Successful pregnancy after cyclophosphamide therapy for systemic lupus erythematosus: a case report

The use of cyclophosphamide in women of childbearing age with severe systemic lupus erythematosus is normally indicated. However, cyclophosphamide is generally avoided during pregnancy due to the risk of teratogenicity, especially since its effect on fetal survival is poorly understood. This is a case report of a lupus patient exposed to cyclophosphamide during pregnancy.

A 35-year-old woman with a history of lupus presented to our outpatient clinic in the 12th week of pregnancy for her sixth routine cyclophosphamide bolus. The fetal echocardiogram result with the gynecology consultation was normal with the recommendation for a medical termination of pregnancy, which has been refused by the patient. Shared decision-making with the patient included a discussion of the maternal risks of continuation of pregnancy in the setting of worsening systemic function and the fetal risks of definitive treatment with cyclophosphamide for a lupus flare and the patient decided to proceed with the pregnancy. Treatment with immunosuppressants, including azathioprine was initiated replacing cyclophosphamide with close monitoring of her and the fetus every month.

The first trimester of pregnancy seems to be particularly susceptible to fetal malformations, although CPA effects on fetuses in later stages of pregnancy are also reported occasionally. Nonetheless, its repercussions on fetal survival remain poorly comprehended.

In conclusion, exposing pregnancy to cyclophosphamide could end with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother. However, in rare cases, it could be without complications.