Megan E.B. Clowse, MD, MPH, director of the Duke Automimmunity in Pregnancy Registry at Duke University Medical Center in Durham, N.C., began her presentation by explaining that pregnancy in lupus is not nearly as disastrous as most clinicians believe. Many lupus pregnancies are easy and result in a healthy baby and mother. Some lupus pregnancies, however, result in pregnancy loss, preeclampsia, preterm birth, and/or a very ill mother. Dr. Clowse’s talk focused on how to decrease the severity of the complications of lupus in pregnant women. Dr. Clowse suggested the use of daily aspirin (81 mg/day) to prevent preeclampsia.
A study of 275 pregnancies found that active systemic lupus erythematosus (SLE) in the three months prior to conception corresponded with a fourfold increase in pregnancy loss. Moreover, SLE activity during pregnancy doubled the risk of loss and preterm birth. Women with lupus nephritis also had an increase in pregnancy loss and preterm birth if the nephritis was active. One study placed the rate of pregnancy loss is as high as 50% in women with current nephritis and the rate of preterm birth close to 75%.
Dr. Clowse explained that the best way to achieve good pregnancy outcomes in patients with lupus is to counsel contraception when SLE is active. “Planning pregnancy is really important,” she said. Once conception has occurred, efforts should be made to maintain low SLE activity during pregnancy. In order to do this, the physician should monitor for rising SLE activity during pregnancy and promptly treat any SLE flare.
Women with lupus need to be counseled on the importance of contraception during active lupus. Dr. Clowse went on to explain her frustrations about practicing medicine in a state that provides abstinence-only education. A physician cannot presume that a woman in North Carolina has received a complete and accurate presentation on the steps necessary to prevent pregnancy. When counseled, many women were only familiar with abstinence—not a realistic option for a young married woman. Thus, physicians need to ensure that clear and accurate information is available on contraception options.
Once pregnant, the goal should be to maintain a low level of SLE activity, characterized as mild arthritis, rash, and mouth ulcers. While some women with mild SLE may be uncomfortable, this level of disease activity does not seem to have a significant effect on pregnancy. In contrast, high SLE activity (low platelets, active nephritis, severe arthritis, or rash) is associated with adverse pregnancy outcomes. In these situations, medications should be continued to prevent a flare.
