The Looming Crisis in Rheumatology: Why Proactive Pregnancy Planning is No Longer Optional
A staggering 37% of women with systemic lupus erythematosus (SLE) aren’t personally ready when they become pregnant, a figure revealed in recent research and highlighted at the 2025 Congress of Clinical Rheumatology West. This isn’t just a matter of personal readiness; it’s a potential cascade of negative outcomes – from increased rates of depression and medication mismanagement to significantly higher risks of preterm birth and preeclampsia – all compounded by a rapidly shifting legal landscape surrounding reproductive healthcare. The era of passively discussing pregnancy with rheumatology patients is over; proactive, comprehensive planning is now a clinical imperative.
The Ripple Effect of Unplanned Pregnancies in Autoimmune Disease
Dr. Megan E.B. Clowse, chief of rheumatology and immunology at Duke University School of Medicine, underscored the critical link between pregnancy planning and positive outcomes for both mother and child. Her team’s analysis of 115 pregnancies in women with SLE from 2018-2023 revealed a stark disparity: while 68% of pregnancies were deemed “medically ready” – defined by adherence to American College of Rheumatology guidelines regarding disease activity and medication management – a substantial 32% were not. This lack of medical readiness translated directly into poorer outcomes.
“We saw higher rates of withholding pregnancy-safe medications, increased SLE activity during pregnancy, and a threefold increase in the risk of preterm birth and preeclampsia in those pregnancies not considered medically ready,” Dr. Clowse explained. But the consequences extend beyond the physical. The study also highlighted a significant correlation between unplanned pregnancies and increased rates of depression, particularly among women who weren’t prepared for motherhood. This aligns with growing recognition of postpartum mental health challenges and the unique trauma associated with pregnancy loss.
Reproductive Trauma: A Growing Concern
The emotional toll of unplanned or complicated pregnancies is increasingly recognized as “reproductive trauma,” a term gaining traction as younger generations openly discuss miscarriage, stillbirth, and pregnancy loss. Research presented by Dr. Clowse revealed a sobering statistic: mothers experiencing stillbirth demonstrated a 2.5 to 6 times increased risk of depression for up to three years post-loss, while fathers faced a sixfold increase in depression risk even sooner. Furthermore, 60% of women with stillbirths met the criteria for post-traumatic stress disorder (PTSD).
Beyond Medical Readiness: The Importance of Personal Preparedness
While medical optimization is crucial, Dr. Clowse emphasized the importance of addressing the patient’s personal readiness for pregnancy. Open-ended questions – “Are you thinking about having children anytime soon?” – can initiate these vital conversations. The 63% of women in the study who felt personally ready experienced significantly fewer negative outcomes, highlighting the power of agency and informed decision-making.
Navigating a Legal Minefield: Abortion Access and Methotrexate
The urgency of proactive pregnancy planning is further amplified by the increasingly complex and fragmented landscape of abortion laws in the United States. As Dr. Clowse illustrated, restrictions vary dramatically from state to state, creating a confusing and potentially dangerous situation for patients. This variability underscores the need for clinicians to be aware of the laws in their region and to provide patients with accurate information.
However, a point of relative clarity exists regarding the use of methotrexate and mycophenolate, immunosuppressants commonly prescribed in rheumatology that can also induce abortion or increase pregnancy loss risk. Dr. Clowse clarified that prescribing these medications for the treatment of rheumatic disease, with clear documentation of the intended purpose, does not expose clinicians to legal repercussions even if a pregnancy is subsequently lost. This distinction is crucial for protecting both patients and providers.
The Future of Rheumatology and Reproductive Health
The convergence of autoimmune disease, reproductive health, and a volatile legal environment demands a paradigm shift in rheumatology care. Moving forward, clinics will need to integrate routine pregnancy planning discussions into standard practice, offering comprehensive counseling on medication management, disease activity optimization, and the potential emotional and legal implications of pregnancy. This proactive approach isn’t just about preventing adverse outcomes; it’s about empowering patients to make informed decisions and safeguarding their reproductive health and overall well-being. What steps will your practice take to prioritize proactive pregnancy planning for patients with rheumatic diseases? Share your thoughts in the comments below!
