, MD, MSc, FRCPC, on behalf of Neda Amiri, MD, MHSc, FRCPC;
Maeve Gamble, MD, FRCPC; Stephanie Garner, MD, FRCPC; Shahin Jamal, MD, MSc, FRCPC; Dharini Mahendira, MD, MScCH, FRCPC; Viktoria Pavlova, MD, FRCPC; Natalia Pittman, MD, MSc, FRCPC; and Jodie Reis, MD, FRCPC
Download PDF
A strong Canadian contingent of rheumatologists attended the 12th International Conference on Reproduction, Pregnancy and Rheumatic Diseases in early September 2023 just steps away from Paddington station and Platform 9¾ in London, England. This collaborative meeting including specialists and allied health professionals provided in-depth and updated information on the health of women in the peripartum period with important reflections on the impact of policy changes on women’s health.
We have summarized key takeaways from the important aspects of women’s health.
1. Abortion
The impact of overturning Roe vs. Wade (Dobbs Abortion Policy) was shared by American rheumatology colleagues with reports of more live babies, travel for abortion, and increased rate of tubal ligations and salpingectomies. Implications on American practice included re-thinking the safety of prescribing methotrexate and mycophenolate mofetil (MMF) without concomitant contraception. A helpful tool known as the MMF REMS (Risk Evaluation and Mitigation Strategy) was presented providing a possible strategy for MMF use in rheumatology clinics.
(www.mycophenolaterems.com/Resources/Docs/PatientResourceKit.pdf)
Important questions about how well-informed patients are, based on how much we counsel them around pregnancy and fetal risks when prescribing teratogenic medications, were discussed.
Another unintended consequence of the changing abortion policies could be the future challenge of conducting much-needed medication trials in pregnancy without access to safe and timely legal abortion.
2. Contraception
Studies in the past five years have shown lower contraception use and counselling in rheumatology patients, with a disconnect between what patients and rheumatologists respectively expect in contraception counselling. Reasons include lack of time, discomfort with the subject, limitations in knowledge about contraception and being out of scope of rheumatology practice. Importantly, the lack of data on contraception safety and efficacy in rheumatic disease patients was once again emphasized.
3. Fertility
Studies confirmed that men with rheumatic diseases have similar concerns to women around how their disease impacts sexual and reproductive health. Men with physical limitations were more likely to find their disease affecting their sexual practices. Infertility continued to be an area of concern for patients. We noted that rheumatologists have limited information about infertility treatments — this is an unmet educational need that can help our patients. The potential for tumor necrosis factor (TNF) inhibition to ensure successful pregnancy outcomes in obstetric antiphospholipid antibody syndrome (APS) through the impact on normal placentation and spiral artery remodelling was presented, covering the first 45 patients in the IMPACT study and a case report presenting a successful pregnancy in
this context.
4. Guidelines/Medications/Counselling
The new 2023 American College of Rheumatology (ACR)/ European Alliance of Associations for Rheumatology (EULAR) Antiphospholipid Antibody Syndrome classification criteria featuring a weighted point system, expanded domains (macro- and micro-vascular, obstetrical, cardiac valve and hematologic) were presented with certain antiphospholipid antibodies (APLAs) receiving higher points (e.g. persistently positive lupus anticoagulant), demonstrating improved specificity (99%) and strong sensitivity (84%) compared to the 2006 revised Sapporo classification criteria. Updates to the British Society for Rheumatology guidelines for prescribing drugs in pregnancy and breastfeeding included changes to the timing of non-steroidal anti-inflammatory drug (NSAID) use, no restrictions on paternal exposures and continued confirmation of the safety of anti-TNFs over other available advanced therapies. Rituximab was recognized as having limited evidence overall but low probability of harm and could be used in breastfeeding, with ongoing questioning of a potential impact on neonatal development limiting a conclusive safety statement. Updated EULAR Points-to-Consider are expected for 2024. The need to talk “early and often” about sexual dysfunction for women and men with rheumatic diseases was emphasized as part of the American College of Rheumatology guidelines (2020).
Canadian Contingent from left to right: Shahin Jamal, Maeve Gamble, Dharini
Mahendira, Sarah Troster, Neda Amiri, Stephanie Garner, Viktoria Pavlova, Jodie Reis, Stephanie Keeling, and Natalia Pittman.
5. Pediatric Considerations
While vaccinations are globally recognized as effective and important, the issue of live vaccination schedules in infants exposed to biologic disease-modifying antirheumatic drugs (DMARDs) in utero was acknowledged as complex. A suggested approach included assessing which specific bDMARD was used to account for differences in persistence in the infant, structure, timing of pregnancy exposure, specific vaccine(s), and risk of infection. Rotavirus vaccine can be administered to babies who have been exposed to anti-TNF biologics in utero according to ACR February 2023 updated guidelines. Non-live vaccines were felt to be safe with no suggested change in the infant vaccine schedule. Despite increased use in pregnancy, breast-feeding rates were low in anti-TNF exposed mothers even though biologic DMARDs are largely inactivated by digestive enzymes with poor systemic absorption.
6. Disease-Specific Considerations
In patients with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome, monitoring of complement levels early and throughout pregnancy was recommended due to the association with poor pregnancy outcomes. The administration of ASA 162 mg daily starting at 11-14 weeks gestational age was recommended in women with SLE to reduce the risk of preeclampsia.
Stephanie Keeling, MD, MSc, FRCPC
Professor of Medicine,
University of Alberta
Edmonton, Alberta
|
