The safest and most effective options most rheumatology patients can use to control when they become pregnant are long-acting reversible contraceptives, including intrauterine devices (IUDs) and devices implanted under the skin, Dr. Sammaritano explained. Condom use alone carries a high risk of unintended pregnancy. Hormone-based pills and patches may be good options for some patients, but those at high risk for blood clots should avoid birth control options with estrogen. These patients include those with highly active systemic lupus erythematosus (SLE) and those with antiphospholipid (aPL) antibodies.
According to the 2020 ACR Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases, for which Dr. Sammaritano was the lead author, most patients with rheumatic diseases underuse effective contraception and may experience unplanned pregnancies. This situation exposes them to risks, such as worsened disease activity, that can threaten maternal health and well-being and lead to adverse pregnancy outcomes, such as pregnancy loss, severe prematurity and limited fetal growth. Some medications used to control rheumatic disease can also result in birth defects if taken during pregnancy.1
“Having really active disease, particularly in your kidneys, increases your risk for pregnancy loss. Having hypertension or high blood pressure that is not well controlled with medications, increases the risk. … Antiphospholipid syndrome … increases the risk of pregnancy loss,” said Dr. Clowse. Most of these risks can be managed, she continued, noting the best course of action is to “delay a pregnancy until you’re sure that you’re [in the] safest spot.”
Emergency contraception, such as over-the-counter progesterone pills, is considered safe for all patients with rheumatic disease, especially given the risks of unplanned pregnancy to some patients.
However, some patients with rheumatic diseases may experience reduced fertility because of their disease or medications, and this, too, may warrant planning, the speakers said. Of the medications used to control disease activity, cyclophosphamide is known to reduce fertility in women because it can cause ovarian failure. Some non-steroidal anti-inflammatory drugs (NSAIDs) may transiently prevent ovulation, and high-dose corticosteroids can also interfere with ovulation and successful conception.
“Methotrexate, mycophenolate, azathioprine, tacrolimus and our biologic medications do not have a negative effect on fertility,” Dr. Sammaritano said.
However, not all of these medications are safe to use during pregnancy. Example: Mycophenolate and methotrexate are teratogens, which can cause birth defects or pregnancy loss if taken during embryonic or fetal development.
