Dr. Chakravarty educates her patients to notify her right away if they become pregnant, even before they come in for their next visit. “There are two things: one is making sure they stop taking any teratogenic medications right away. The second thing is making sure that they don’t stop taking safe medicines. That’s just as important. Right away some patients say, ‘All medicines are bad,’ and they stop everything. Then they are at huge risk for a flare. It can make their disease unstable.” Dr. Chakravarty has patients come in as soon as possible to switch them to medications compatible with pregnancy, if necessary, and to provide further information and support.
Dr. Chakravarty notes that most of the time patients on teratogenic medications are not expecting to conceive. When women do unexpectedly become pregnant while taking such medications, Dr. Chakravarty tries to provide them with information. She notes that 85% of babies exposed to methotrexate will be born without significant birth defects. “I want to empower women to make the right choice for them. I give them all the information, all the connections with perinatology so they do other prenatal testing to see the best they can about any potential birth defects. Then they can make the most informed decision for where they are in their lives.”
She also talks to women about their lives to see if having a child is a reasonable option right now. “I also want to make sure that if they have time they can consider not continuing the pregnancy if they don’t want to.”
Improved Counseling Moving Forward
There remain large unmet needs in providing women with rheumatic disease the preconception counseling and planning that they need. Meeting these needs may require a variety of changes.
Dr. Birru Talabi suggests that better education during residency and fellowship may play a role in the future. She points out that literature suggests that some physicians who complete residencies in internal medicine (such as rheumatologists) receive inadequate training in contraception and family planning counseling.
She adds, “I think a systems approach will be important as well. This could include a series of prompts in the electronic medical record that provide an educational printout for patients. Or it could include prompts to help providers figure out what might be safe contraception options for a patient—are all really important things.”
Dr. Sammaritano agrees about the importance of ongoing physician and patient education and also notes the need for more specific clinical research in this area. Recently, Dr. Sammaritano, Dr. Chakravarty and some other clinicians initiated a reproductive health abstract category at the ACR and a yearly reproductive health study group. They are also working with clinicians from many medical backgrounds to produce ACR-sponsored clinical guidelines for reproductive health in rheumatic disease patients. These will be presented at the 2018 ACR/ARHP Annual Meeting. She notes that unfortunately many of the recommendations in these guidelines will be based on extrapolation from other studies, not from studies specifically focused on rheumatic disease patients.
