Pregnant women with autoimmune-related interstitial lung disease (ILD) can have safe pregnancy outcomes if closely monitored by a multidisciplinary team of physicians.
While pregnant patients with ILD have a higher risk of adverse outcomes, termination may not be needed if women are carefully monitored before, during, and after pregnancy. Megan E. B. Clowse, MD, MPH, associate professor of medicine, Division of Rheumatology and Immunology at Duke University and colleagues presented this research at the American College of Rheumatology’s November 2020 Convergence meeting.
Patients with ILD develop scarred lung tissue from inflammation that may result in difficulty breathing. The condition may accompany other autoimmune diseases such as lupus, sarcoidosis, and scleroderma. Avoiding or terminating pregnancy is often recommended to these patients due to limited data on adverse pregnancy outcomes for women with ILD.
To conduct the study, Clowse and colleagues used Duke University Health System medical records to study retrospective data on pregnant patients with ILD secondary to autoimmune disease from January 1996 to July 2019. The research team classified pregnancies according to ILD severity based on forced vital capacity and diffusion capacity for carbon monoxide, and set cut off values for mild, moderate, and severe lung disease. To date, this is the largest cohort ever studied to improve pregnancy recommendations for women with ILD.1
Ninety-four pregnancies were examined among 67 women, with 5 being twin pregnancies. Eighty-three percent of women identified as Black, and the average maternal age was 32.1. Clowse and colleagues defined adverse outcomes that included neonatal death, fetal death, small for gestational age, preterm delivery, and preeclampsia, according to the PROMISSE-APO and PROMISSE-APO SEVERE standard scores.
Sarcoidosis was diagnosed in 69% of pregnant patients, while 31% had an ILD- associated connective tissue disease. Eleven percent of pregnant patients were classified as having severe ILD, 25% moderate, 50% mild, and 14% normal. The severe ILD group only consisted of pregnant patients with ILD-associated connective tissue disease, while sarcoidosis was present in 89% of normal pregnancies. Seven pregnant patients had been taking mycophenolate during conception, which is documented as causing major birth defects and pregnancy loss.
The results of the study revealed 70% of pregnancies resulted in live birth, and none of the women died. ICU care only was required for 2.1% of patients during or immediately following delivery. Ten percent of pregnancies were terminated, and 15% of pregnant patients were diagnosed with pre-eclampsia.
The study found that pregnant patients with severe ILD had more adverse outcomes. Increased fluid volume in the lungs around the time of delivery resulted in 4.2% of patients with ILD to experience significant shortness of breath, and one patient developed heart failure postpartum. One patient required intubation for asthma during mid-pregnancy, while 8 pregnancies required oxygen delivered to the patient during delivery.
Clowse told Contemporary OB/GYN that the most significant aspect of the study is the change in pregnancy recommendations for pregnant patients with autoimmune-related ILD. “Historically, we have been nervous about women with chronic lung disease and pregnancy, but the data from this study demonstrates that these pregnancies went remarkably well. There are certainly risks, but our patients do better than previously anticipated. These patients really can have healthy pregnancies if we work with them.”
She added that treatments for patients with lupus, sarcoidosis, and a range of other rheumatological diseases are different. “Many of the study patients with sarcoidosis were not taking immunosuppressant medication during pregnancies, but patients with rheumatic disease like lupus continued their anti-rheumatic medications throughout pregnancy to control their diseases. There are multiple safe medications available to treat lupus and ILD during pregnancy, so patients do not need to stop their medicine,” she said. She also noted that an updated guideline publication is available from the American College of Rheumatology for rheumatic medications in pregnancy.
“It is important that we come up with a good plan for these patients that involves careful monitoring,” Clowse told Contemporary OB/GYN. “We also still need more data in the form of larger, prospective, multicentered studies that can tell us how these patients do in pregnancy and how we can manage them best.”
Safe pregnancy is possible for women with interstitial lung disease. November 2020. https://www.eurekalert.org/pub_releases/2020-11/acor-spi110520.php. Accessed November 13, 2020.