Preconception planning is essential to help women with autoimmune disease have optimal pregnancy outcomes. Unplanned pregnancy can also negatively impact disease course in some patients. Yet many rheumatologic patients of childbearing age do not receive adequate contraception or prepregnancy education and counseling. Rheumatologists must work collaboratively with other healthcare providers to make sure rheumatic patients have access to and receive these critical services.
Most autoimmune and inflammatory diseases seen by rheumatologists are more common in women, many of whom are of childbearing age. Historically, some women with rheumatologic diseases, such as lupus, were discouraged from becoming pregnant due to poor pregnancy outcomes. Lupus, for example, is associated with an increased risk of thrombosis, preeclampsia, infection, thrombocytopenia, Cesarean section, lower birth weight, preterm labor, and fetal and maternal mortality. Many other rheumatic autoimmune diseases, including systemic sclerosis, rheumatoid arthritis, vasculitis, and inflammatory myopathies, have also historically been associated with poorer pregnancy outcomes.1,2
Fortunately, rates of such adverse outcomes have substantially decreased over the past several decades, probably due to changing treatment options and better guidance for lowering pregnancy risk.1 With proper care, most women with rheumatic autoimmune disease can now complete a pregnancy safely, although a small percentage of women may not be able to do so because of severe disease-related damage.
These improvements highlight the importance of proper disease care and family planning. For example, in women with rheumatoid arthritis, lupus and inflammatory myopathies, well-controlled disease at conception and during pregnancy is less likely to result in preterm deliveries and underweight deliveries. By contrast, in studies of women with vasculitis, inflammatory myopathies, systemic sclerosis, lupus and antiphospholipid antibody syndrome, poorly controlled disease has been linked to such problems as intrauterine growth restriction, cesarean section and fetal loss.2
Most commonly, disease that is active at the start of pregnancy will remain so throughout the pregnancy, putting mother and baby at increased risk. Active disease at the start of pregnancy may also increase the risk of a postpartum flare.3
Pregnancy also worsens disease symptoms in some patients, especially in certain diseases such as lupus. Although it was previously thought that symptoms improved during pregnancy in some types of rheumatic disease, such as rheumatoid arthritis, it has become clear that this is not always the case.4
Another important consideration is that many women with rheumatic autoimmune disease take teratogenic medications. For all these reasons, it is critical that women with rheumatic autoimmune disease receive proper family planning services.
It is not only women with rheumatic disease who have unmet contraceptive needs: 45% of pregnancies in the U.S. are unplanned.5 But in many patients with rheumatic disease, the risks and consequences are higher.