Fertility Treatment
When women with lupus undergo fertility treatment, rheumatologists should work closely with the reproductive endocrinology and infertility (REI) specialist to ensure the best possible outcomes. The rheumatologist must monitor the medical condition in women undergoing assisted reproductive technologies.
Rheumatologists should also have some basic familiarity with the medications used in fertility treatment as they can affect lupus activity. In particular, drug-induced estrogen levels during this treatment can be up to 20 times higher than those seen in a normal menstrual cycle, and hyperestrogenemia may precipitate a flare in some women.
It is not yet clear whether drugs that produce elevation of endogenous estrogen levels, such as clomiphene citrate (Clomid), have the same effect as drugs that deliver a large amount of synthetic, exogenous estrogen, such as the combined oral contraceptive.
Management in Pregnancy
When managing lupus during pregnancy, remember that it is a two-way street: The disease may affect the pregnancy, and the pregnancy may affect the disease. Of all the diseases out there, lupus is the perfect example of this phenomenon.
Rheumatologic assessments during pregnancy entail monitoring disease activity with vigilance for problems and awareness of special issues posed by pregnancy, such as hypercoagulability. Clinical course can be difficult to predict as the sensitivity of lupus to the hormonal changes of pregnancy varies on a case-by-case basis.
Pregnant patients with lupus are typically seen by a rheumatologist every 1-8 weeks depending on disease activity and other issues. Routine lab work is generally repeated roughly every 4 weeks, unless circumstances require more frequent monitoring, but serology does not have to be done that often.
Certain factors present in the first trimester are associated with a poor prognosis and may warrant discussion of termination. They include active disease, hypertension, proteinuria of at least 2 g/day, and an increased serum creatinine level.
If patients have ever had renal impairment from their lupus, no matter how stable they are going into the pregnancy, you are likely to see elevated protein excretion between 20 and 25 weeks. This is caused by the increased glomerular permeability that occurs in pregnancy, and patients can develop significant proteinuria.
Although management in the lupus patient during pregnancy is a multidisciplinary team effort, it is wise to have a lead internist coordinating all of the patient’s care. Often, pregnancies in this population result in involvement of many subspecialists, sometimes to the detriment of good communication.
Dr. Laskin disclosed that he has affiliations with Amgen, GlaxoSmithKline, Janssen Pharmaceutical, and UCB Pharma.
Dr. Laskin is founding director of the Obstetric Medicine Program at the University of Toronto and a founding partner of the LifeQuest Centre for Reproductive Medicine, also in Toronto.