When women with lupus want to have children, they turn to Dr. Eliza Chakravarty
It started with the bulletin board.
There, on a framed, cork rectangle that now hangs on the south wall of her office, Dr. Eliza Chakravarty began pinning up photos and cards featuring the children she calls “my babies.” And most were very young indeed. Swaddled in blankets or cradled in the arms of mothers and dads. One dressed as a mermaid. Another in a knit Winnie the Pooh costume. Many so new to the world their necks couldn’t yet support their oversized heads.
The board filled, but the photos and cards kept coming. Chakravarty couldn’t bear the thought of stowing even a single one in a drawer. So, on the wall behind her desk at the Oklahoma Medical Research Foundation, she continued the gallery.
But as the photo parade stretched out, a funny thing happened. The babies were joined by laughing toddlers. A young girl whitewater rafting. A pair of preschool-aged siblings doing their best Bruce Lee imitations.
“It’s hard to believe, but some of the kids are about to start first grade,” says Chakravarty.
While none are her biological children, Chakravarty tracks their progress almost as if they were. Really, it’s not a stretch to say she helped bring each one into the world.
In OMRF’s Rheumatology Research Clinic, where she’s been seeing patients since joining the foundation in 2011, the physician-scientist has developed a rare specialty: helping women with lupus have healthy pregnancies and healthy babies.
Although she’s not an obstetrician or a gynecologist, Chakravarty uses her training as an immunologist and a rheumatologist to guide women with lupus from conception to childbirth. She’s one of only a small cadre of physicians in the U.S. who focus on this area. But in a country with as many as 1.5 million lupus patients—overwhelmingly women, and many of child-bearing age—it’s an area of medicine that needs more attention, she says.
“Most American doctors have the philosophy of not giving any meds during pregnancy because of potential birth defects.” But, it turns out that “the underlying disease is actually the biggest risk to pregnancy.” For the best chances of a healthy pregnancy, she says, doctors should use the proper medications to keep the mother’s lupus in check.
It’s a fine line, but Chakravarty has made a career of walking it successfully. Still, it wasn’t long ago that her specialty was virtually unthinkable—right along with the idea of a woman with lupus wanting to have a child.
Following medical school and residency, Chakravarty began a fellowship in rheumatology and immunology at Stanford University in 2001, the year after she’d given birth to her daughter, Kiran. It had not been an easy pregnancy. Infertility problems had made conception difficult. Then a viral infection landed Chakravarty in the hospital and ultimately led to pre-term labor.
“I definitely understand how terrifying it is to have an at-risk pregnancy,” she says. “But I also know the absolute joy of being a mother.” It was a joy she wanted to share with other women whose pregnancies faced significant obstacles.
At Stanford, she became involved with a clinical research study looking at the pregnancy outcomes for women with lupus. With her training in rheumatology (disorders that affect the joints) and immunology (the workings of the immune system), Chakravarty was a perfect fit for lupus.
In lupus, the immune system loses the ability to distinguish its own cells from foreign invaders. As a result, the body mistakenly turns its weapons on itself, launching attacks on a host of tissues and organs. Over time, these attacks, known as flares, can lead to debilitating arthritis, pain, exhaustion and, sometimes, organ failure.
Like many “autoimmune” diseases, lupus disproportionately strikes women. And it often does so at an early age. In the clinic at Stanford, Chakravarty worked with numerous lupus patients. She took a particular interest in those who wanted to become mothers.
“We were still in an era where doctors would often dismiss the idea out of hand,” says Chakravarty. “They’d say, ‘We just saved your kidneys’”—the organ most commonly affected by lupus flares—“‘why have a baby?’”
On the surface, their reluctance seemed to make sense. Lupus is a life-threatening condition caused by an out-of-balance immune system. And what swings the body more out of balance than pregnancy?
But Chakravarty understood that, for many women, the decision to have a child represented a life-defining moment. Not getting pregnant was simply not an option. At Stanford, she treated patients who ended up in kidney failure because they’d gone off all of their medications in pregnancy. “It was that important to them to be mothers.”
Ultimately, Chakravarty decided, her role was not to counsel patients about whether to become pregnant. “To me, if women want babies, they should be able to have them. It’s not for me to judge their decisions.” Instead, she’d build her specialty around what followed those decisions.
“Every time a woman comes to me and says, ‘I want to get pregnant,’ I’m in,” says Chakravarty. “We work hard to reduce risk factors for pregnancy complications as much as possible before conception, but we cannot take away all risks, which vary case by case.” Her aim is to give that pregnancy the best chance of success. It’s a lofty goal, and one that helps her build a deep and personal bond with each patient. “You’re helping to make a whole person. What could be cooler than that?”
In her practice, Chakravarty determined the prevailing wisdom—lupus patients need to get off their medications if they want to get pregnant—did not yield the best outcomes. She soon joined a small circle of physician-researchers who sought, through trial and observation, to map new paths to safer pregnancies.
“Instead of taking patients off their meds, we’d switch to ones not associated with increased risks of birth defects,” she says. The key, she found, “was to keep inflammation in the body in check.” The traditional approach of halting treatment during pregnancy did exactly the opposite.
“One of the things we’ve learned is that having active disease while pregnant is not only dangerous for the mother, but it’s also a big risk factor for pregnancy complications,” says Chakravarty. In particular, disease activity during the first trimester carries the highest risk of causing miscarriage, birth defects, premature delivery and low-birthweight babies.
Consequently, Chakravarty and her colleagues treat the disease aggressively at the outset of pregnancy. That can mean, for example, resorting to steroids such as prednisone to counter flares. “Prednisone has a lot of side effects,” she says, “But it works fast.” While the mother’s placenta largely protects a fetus from the steroid’s effects, “you still want to use the lowest doses for the shortest period.”
Chakravarty typically works in tandem with an obstetrician/gynecologist. “They know pregnancy, but they may not be comfortable with treating lupus because they haven’t had enough training in that area.” The patient will keep her usual schedule of visits with the OB/GYN, and she’ll also see Chakravarty at regular intervals—generally once a trimester, unless there are problems. Chakravarty also gives her sicker patients her cell number, which she answers anywhere, anytime. “I want to make sure the communication line is always open.”
This approach has served her patients well in the more than 200 lupus pregnancies Chakravarty has cared for. Every mother has survived, as have the overwhelming majority of babies. Unfortunately, though, there have been miscarriages. Each one, says Chakravarty, is “devastating.” Even with her many years of medical experience, “It never gets easier.”
Chakravarty doesn’t impose many conditions on her patients. “Their goal is to live their lives; my job is to adjust their treatment to maximize their ability to do that.” But there is one rule that is non-negotiable: After a successful pregnancy, she gets to hold the baby.
Of course, she loves cradling the bundles of joy. But that post-delivery visit also ushers in a new, equally important phase of care: postpartum treatment.
The OMRF physician follows her patients closely after they give birth to ensure their disease remains stable. “I worry their lupus will flare postpartum,” as hormonal changes that occur with delivery, breastfeeding and stopping breastfeeding can act as triggers for lupus. “I don’t want to see women who are trying to bond with their babies also have to deal with symptoms of the disease.”
However, that’s precisely what happened to Katie Friddle.
Under Chakravarty’s care, Friddle’s pregnancy with her daughter, Eleanor, progressed normally. “I was stable, and my lupus symptoms were completely under control,” she says. “It was almost as if I didn’t have lupus at all.” Eleanor was born healthy, and Friddle breastfed her daughter without a problem. But when her daughter began weaning, Friddle says, things began to “get screwy.”
Her days would begin with her hands feeling puffy and stiff. Sometimes, her ankles and knees would also swell. The pain and inflammation interfered with her ability to go about her normal activities—raising Eleanor, working as a historic preservation officer in the Oklahoma City Planning Department. But things really went off the rails when Friddle and her husband, Shane, took Eleanor to the zoo one spring day.
Despite applying sunscreen, Friddle suffered what she at first believed was a moderate sunburn. But lupus can cause extreme sensitivity to ultraviolet rays, and by the next morning, her skin had turned bright red. Her joints ached, and she was running a fever. She eventually “put two and two together” and realized her symptoms were likely related to her lupus. She called Chakravarty, who quickly admitted her to the hospital.
There, tests showed that Friddle’s white blood cell count was plummeting. Something—sun exposure, the hormonal effects of halting breastfeeding, or, most likely, a combination of both—had caused her body to turn on itself. Friddle was suffering a lupus flare, a serious and potentially life-threatening bout of disease activity.
For four days, her physicians treated her with massive doses of steroids. Over time, the drugs quelled the widespread inflammation that had sent her immune system into attack mode.
“I’d never had a flare that severe before,” says Friddle. But the episode served as a wake-up call of sorts. “I had to come to grips with the fact that this was going to be my reality, dealing with fatigue and joint inflammation.”
That autumn, she began experiencing soreness in her hip. An MRI revealed vascular necrosis; the bone in her hip was collapsing due to lack of blood supply. “The ball of my femur was basically flattened,” she says. Her doctors couldn’t say for sure, but they suspected the long-term use of prednisone to control lupus flares had caused the condition.
Following months of mounting pain and immobility, Friddle opted to undergo hip replacement surgery. She was 31 years old.
After a successful recovery, Friddle continued to see Chakravarty regularly. Through a combination of careful monitoring and medication adjustments, the flares had subsided. When she nervously broached the idea of a second child, Chakravarty gave her the thumbs up. “As always, Eliza was supportive and encouraging,” says Friddle.
The OMRF physician worked closely with her patient to plan for the pregnancy. They tracked Friddle’s symptoms, and Chakravarty changed her meds to “pregnancy safe” options. Once Friddle conceived, Chakravarty encouraged her to be vigilant and to keep in constant contact. “She helped me learn to listen to how I was feeling and to speak up—call, come in, get checked out—if something was off.”
Jack Friddle was born in June 2017. The pregnancy was uneventful, and the healthy newborn tipped the scales at seven pounds.
Chakravarty adjusted her patient’s treatment regimen following Jack’s birth. These days, Friddle feels great. “My blood work has been very good and stable, and I really don’t have any symptoms to report.”
She knows her bout with lupus is far from over. But with Chakravarty in her corner, she feels confident about managing her disease. “Eliza is so responsive and knowledgeable. She always helps me think through my options and my goals for my health.”
Chakravarty is only too happy to help her patients navigate the waters of pregnancy—and beyond. “I care about them. I care about their babies. My goal is for every one of them to live happy, healthy lives.”
Each year, come the holidays, there are few things Chakravarty enjoys more than receiving a fresh batch of cards. Her bulletin board may be full, but there’s still plenty of space left on the walls for new photos of kids. No matter their age, they’ll always be her babies.
