Modifying Predictors of Adverse Maternal and Obstetric Outcomes in SLE

Contraception in SLE

Contraceptive choices for women with SLE are the same as for other women, although a number of medical concerns influence the decision. The 3 main classes of contraception are barrier methods, oral or implanted hormones, and intrauterine devices (IUDs).

Among women with SLE, contraception performs a dual function. In addition to preventing unwanted pregnancy, contraception is important to establish optimal timing of pregnancy to quiescent periods of disease to reduce the risk for lupus complications. Although contraceptive efficacy is always important, it is critical to the well-being of the woman with SLE.

A literature review by Yazdany and colleagues19 identified 1-year failure rates for barrier methods ranging from 15% to 21%. Failure rates for the cervical cap were as high as 32% in women who had previous term pregnancies. In comparison, the authors reported much lower failure rates for hormonal methods, ranging from 3% for medroxyprogesterone injection to 8% for the hormonal patch, ring, progestin-only, and combination estrogen-progestin oral contraceptives (OCs).19 The failure rate for IUD use is approximately 2% per year.16

Barrier methods

The majority of women with SLE who do use contraception use barrier methods, including male and female condoms, diaphragm with spermicide, and the cervical cap.17 Barrier methods are inexpensive, easily accessible, and associated with few complications; however, they are not highly effective. Because of the significant differences in contraceptive reliability among barrier methods, the Centers for Disease Control in 2010 recommended against the use of behavioral and barrier methods as the only contraception techniques.18

Special concerns about OCs in women with SLE

The use of OCs by women with SLE has been somewhat controversial for a number of reasons. The high prevalence of SLE among women of childbearing age strongly points to a hormonal interaction. Fluctuating hormones late in pregnancy have also been associated with SLE flares in some studies,20-22 contributing to the belief that hormonal contraceptives would include a similar risk. Therefore, estrogen-only formulations are generally contraindicated in these women.16 In 2010, Duarte and Ines reported on a number of studies that contradicted this risk. They concluded that, overall, data from multiple randomized controlled trials suggests that the use of low-dose combination OCs is unlikely to increase the risk for disease flares.20

A more significant concern with OC use is the increased potential for thromboembolic events. The presence of antiphospholipid antibodies is a common feature in SLE that already predisposes these women to thrombotic risk.23,24 Thrombolysis is reported to occur in 13.3% to 22% of those with SLE, and a 2016 study reported an incidence 27- to 43-fold higher than in the general population.25-29

Intrauterine Devices

The risks of IUD use are the same for those with SLE as for the general population. These include a 5% rate of device expulsion and the risk for irregular bleeding and infection post-insertion, making this method unsuitable for women with a history of lupus nephritis.16 IUDs must be replaced every 5 years, with careful monitoring during the time the device is used. If these concerns are managed, this method is a good choice for many women with SLE because it provides the highest degree of protection against pregnancy without the risk for disease flares associated with OCs.

Summary and clinical applicability

Contraceptive counseling is essential for women with SLE to select the safest, most reliable method to prevent immediate conception. Similarly, counseling is important to the planning of pregnancy to allow for conception at a quiescent period in SLE, which allows the best possibility to ensure an uneventful pregnancy and delivery of a healthy child.

All women who are being treated for SLE should be counseled routinely about the risks of unintended pregnancy and the opportunity to reduce these risks through effective contraception. Women who are planning to become pregnant should be monitored by their physician to reach a minimum period of 4 months of inactive disease before attempting conception.

References

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