Baby on Board: The Rheumatologist’s Role in Family Planning for Patients with Lupus

ATLANTA—Although rheumatologists may not consider family planning a core competency of their specialty, discussions about contraception, fertility, pregnancy and breastfeeding are critical when caring for patients with rheumatologic conditions. This topic is, perhaps, most significant for patients with systemic lupus erythematosus (SLE). During a session at the 2019 ACR/ARP Annual Meeting, Transform SLE Pregnancies: Prepared Providers, Empowered Patients, multiple presenters spoke directly to this point.

Prevention
Mehret Birru Talabi, MD, PhD, assistant professor of medicine at the University of Pittsburgh, began the session by describing how contraception is underutilized in women with SLE. In a study of 206 women involved in the University of California, San Francisco, Lupus Outcomes Study, 59% of these patients had not received contraceptive counseling in the preceding year. Additionally, 22% reported inconsistent contraceptive use, and 53% depended solely on barrier methods of contraception. The more reliable contraceptive method—in which a hormone-releasing or copper intrauterine device (IUD) is placed within the uterus—was used by only 13% of patients.¹

Rheumatologists may feel discussing contraceptive methods is outside their scope of practice, Dr. Talabi noted. But rheumatologists are uniquely qualified to provide anticipatory guidance on all aspects of living with an autoimmune disease. Family planning clearly falls into this category. Among the most effective methods of contraception are surgical interventions, such as tubal ligation and vasectomy; contraceptive implants, such as hormone-releasing implants placed under the skin of the upper arm; and IUDs. These methods are beneficial because they are long lasting, are not contraindicated in lupus patients and eliminate the potential for human error inherent to other birth control methods, such as taking an oral medication or correctly positioning a barrier contraceptive.

Dr. Talabi discussed how to use the resources on www.bedsider.org, an online birth control support network providing extensive guidance from obstetricians and gynecologists with the goal of preventing unplanned pregnancies.² The website includes descriptions and photos of various contraceptive methods, and access to online and smartphone applications that allow patients to set reminders to use their contraception. Additionally, the site offers user-generated content, including articles on personal experiences with contraception and family planning.

Pregnancy & Medication
The session’s second speaker was Bonnie Bermas, MD, the Dr. Morris Ziff Distinguished Professor in Rheumatology at UT Southwestern Medical Center, Dallas. Dr. Bermas described how the U.S. Food and Drug Administration’s (FDA’s) newly improved pregnancy and lactation labeling has helped clinicians determine which medications are safe for lupus patients while pregnant and breastfeeding. Previously, the FDA categorized risks of taking a drug or biological treatment during pregnancy under a five-letter system (A, B, C, D and X) based on what was known about that product. But many providers found this system confusing, overly simplistic and, sometimes, prone to resulting in false assumptions about medications based on limited data.