Baby on Board: The Rheumatologist’s Role in Family Planning for Patients with Lupus

ATLANTA—Although rheumatologists may not consider family planning a core competency of their specialty, discussions about contraception, fertility, pregnancy and breastfeeding are critical when caring for patients with rheumatologic conditions. This topic is, perhaps, most significant for patients with systemic lupus erythematosus (SLE). During a session at the 2019 ACR/ARP Annual Meeting, Transform SLE Pregnancies: Prepared Providers, Empowered Patients, multiple presenters spoke directly to this point.

Prevention
Mehret Birru Talabi, MD, PhD, assistant professor of medicine at the University of Pittsburgh, began the session by describing how contraception is underutilized in women with SLE. In a study of 206 women involved in the University of California, San Francisco, Lupus Outcomes Study, 59% of these patients had not received contraceptive counseling in the preceding year. Additionally, 22% reported inconsistent contraceptive use, and 53% depended solely on barrier methods of contraception. The more reliable contraceptive method—in which a hormone-releasing or copper intrauterine device (IUD) is placed within the uterus—was used by only 13% of patients.¹

Rheumatologists may feel discussing contraceptive methods is outside their scope of practice, Dr. Talabi noted. But rheumatologists are uniquely qualified to provide anticipatory guidance on all aspects of living with an autoimmune disease. Family planning clearly falls into this category. Among the most effective methods of contraception are surgical interventions, such as tubal ligation and vasectomy; contraceptive implants, such as hormone-releasing implants placed under the skin of the upper arm; and IUDs. These methods are beneficial because they are long lasting, are not contraindicated in lupus patients and eliminate the potential for human error inherent to other birth control methods, such as taking an oral medication or correctly positioning a barrier contraceptive.

Dr. Talabi discussed how to use the resources on www.bedsider.org, an online birth control support network providing extensive guidance from obstetricians and gynecologists with the goal of preventing unplanned pregnancies.² The website includes descriptions and photos of various contraceptive methods, and access to online and smartphone applications that allow patients to set reminders to use their contraception. Additionally, the site offers user-generated content, including articles on personal experiences with contraception and family planning.

Pregnancy & Medication
The session’s second speaker was Bonnie Bermas, MD, the Dr. Morris Ziff Distinguished Professor in Rheumatology at UT Southwestern Medical Center, Dallas. Dr. Bermas described how the U.S. Food and Drug Administration’s (FDA’s) newly improved pregnancy and lactation labeling has helped clinicians determine which medications are safe for lupus patients while pregnant and breastfeeding. Previously, the FDA categorized risks of taking a drug or biological treatment during pregnancy under a five-letter system (A, B, C, D and X) based on what was known about that product. But many providers found this system confusing, overly simplistic and, sometimes, prone to resulting in false assumptions about medications based on limited data.

Beginning in 2015, the FDA revised the labeling system, which now offers more descriptive, up-to-date and well-organized information about a medication’s risks to the expectant mother, the developing fetus and the breastfed infant. A new label subsection was also created to address relevant information about pregnancy testing, birth control and a medication’s effect on the fertility of both women and men. Using this information, as well as the Drugs and Lactation Database (LactMed), maintained by the U.S. National Library of Medicine, rheumatologists can better counsel patients on which medications are safe to use during pregnancy and breastfeeding, and which should be discontinued prior to a planned pregnancy.³

Example: The updated labeling indicates that aspirin is safe to use during pregnancy. In 2018, the American College of Obstetricians (ACOG) released a committee opinion advising that women at increased risk of pre-eclampsia—which includes all lupus patients—be prescribed low-dose aspirin (81 mg daily) as a prophylactic measure between 12 and 28 weeks’ gestation.⁴ Despite this recommendation, a 2019 study of 475 pregnancies in lupus patients showed aspirin prophylaxis was used in only 25% of pregnancies.⁵ This and other examples of the underuse of appropriate medications in pregnant lupus patients indicates the ongoing need for provider education about this subject, Dr. Bermas noted.

Patient Communication
The final speaker was Megan Clowse, MD, MPH, associate professor of medicine, rheumatology and immunology at Duke University, Durham, N.C. Dr. Clowse discussed the HOP-STEP program, which stands for Healthy Outcomes in Pregnancy with SLE Through Education of Providers. With an easy-to-navigate website and series of printable handouts, the HOP-STEP program is designed to help start productive conversations between rheumatologists and SLE patients about how best to achieve healthy pregnancies.

Dr. Clowse noted the most effective way to begin this conversation is with the open-ended question: “Would you like to become pregnant in the next year?” Based on the discussion that follows, the program’s Preparing for Pregnancy handout is designed to guide providers and patients through a series of checklists that include reviewing which medications are safe during pregnancy and the patient’s current level of disease activity. The handout also addresses identifying key specialists who may play a role in the patient’s care before, during and after pregnancy, and planning the management of specific medical issues, such as antiphospholipid antibody syndrome, hypertension and screening for neonatal lupus in patients with Ro/SSA antibodies.

The website also includes video interviews with lupus patients who discuss their experiences with pregnancy, their views on family planning and their expectations for how best to have supportive and healthy discussions about these topics with their providers.

The session concluded with audience members practicing how to use the key question—would you like to become pregnant?—to best prepare to help their patients navigate the complex world of family planning, as well as foster trust and openness in the therapeutic relationship. Given these tools, rheumatologists can feel empowered to help their lupus patients follow their dreams of starting a family, while maintaining the best health possible both in the near future and in years to come.

Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his MD. He is currently in practice with Arthritis, Rheumatic, & Back Disease Associates, New Jersey.

References

1. Yazdany J, Trupin L, Kaiser R, et al. Contraceptive counseling and use among women with systemic lupus erythematosus: A gap in health care quality? Arthritis Care Res (Hoboken). 2011 Mar;63(3):358–365.
2. Power to Decide, the campaign to prevent unplanned pregnancy. Bedsider.org. 2019.
3. Drugs and Lactation Database (LactMed). 2019. Bethesda, Md: U.S. National Library of Medicine.
4. ACOG Committee Opinion No. 743: Low-dose aspirin use during pregnancy. Obstet Gynecol. 2018 Jul;132(1):e44–e52.
5. Mendel A, Bernatsky SB, Hanly JG, et al. Low aspirin use and high prevalence of pre-eclampsia risk factors among pregnant women in a multinational SLE inception cohort. Ann Rheum Dis. 2019 Jul;78(7):1010–1012.