Medication decision making under uncertainty: Considering chronic disease and pregnancy potential

People with chronic illness who are (or could become) pregnant and their clinicians may face difficult decisions about the use of medications that can affect fetal health and development. In these situations, people must make the choice whether to use a drug with limited information about teratogenicity to treat their illness, putting an existing or potential pregnancy at risk. This manuscript serves as a call to action for all clinicians whose patients face such treatment choices regarding teratogenic medications or medications with unknown fetal safety. It offers an approach to guiding patient-provider conversations on medication management for individuals who are or might become pregnant, grounded in a review of the existing literature on medication decision making for drugs with known or potential teratogenic properties and informed by the current tools available for offering decision support. As a case study for highlighting current challenges and potential solutions around safe prescribing, we focus on two systemic autoimmune and rheumatic diseases, systemic lupus erythematosus and rheumatoid arthritis, which disproportionately affect females compared to males (with incidence ratios of 9:1 and 3:1, respectively). We address how recent reproductive policy changes that restrict abortion access may affect both a provider and a patient's decision calculus. Finally, we highlight several gaps that could be addressed by future research and the implementation of new data collection practices by federal bodies, while offering an approach to optimize patient-provider communication under conditions of ongoing uncertainty around the safety of drugs for those who may become pregnant while using them.