Megan Clowse, MD, on Lupus in Pregnancy
Lupus is typically diagnosed in women during their reproductive years, making pregnancy a challenge for many women with lupus. There are several risks associated with pregnancy in patients with lupus, which include the risk of miscarriage, preterm birth, and maternal risk. Managing and monitoring lupus in women who are pregnant is vital to ensuring a safe childbirth.1
Consultant360 recently spoke with Megan Clowse, MD, who is an associate professor of medicine at Duke University School of Medicine. Dr Clowse focuses her research on rheumatologic diseases in pregnancy and will be speaking at the Association of Women in Rheumatology (AWIR) annual conference in August about lupus in pregnancy.2 Dr Clowse offered insight on how to treat a pregnant woman with lupus, as well as effective ways to communicate with these patients.
Consultant360: Your session at AWIR’s meeting is about lupus in pregnancy. What are the common misconceptions about treating lupus, or any rheumatic disease, in pregnant women?
Megan Clowse: An important misconception is that all pregnancies in women with lupus end in catastrophe. In fact, up to 80% of pregnancies in women with controlled systemic lupus erythematosus managed by experts result in a live, term infant.3 However, active lupus is harmful to pregnancies. Management with medications can prevent flares and control lupus, making pregnancy safer for the woman and her baby.
Hydroxychloroquine (HCQ) and azathioprine (AZA) are the safest lupus medications we have for pregnancy.
Prednisone is good for controlling significant lupus, but too much or unneeded doses can be risky. I try to limit the use of prednisone by treating with HCQ and AZA instead.
C360: What are the key takeaways from your session at AWIR’s meeting? What lessons do you hope practicing rheumatologists take home?
MC: The key to a safe lupus pregnancy is PLANNING the pregnancy. It is essential to ASK women about their desire for pregnancy in an OPEN way—try this: “Would you like to become pregnant in the next year?” This gives the woman the opportunity to be honest with you about what she wants. It will also give you the opportunity to either talk about contraception or pregnancy planning (or both).
This tactic is referred to as the “One Key Question” and has been shown in studies to improve pregnancy planning and decrease unplanned pregnancies.4
Many women with lupus do not tell their rheumatologist when they are trying to conceive. Many admit to being less than truthful about their reliable use of contraception to their rheumatologist, and many women with lupus do not think that their rheumatologist will ever give them the go-ahead for pregnancy, so they get pregnant without talking to their rheumatologist.
C360: A study you were previously involved with concluded that hydroxychloroquine may protect against congenital heart block from neonatal lupus. Which other treatment options are safe for maternal use?
MC: I’m going to give you the unsafe medications; it is a much shorter list. There are 3 main medications known to cause human birth defects: methotrexate, mycophenolate, and cyclophosphamide. All of these should be stopped at least 1 month prior to conception. Mycophenolate and cyclophosphamide are the most dangerous, causing birth defects in an estimated 1 in 4 live births. All 3 drugs cause around a 40% miscarriage rate.
C360: What is the next step in your research?
MC: My current goal is to enable all rheumatologists to provide expert-level pregnancy care for their patients. We are working on an in-person training session, which will be included in the AWIR meeting, to enhance communication around lupus in pregnancy planning and management. We are also building a website called HOP-STEP with information for both physicians and women with lupus to be able to get accurate and specific information to help guide decisions.
C360: What other knowledge gaps exist among rheumatologists regarding lupus and pregnancy?
MC: Knowledge about the newer contraceptive options is lower than I had expected—there are great, long-acting contraceptives now available that can prevent pregnancy for several years and are fool-proof. These include the IUD and Nexplanon®, and both are considered safe for women with lupus. While rheumatologists do not need to start putting these in their patients, they should mention them as the best form of contraception for them when pregnancy needs to be avoided. The rheumatologist may also need to send a note to the gynecologist or primary care physician, so they know that these contraceptive options are safe for women with lupus.
- Petri M. Lupus and pregnancy. The Johns Hopkins Lupus Center. https://www.hopkinslupus.org/lupus-info/lifestyle-additional-information/lupus-pregnancy/. Accessed June 25, 2018.
- Clowse M, Criscione L. Lupus and pregnancy: HOP-STEP. Association of Women in Rheumatology; August 16-19, 2018; Hilton Head, SC.
- Buyun JP, Kim MY, Salmon JE. Predictors of pregnancy outcomes in patients with lupus. Ann Intern Med. 2016;164(2):131. doi:10.7326/L15-0500.
- One key question: are you asking it? March of Dimes. https://www.marchofdimes.org/materials/one-key-question-overview.pdf. Accessed June 26, 2018.