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A New Outlook on Pregnancy in Women with Lupus

Until just a few decades ago, women of reproductive age with certain rheumatic diseases were told that they should not become pregnant because of the risks both to them and to their unborn children. Fortunately, advances in diagnosis and treatment have dramatically improved outcomes for people with rheumatic disease, including women wishing to become pregnant.

"In the 1980s, experts started to recognize that women needed to be in remission from their disease when they tried to get pregnant," says rheumatologist Bella Mehta, MBBS, MS. "There also began to be more emphasis placed on good communication between rheumatologists and maternal-fetal medicine specialists."

"This study showed us that … women are having successful deliveries," says Dr. Mehta.

But to what degree these advances have impacted pregnancy in women with rheumatic disease has not been clear. In 2019, Dr. Mehta and colleagues published a study in the Annals of Internal Medicine that looked at pregnancy outcomes between 1998 and 2015 in women with systemic lupus erythematosus using data from the National Inpatient Sample database. They found that during that period, in-hospital maternal deaths in women with lupus decreased significantly, from 442 per 100,000 to less than 50 per 100,000. Complications such as preeclampsia also decreased.

The improvements observed in this study were good news for women with lupus — and their doctors. "This study showed us that more women are attempting pregnancy, most physicians are not recommending against it and women are having successful deliveries," says Dr. Mehta.

But she emphasizes that further progress is still needed. Maternal death rates in women with lupus were still much higher than those in women without the disease (for whom deaths numbered 10 per 100,000 in 2015). Other specific concerns noted in the study included higher risks of fetal death, higher incidence of preeclampsia and eclampsia, longer hospital stays and increased rates of caesarian sections and hospital admissions not related to delivery.

Addressing Reproductive Health at Every Stage of Life

In addition to Dr. Mehta’s study, recent work led by rheumatologist Lisa Sammaritano, MD, focuses on new comprehensive guidelines for the reproductive health of women with lupus and other rheumatic conditions.

"Questions about reproductive health and pregnancy come up again and again with our patients," says Dr. Sammaritano. "This is especially true because autoimmune disorders tend to affect women at much higher rates than men — including women of childbearing age."

The forthcoming American College of Rheumatology guidelines address aspects of reproductive health at every stage of a woman’s life. This includes direction on the most effective and safe forms of birth control for an individual patient, the use of various medications for rheumatoid disease during pregnancy and while breastfeeding and the benefits and drawbacks of taking hormone replacement drugs to relieve menopause symptoms.

"The guidelines are directed at rheumatologists, but we think they will also be helpful to obstetriciangynecologists," Dr. Sammaritano says. "They are very specific in that they give recommendations for a number of different rheumatic diseases. This was important to include because not all autoimmune disorders call for the same management."

Dr. Sammaritano is also involved in setting up a reproductive health center within the Barbara Volcker Center for Women and Rheumatic Diseases at HSS.

"For years we’ve been treating pregnant women and consulting with their obstetrician-gynecologists," she says. "Formally establishing the new center will make the care we offer more structured and more widely available. It will also provide a way for us to involve our fellows and improve their education, collaborate more fully with our obstetrics and gynecology colleagues and further our research into the specific challenges for people with rheumatic disease." Page


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