Pregnant women with interstitial lung disease (ILD) related to autoimmune disease may not necessarily need to terminate their pregnancies if they have close monitoring before, during, and after pregnancy with a multidisciplinary team of physicians, new research suggests.
Senior author Megan Clowse, MD, MPH, associate professor of medicine in the Division of Rheumatology at Duke University in Durham, North Carolina, explained at an ACR Convergence 2020 press conference on Friday that women with ILD are often advised by obstetricians or rheumatologists to avoid conception or terminate their pregnancy, though evidence for that has been based on small studies of 9-15 patients that have had mixed results.
Additionally, “Many of these pregnancies were delivered 20-30 years ago, definitely with different rheumatic and obstetric care than we can provide now,” she said. “It’s really time to rethink our approach to interstitial lung disease and pregnancy.”
This study showed that while adverse pregnancy outcomes are common in these women, overall maternal morbidity and mortality is low.
ILD may be a secondary disease in people who have scleroderma, lupus, and sarcoidosis.
Largest Study to Date
This Pfizer-sponsored retrospective study of 67 pregnant women is the largest to date, and it analyzed 94 pregnancies (including five sets of twins).
Sarah Rae Easter, MD, maternal-fetal medicine doctor in the Department of Obstetrics/Gynecology at Brigham and Women’s Hospital in Boston, Massachusetts, called the work “exciting” as the researchers were able to look back at a large number of cases for a rare condition for more than 20 years.
“Their data provides much-needed evidence to provide some reassurance for women affected by this type of pulmonary disease regarding the relative safety of pregnancy,” she told Medscape Medical News.
Study Spanned 23 Years
The researchers reviewed pregnancy records in patients diagnosed with ILD secondary to autoimmune disease at Duke University Health System from January 1996 to July 2019.
They classified the severity of ILD based on two standard breathing tests — forced vital capacity and diffusion capacity for carbon monoxide.
Overall, 69% of the women were diagnosed with sarcoidosis and the remaining 31% had a connective tissue disease associated with ILD (CTD-ILD). Of those measured for ILD severity, 11% were severe, 25% were moderate, 50% were mild, and 14% were normal. Their average maternal age was 32.1 and 83% were Black.
While 70% of the pregnancies resulted in live births, 9% were terminated. The remainder resulted in miscarriage or stillbirth.
Researchers report a 15% rate of preeclampsia, a 34% rate of the composite measure PROMISSE-Adverse Pregnancy Outcome (APO), and a 15% rate of PROMISSE-APO SEVERE. Patients with severe disease had the highest rates of PROMISSE-APO (P = .03 across groups).
(PROMISSE stands for the Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus study.)
None of the Women Died
Clowse said it was a pleasant surprise to find that none of the women died, though patients with severe ILD had more adverse outcomes. Only 2.1% were treated in an intensive care unit during or soon after delivery. In 4.2%, ILD patients had significant shortness of breath due to fluid volume overload around the time of delivery.
For the women who had normal-to-moderate lung disease, Clowse said, “they really had remarkably good outcomes, really pretty comparable to the general population. About 15% delivered preterm and about 20% suffered a pregnancy loss.”
Easter, who was not involved with the study, noted the large number of Black women in the cohort.
“Focusing in on improving outcomes for Black and brown women related to pregnancy in our country is a much-needed undertaking,” Easter said.
Being able to quote percentages from this research, based on a good-sized study “at least gives people a benchmark about what kind of risk they are willing to assume for themselves,” she said.
For providers, being able to place this rare disease within the spectrum of other diseases where there is more data is also very helpful, she said.
Clowse told Medscape Medical News the preponderance of Black women in the study was a surprise but may be explained by two factors: sarcoidosis is seen more frequently in Black women and in the study area in North Carolina there is a large population of Black women.
“Also, our patients with more severe lupus, the ones who are more likely to have interstitial lung disease, are often Black and that’s likely contributing as well,” she said.
Multidisciplinary Teams Advised
Clowse emphasized that women with ILD need multidisciplinary teams in pregnancy and should be managed at a tertiary care center where there is a full complement of obstetric and internal medicine experts.
“We do recommend evaluating the severity of their lungs and their heart disease around the time of pregnancy and during pregnancy if they have shortness of breath,” she said.
“We currently recommend that these patients with moderate or severe disease stay in the hospital for up to a week, just for monitoring,” she said.
Easter said having that kind of access to a large academic healthcare center should be an important part of the decision-making.
Patients need to think about whether they would have access to care similar to what the researchers are describing when they are making the decision to pursue or continue pregnancy, she said.
The study was sponsored by Pfizer Inc. Clowse reported relationships with UCB, GlaxoSmithKline, Astra Zeneca, and Pfizer. Easter has disclosed no relevant financial relationships.
American College of Rheumatology (ACR) 2020 Annual Meeting: Abstract 1446. Presented November 8, 2020.
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.
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