Dr. Clowse spoke on the subject of reproductive counseling for patients with rheumatic conditions, a topic that has been the focus of much of her research and scholarship.
Dr. Clowse
Risks & Pregnancy Termination
She began by explaining that rheumatic diseases can be associated with increased risks for both mother and baby, and include the increased risk of preterm delivery and pre-eclampsia seen in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis.
The incidence rate of induced abortions among women with SLE is about 17 per 1,000 person-years, a similar rate of induced abortions as in the general population.1 Patients with SLE often have medical indications for this procedure. Many patients with SLE are exposed to teratogens, such as methotrexate or mycophenolate mofetil, and complicated pregnancies in which the health of the baby or mother are affected can have lasting consequences for patients.
In the U.S., pregnancy termination has historically been an option for women when there may be health consequences of continuing the pregnancy, but Dr. Clowse noted that the changing abortion laws in the wake of the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization in 2022 have limited accessibility of this procedure based on where a patient resides.2,3
A Pregnancy Plan
Pregnancy planning often makes a significant difference in choosing the right time to conceive. However, real-world experience has shown that there is a wide range of planning for pregnancy seen in patients with rheumatic diseases, and unplanned pregnancies are not uncommon.
It’s important to consider whether an individual patient is medically and personally ready for pregnancy and to counsel patients on this subject, noted Dr. Clowse. Rheumatologists must be open and honest with patients in discussing preferences about if and when to conceive. Offering clear, concise, evidence-based information on the topic helps build trust.
Dr. Clowse and colleagues have developed a program called HOP-STEP, which stands for Healthy Outcomes in Pregnancy with SLE Through Education of Providers. The program has three steps: 1) ask 2) discuss and 3) share.
In the Ask step, providers should inquire what type of contraception a patient is using and what planning the patient is or is not doing with regard to pregnancy. A simple question to ask is, “Do you want to be pregnant in the next 12 months?”
The Discuss step should be a personalized, supportive conversation replete with accurate information to guide decisions. Dr. Clowse and colleagues have developed discussion guides for this conversation that can be printed and used with patients. Easy-to-use HOP-STEP guides on birth control in lupus and other rheumatic diseases exist. Rheumatologists can use these guides to assist in complex discussions for which they may feel inadequately prepared or uncomfortable.
Share: The written guides are also helpful for patients and family members because they can be brought home from the clinic and read more than once. Much of this information can then be made available to other providers. Patients can be asked to take these guides to their OB/GYN to make sure all specialists are on the same page.
Fast Facts
Dr. Clowse shared several pearls with regard to reproductive counseling. For example, progesterone-only birth control pills are very safe, but they are less effective than other forms of contraception that don’t require the frequent oral administration of a medication.
It is important to encourage patients to use more than one form of birth control at a time, such as an intrauterine device (IUD) as well as condoms.
Emergency contraception, such as Plan B, is progesterone only and, thus, is safe; no prescription is needed, and it does not cause an abortion if the patient is already pregnant.
Patients may answer the question “Is my lupus well controlled?” differently than their clinician might, given what control of lupus means to them. To a rheumatologist, disease control often has to do with measuring inflammatory markers, looking for proteinuria or signs of organ involvement, and ensuring that there is no ongoing need for corticosteroids. However, for a patient, symptoms such as fatigue and myalgias that are common in lupus may still be present and, therefore, may indicate to the patient that their disease is active even when it would be safe for them to become pregnant.
Medication Guides & More
With regard to medication recommendations, the guides developed by Dr. Clowse and colleagues include information on which treatments are safe, or not safe, in pregnancy. Azathioprine tends to be a go-to medication that is compatible with pregnancy, and all patients with SLE should be on hydroxychloroquine, which is known to reduce lupus disease activity and adverse outcomes in pregnancy.4-7
If a change in medication is made, it may sometimes be reasonable for a patient to wait three to nine months after this change before conceiving to ensure the new medication regimen remains effective.
Dr. Clowse encourages providers to have a plan for other issues that may arise. Examples include appropriate anticoagulation for patients with antiphospholipid syndrome, monitoring for congenital heart block in patients with anti-SSA antibodies, avoidance of ACEi/ARB medications during pregnancy and plans for how to manage pain during pregnancy.
Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.
References
- Venne K, Scott S, Bernatsky S, Vinet E. Induced abortions in women with systemic lupus erythematosus. Lupus. 2021;30(3):484–488.
- Dobbs, State Health Officer of the Mississippi Department of Health, et al. v. Jackson Women’s Health Organization et al. U.S. Supreme Court. 2022 Jun 24.
- Bermas BL, Blanco I, Blazer AD, et al. Overturning Roe v. Wade: Toppling the practice of rheumatology. Arthritis Rheumatol. 2022 Dec;74(12):1865–1867.
- Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken). 2020;72(4):461–488.
- Sperber K, Hom C, Chao CP, et al. Systematic review of hydroxychloroquine use in pregnant patients with autoimmune diseases. Pediatr Rheumatol Online J. 2009 May 13;7:9.
- Clowse MEB, Magder L, Witter F, et al. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum. 2006 Nov;54(11):3640–3647.
- Costedoat-Chalumeau N, Amoura Z, Duhaut P, et al. Safety of hydroxychloroquine in pregnant patients with connective tissue diseases: A study of one hundred thirty-three cases compared with a control group. Arthritis Rheum. 2003 Nov;48(11):3207–3211.
