Patient with Long-Term Lupus Seeks Advice after Becoming Pregnant with Twins

Rheumatic diseases require specialized care for high-risk pregnancies

Quick Case Study

After learning that she was pregnant with twins, a woman with a 10-year history of systemic lupus erythematosus (lupus) sought a consultation from a Duke clinic created for women with rheumatological rheumatic diseases who are pregnant or considering pregnancy. The Duke Autoimmunity in Pregnancy Clinic is one of only a few of its kind in the country. The patient, 35, had been receiving care from Duke specialists for several years as she underwent two hip replacements to repair bone damage related to severe avascular necrosis (AVN), a condition common among young women with lupus who require high levels of prednisone to manage inflammation. 

The patient’s most severe lupus symptoms had diminished before she presented to Megan E. B. Clowse, MD, MPH, the Duke rheumatologist who leads the clinic. But the patient had been prescribed apremilast by another rheumatologist to treat arm and hand pain resulting from a recent episode of psoriatic arthritis and rheumatoid arthritis. Because of her long history with rheumatic disease, the patient was anxious about the health of the twins.

Question: Given the patient’s current medication and concerns about her pregnancy, what actions did Clowse take to manage the rheumatic diseases and ensure the health of the twins during the pregnancy?

Answer: Clowse immediately halted the use of apremilast, which has very limited safety data in pregnancy, and switched the patient to hydroxychloroquine, which is safe for use during pregnancy. To decrease the risk of preeclampsia and preterm birth, Clowse also prescribed aspirin. She reassured the patient that a full-term pregnancy was possible. 

The patient delivered two healthy boys at 36 weeks. “She developed preeclampsia at the end of the pregnancy, but it occurred at the point when she was nearly full term,” Clowse says. “Given the challenges she faced with lupus and psoriatic arthritis, this patient has had a very good outcome.” 

Under Clowse’s direction, the Duke clinic encourages the use of anti-rheumatic drugs such as hydroxychloroquine to relieve symptoms of rheumatologic disease during pregnancy.  Controlling and preventing inflammation during pregnancy using medications compatible with pregnancy is thought to increase the likelihood of delivery of a healthy baby to a healthy mother. The use of aspirin reduces the risk of preeclampsia by about 20 percent, Clowse says.

According to Clowse, another important factor in the patient’s successful pregnancy was the work of Samuel S. Wellman, MD, a Duke orthopaedic surgeon specializing in joint replacement, who helped resolve the patient’s AVN with two complex surgeries before she became pregnant. 

“AVN can be very painful, and the medications we use to treat lupus patients don’t touch it,” Clowse says. “Our only treatment is pain medicine. The early surgical solution proved to be a great help for a woman who would be carrying extra weight with twins.”