When Pregnancy Became a Battle Against Time: Managing a High-Risk Pregnancy with Systemic Sclerosis and ILD

When Pregnancy Became a Battle Against Time: Managing a High-Risk Pregnancy with Systemic Sclerosis and ILD

Some pregnancies are straightforward. Some demand constant vigilance.

And then there are pregnancies where every decision has to be weighed against the possibility of two lives being at risk.

This was one such case.

I recently had the opportunity to manage a young woman with systemic sclerosis (scleroderma) complicated by interstitial lung disease (ILD) who presented to us late in pregnancy.

From the very beginning, this was not a pregnancy that could be considered routine.

Systemic sclerosis can affect multiple organs, and pregnancy in a woman with significant cardiopulmonary involvement carries substantial maternal and fetal risks. The presence of pulmonary hypertension, in particular, can make pregnancy exceptionally dangerous and, in established pulmonary arterial hypertension, pregnancy is generally considered contraindicated.

The importance of pre-pregnancy counselling

This case also highlights something I strongly believe in:

Women with systemic sclerosis should ideally receive pre-pregnancy counselling before planning a pregnancy.

Pregnancy should not be entered into without understanding the potential risks to the mother and baby.

A woman with systemic sclerosis needs an individualized assessment before conception, including evaluation of pulmonary function, cardiac status, renal function, disease activity and, where appropriate, screening for pulmonary hypertension.

Unfortunately, this patient had presented to us only after the pregnancy was already well advanced.

By that stage, the situation was much more complicated.

Because of the significant maternal risks, several doctors had understandably been reluctant to take responsibility for continuing the pregnancy. At the same time, the pregnancy had progressed to a point where termination was no longer a straightforward decision.

We were therefore faced with a difficult question:

Could we safely continue the pregnancy?

Assessing the risk — one parameter at a time

We decided that this could not be a decision based on fear alone.

It had to be based on careful clinical assessment.

We evaluated her extensively. Her baseline investigations were reassuring, and importantly, her two-dimensional echocardiography did not show pulmonary hypertension at that stage.

After detailed discussion with the multidisciplinary team, we decided to continue the pregnancy—but with the understanding that this was a high-risk pregnancy requiring extremely close surveillance.

There was no room for complacency.

Her respiratory status needed to be monitored closely. Her cardiac status had to be reassessed. Maternal symptoms, fetal growth and fetal well-being all required regular evaluation.

Most importantly, we knew that the situation could change rapidly.

When the situation changed

As the pregnancy progressed, we were constantly watching for signs that the maternal condition was deteriorating.

Eventually, she developed a relapse/worsening of her systemic condition with severe breathlessness, and pulmonary hypertension became a concern.

At that point, the equation changed.

Continuing the pregnancy was no longer the safest option for the mother.

After discussion among the treating teams and careful assessment of the maternal and fetal condition, we made the difficult decision to deliver.

She delivered at 31 weeks of gestation.

It was a premature birth, but in a pregnancy where maternal respiratory and cardiovascular status were deteriorating, timely delivery was an important part of protecting both mother and baby.

The team behind the outcome

This was never a one-doctor success.

It was a team effort.

I am deeply grateful to:

• Dr. Deepak Malgutte – Rheumatologist, for his expertise in managing the underlying systemic disease.

• Dr. Hemil Jasani – Pulmonologist, for his meticulous assessment and management of the respiratory component.

• Dr. Irfan – Neonatologist, for taking care of our extremely premature baby and ensuring the best possible neonatal support.

The obstetric, rheumatology, pulmonology, anesthesia, neonatology and critical-care teams had to work together throughout the pregnancy.

Every decision was discussed. Every change in the mother’s condition mattered.

And then came the moment we had hoped for

Despite the complexity of the pregnancy, both mother and baby are doing well.

The mother recovered remarkably well after delivery and was discharged on the 4th postoperative day.

For me, that was one of the most satisfying moments of this entire journey.

Not because the pregnancy had been easy—it certainly wasn’t.

But because careful planning, continuous monitoring, timely decision-making and coordinated multidisciplinary care had helped us navigate an exceptionally difficult situation.

The lesson I take from this case

This case is not a message that women with systemic sclerosis should simply go ahead and become pregnant.

Quite the opposite.

It is a reminder of why pre-pregnancy counselling is so important.

A woman with systemic sclerosis who is considering pregnancy should ideally be evaluated before conception by a multidisciplinary team. The presence or risk of pulmonary hypertension, significant interstitial lung disease, cardiac involvement and other organ complications must be carefully assessed.

If significant pulmonary hypertension is present, pregnancy can carry an extremely high maternal risk and may be contraindicated.

But when a patient presents late in pregnancy, the situation becomes different.

The treating team may be faced with difficult decisions where there are no perfect answers—only carefully considered choices based on the mother’s current condition, fetal maturity, available investigations and the risks of continuing versus delivering.

A story of trust, teamwork and resilience

This patient came to us at a time when there were many reasons to be apprehensive.

She trusted us.

Our team trusted the process.

And together, we monitored, reassessed and adapted whenever the clinical situation changed.

Her journey reminded me that in high-risk obstetrics, vigilance is not a single event—it is a continuous process.

Sometimes, the most important intervention is not a medication or a procedure.

Sometimes, it is recognizing the moment when the balance of risk has changed and having the courage to act.

I am grateful to the entire healthcare team at Acme Hospital for their commitment, expertise and teamwork.

Most of all, I am grateful to our patient for her trust, resilience and strength throughout this challenging journey.

This case reaffirmed one of the most important principles in high-risk obstetrics: when complex disease meets pregnancy, the best outcomes come from early risk assessment, meticulous surveillance, multidisciplinary collaboration and timely decision-making.

Patient details have been modified/kept anonymous to protect confidentiality. This case is shared for educational purposes and does not replace individualized medical advice.