Ethics Forum: Patients’ Unplanned Pregnancies Present Counseling Issues for Rheumatologists

The Case

A 27-year-old woman with seven years of rheumatoid arthritis presents for a return visit. She is taking hydroxychloroquine and methotrexate for the management of her disease. Although you have counseled her about using reliable birth control while taking methotrexate, she mentions to you that she thinks that she may be pregnant. A serum β-HCG test and pelvic ultrasound confirm that the patient is seven weeks pregnant. The patient asks your advice on what to do about the pregnancy. What do you tell her?

The Ethical Issues

Forty-nine percent of pregnancies in the United States are unplanned.¹ While practicing rheumatologists may have more opportunities and impetus to discuss family planning with their patients than clinicians in other fields, inadvertent pregnancies in our patients can and do occur.³ Thus, the treating rheumatologist may be asked to weigh in on reproductive issues when a developing embryo/fetus is inadvertently exposed to an antirheumatic drug. Some of the medications we regularly prescribe, such as methotrexate, are absolutely contraindicated during pregnancy. This is based on both its known teratogenicity and abortogenic effects and, accordingly, the FDA considers methotrexate to be a category X for risk for use during pregnancy.^2,3 As the prescribing clinician, you recognize that your patient’s developing embryo is at risk for congenital anomalies. How do you counsel your patient? Do you recommend termination? What if you and the patient have different religious, ethical, or philosophical beliefs regarding family planning? This presentation raises the additional challenges of decision making in cases of hypothetical versus certain risk of congenital anomaly.

Discussion

There is a large amount of literature on the ethics regarding family planning decisions. One of the many challenges in this area is determining who is the patient—the mother and/or the developing embryo/fetus—and whose rights take precedent in medical decision making. While these complex concepts are beyond the scope of this discussion, there are some constructs that are helpful in considering the above-mentioned case. Cervenak and McCullough argue that, “the previable fetus becomes a patient when the pregnant woman confers that status on it. The viable fetus becomes a patient when the pregnant woman is presented for obstetrical care.”⁴ They further maintain that, “when a fetal anomaly of any kind is diagnosed in pregnancy before viability, the physician should explain the nature and prognosis of the anomaly and offer both continuation of the pregnancy and induced abortion.” Presenting the full range of options to the pregnant woman fulfills the physician’s obligation of informed consent and enables the patient to make her own decision regarding their pregnancy. Wilkinson underscores this concept by asserting that physician counseling following prenatal diagnosis should be nondirective. This is only more so in the circumstances of uncertain prenatal diagnoses.⁵ However, a recent survey by Heusner et al indicated that, at least in the case of severe fetal anomalies, practitioners were somewhat directive in their counseling practices.⁶

In the presented case, guiding the patient toward a decision should be as information focused and nondirective as possible. The first step is to understand what the risk of a medication exposure is to the developing fetus. In this particular circumstance, good data exist to suggest that the highest risk period for in utero methotrexate exposure is between 6–8 weeks of gestation at doses greater than 10 mg a week.⁷ There have been case reports of pregnancies in which the fetus did not suffer any congenital anomalies, and this needs to be disclosed to the patient as well.⁸ Nonetheless, most clinicians would maintain that methotrexate is highly teratogenic and ought to be avoided in women desiring pregnancy.⁹ For some patients, this potential risk in the early embryonic stage will be of great enough concern that they elect early termination of pregnancy. Others may feel uncomfortable making any decision without a more realistic assessment of the actual risk of congenital anomaly occurring in the fetus. In these circumstances, referral to a maternal–fetal medicine specialist for a high resolution–screening ultrasound at the time following organogenesis can be helpful in determining whether a fetal malformation has occurred. Timing of this evaluation is crucial as patients who opt for a late-term termination upon discovery of an anomaly are restricted by state statutes on the timing of such procedures. While, arguably, antenatal diagnosis supports indication-based approaches to selective termination, I disagree with the notion that “Clinicians tend to understand prenatal diagnosis and termination of pregnancy as parts of the same clinical pathway, which shapes their clinical actions and decisions to a substantial degree.”¹⁰ Rather, I would maintain that prenatal diagnosis allows the clinician to impart important information to patients, thereby enabling them to make an informed autonomous decision.

Conclusion

How one should counsel the pregnant patient in the case of a potentially teratogenic medication exposure is difficult. The uncertainty as to whether the fetus has suffered teratogenic effects in addition to the interplay of both the treating clinician’s and patient’s religious, ethical, and philosophical beliefs contribute to the complex decision making these cases invoke. In these circumstances, the clinician needs to divorce his or her own beliefs from the decision-making process. This is best done by providing as much information to patients about potential risk to the developing fetus and, when appropriate, high-technology screening to assess for the development of a congenital anomaly. The clinician’s role is, therefore, to provide information, support, and appropriate referrals for management, but not to impart influence and judgment.

Dr. Bermas is the director of the Lupus Center and co-director of the Program in Pregnancy and Rheumatic Diseases at Brigham and Women’s Hospital in Boston.

References

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