Other helpful resources on contraceptives include The Centers for Disease Control’s “U.S. Medical Eligibility Criteria for Contraceptive Use,” which provides more detailed contraceptive information for women with specific medical conditions.15
Trying to Conceive
Ideally, patients and doctors should collaborate about the best time to start trying to conceive. It is important that patients understand that this will give them the best chance of a healthy pregnancy.
“If someone is trying to conceive, I do everything I can to try to get their disease as controlled as possible,” explains Dr. Chakravarty. “Then I make sure that they are on medicines that they can continue to take throughout their pregnancy, because even changing a medicine could destabilize the disease and then make the pregnancy higher risk.”
Ideally, any high-risk medications should be switched over several months prior to conception. Such medications include cyclophosphamide, methotrexate, mycophenolate mofetil and leflunomide.1 (Note: For further information on drug safety information during pregnancy, the CDC’s “Treating for Two” is a helpful resource.)
As part of a preconception planning, physicians should also assess possible disease damage that might preclude pregnancy. Clinicians may also need to check for autoantibodies that increase pregnancy risk, such as aPL antibodies and anti-Ro/La antibodies (which increase the risk of neonatal lupus syndrome).16 From there, physicians can synthesize this information and discuss risks, recommendations and prognosis with the patient.
This is part of the reason it is beneficial for clinicians to have ongoing conversations with patients about their pregnancy plans. “If I have somebody that I need to start on a medicine, and they are thinking about getting pregnant in 18 months, then I’m going to go ahead and get them started on a medicine they don’t have to stop and change,” notes Dr. Chakravarty.
Patients desiring pregnancy should also be started on folic acid supplementation, to reduce the risk of birth defects. This is especially important for patients who have been given methotrexate previously. These patients should be given 1 mg daily prior to conception and at least through the first trimester.3
Occasionally, a physician will encounter a patient who desires pregnancy even when it poses a substantial risk to her health. This can be challenging for clinicians, but Dr. Birru Talabi encourages clinicians to try to provide information nonjudgmentally while continuing to support these patients. “Women are not making pregnancy decisions necessarily based on their disease or their medications. There are lots of personal factors that go into these decisions. In order to get on the same page with patients, we have to have an open ear, and we have to be respectful of them. If patients sense that we are judging them, they will not look to us as the resources that we can be.”
Counseling a Patient Unexpectedly Pregnant
Even though it is ideal for women with rheumatic autoimmune diseases to plan their pregnancies, this does not always happen.
