Thread by @kidneymo

We don’t talk about Bruno 🤫, but we can talk about pregnancy and lupus nephritis (LN)!

Time for a tweetorial! 🚨

#Nephmadness2022 Lupus Region: Tweetorial 🧵
@jkidd03 @Dr_KeishaGibson @anna_burgner @maximal_change

ajkdblog.org/2022/03/11/nep…

1/19

Disclaimer‼️
The information presented in this tweetorial is for informational purposes only and does NOT constitute or substitute medical advice.Medical decisions should be made according to the latest guidelines and medical literature and after consulting with your doctor. 2/19

⦿ SLEs disproportionately affects 👩🏻‍🦰 of child-bearing age

⦿ Patients are at risk of unplanned pregnancies
pubmed.ncbi.nlm.nih.gov/18512717/

⦿ Family planning is 🔑 to prevent poor maternal and fetal outcomes due to lupus flares 🔥 3/19

Poll 1: A 23-year-old 👩🏻‍🦰 with SLE desires to become pregnant. Who should counsel her on family planning? 4/19

The answer is all! Nephrologists play a 🔑 role in this approach!

Your patient currently has LN flare 🔥 and asks you if she should avoid pregnancy. How would you reply?

5/19

Avoid pregnancy!

💥 Experts recommend that pregnancy should be delayed until patients have had quiescent disease for at least 6 months

pubmed.ncbi.nlm.nih.gov/32090480/

6/19

She decides to postpone her pregnancy plans and inquires about contraception.

You explain that:
💥 Each contraceptive method carries risks and benefits
💥 Hormonal contraception, for example, can increase risk of lupus flares 🔥, thrombosis and thrombocytopenia🩸

7/19

Here is a nice table adapted from pubmed.ncbi.nlm.nih.gov/25228715/
summarizing the risks and benefits of each contraceptive method. 8/19

A 👩🏻‍🦰 with Antiphospholipid syndrome :

💥 Should NOT receive estrogen-based contraception
💥 Warfarin should be switched to LMWH if desires to become pregnant
💥 Should receive aspirin during pregnancy for preeclampsia prophylaxis

ard.bmj.com/content/78/10/…
9/19

What about “Bruno”? I mean the “teratogenic effect of lupus medications”? Check the table below.👇🏽

▶︎ Always weigh the benefits and risks of each medication and discuss with the patient before prescribing‼️10/19

Does Cyclophosphamide affect fertility?
pubmed.ncbi.nlm.nih.gov/34995765/
💥 Cyclophosphamide is EXTREMELY gonadotoxic. Fertility preservation prior to initiation is essential:
👉🏽 GnRH Agonists
👉🏽 Cryopreservation
👉🏽 Refer WOMEN & MEN to a fertility specialist
11/19

Our patient waited, and after 6 months of quiescent disease, she got pregnant! She is now 30 weeks pregnant 🤰. She is at high risk of:

12/19

All of the above! She is also at increased risk of preeclampsia and HELLP Syndrome!

13/19

So how can we differentiate between Preeclampsia and Lupus Nephritis flare?

Here are some clues 👇🏽
14/19

She develops 12 g proteinuria. C3 & C4 are normal. Anti-ds-DNA Abs negative. She asks you about the risk of maternal and fetal complications from a kidney biopsy. You tell her that the risk is highest after:

15/19

If biopsy will change management, experts recommend kidney biopsies during pregnancy to be performed <30 weeks gestation, preferably <20 weeks gestation due to the risk of complications reported after 20 weeks of gestation. pubmed.ncbi.nlm.nih.gov/33328069/
pubmed.ncbi.nlm.nih.gov/23320849/
16/19

You opt AGAINST a kidney biopsy and decide to treat empirically for LN flare 🔥. What are potentially safe options you can use?

pubmed.ncbi.nlm.nih.gov/32090480/

ajkdblog.org/2022/03/01/nep…

Always look up the latest medical literature and weigh the risks vs benefits!

17/19

Hope you enjoyed my first tweetorial!
Stay tuned for more tweetorials by #Team2k22

@anandthedoc @Hmzrage @rachhung @bilalsheikh @kidneyrachael @merlomar2019 @hemoncfellow @willialVasEsp #Pod2k22
18/19

A big shoutout 📣 to the awesome #NSMC2022 Team!

@nsmcinternship, @NephMadness, #NephMadness @swastithinks @amyaimei @Nephro_sparks @docanjuyadav @menonshina @Elena_Cervants @JMTeakell @nephromythri @hswapnil

Don’t forget to submit your bracket before March 31!

19/19