So, how can we optimize the chances for pregnancy success for a woman with SLE? Are there strategies that we can use to decrease her risks? Can we improve her chances of delivering a full-term, healthy baby? Fortunately, I think that we can. Here are some of the steps that we, as rheumatologists, can take to help our patients grow healthy babies.
Step 1: Conceive when Lupus is Quiescent
To give a pregnancy the best chance for success, the woman should have quiet lupus at the time of conception. The importance of lupus activity at the time of conception has been known for years.10 The Hopkins Lupus Cohort offers a clear demonstration of the negative effects of SLE activity at conception. In this cohort of 265 pregnancies, 42% of women with SLE activity in the six months prior to conception suffered a pregnancy loss, compared with 11% who conceived during a period of quiescence.11 Similarly, lupus activity in the first trimester – whether assessed with a physician’s global assessment, thrombocytopenia, or proteinuria – led to a several-fold increase in pregnancy loss over more stable SLE patients.12
Though the timing of any pregnancy can be challenging, it is clearly important in women with SLE. Women with active lupus should be offered contraception in order to avoid the pregnancy tragedies that may result. Because women on cyclophosphamide may still be fertile during therapy, a pregnancy test should be performed prior to each intravenous dosage and contraception should be encouraged. Good contraception options for women with active lupus include progesterone-only pills or the Depo-provera shot, an intrauterine device (IUD), or barrier methods (condoms or a diaphragm). Though estrogen-containing oral contraceptives may be safe for women with mild or inactive lupus, they have not been tested in women with significant disease activity.13,14
It is important to weigh the potential risks of each medication to the developing fetus versus the benefit of each in maintaining low lupus activity prior to and during pregnancy.
Step 2: Continue Some Medications, Discontinue Others
The need to conceive when lupus is quiet brings us to the use of medications to control lupus activity. Discontinuing all medications when a woman is ready to conceive will often prompt an SLE flare, thus endangering her pregnancy. Therefore, it is important to weigh the potential risks of each medication to the developing fetus versus the benefit of each in maintaining low lupus activity prior to and during pregnancy. (See summary in Table 1.)
