Lupus and Pregnancy
Older medical textbooks warned that lupus patients — most of them women of childbearing years — should not have babies, and they even urged abortion if pregnancy did occur. Fortunately, this alarming advice has proved unfounded in most cases, because women with lupus have preserved fertility and most women with this disorder can have a successful pregnancy. Although the complication rate is higher among women with lupus, about half of all lupus pregnancies are totally normal, whereas 25% end with the premature delivery of a normal baby and another 25% end in miscarriage or stillbirth.
Great caution is advised for women with lupus because those with moderate to severe involvement of the central nervous system, lungs, heart, kidneys or other internal organs may be at serious risk if they become pregnant. If you have one or more of these problems, pregnancy is considered dangerous and is not advised. A planned pregnancy may be acceptably safe later, once disease is under better control.
Even if you don't have these complications, your pregnancy will likely be defined as high risk, because some serious health problems, such as hypertension, are more common among pregnant women with lupus than in the general population. And about 10% to 20% of women with lupus develop preeclampsia (versus only 5% of other women), characterized by a sudden rise in blood pressure, protein in the urine, and pronounced swelling of the legs or other body parts.
Pregnancy does not reliably worsen lupus, and there is a suggestion that the incidence of worsening of disease is falling, perhaps because of better planning or treatment of disease. If you do experience any flare-ups, they may occur during any trimester or in the two months after you've given birth. In most cases, these "flares" are mild and involve such symptoms as rashes, fatigue or arthritis.
You may be able to reduce your risk of flares by timing your pregnancy so it begins during a period of disease remission. Studies demonstrate an improved outcome when pregnancy follows six months of inactive disease.
Many lupus medicines, including prednisone and prednisolone, are believed to be safe to use during pregnancy, but check with your doctor to be sure. Cyclophosphamide and methotrexate, however, are known to be harmful to a fetus, and the safety of azathioprine has not been fully established. Nonsteroidal anti-inflammatory drugs (NSAIDs) and hydroxychloroquine are among the most commonly prescribed medicines for patients with lupus and are considered acceptably safe during pregnancy when needed, although all medications used during pregnancy should be approved by your obstetrician and rheumatologist. NSAIDs should be discontinued during the last several weeks of pregnancy.
If you're one of the 33% of lupus patients with antiphospholipid antibodies (also called the lupus anticoagulant or anticardiolipin antibodies), there's another risk — antibodies can cause blood clots in the placenta that keep the fetus from growing normally. Because a developing baby receives nutrients from its mother through the placenta, blockage by blood clots compromises fetal growth and could lead to miscarriage.
Several drugs, including heparin, are sometimes used for this condition, but none of them are entirely successful at preventing miscarriage. Whether or not you have these antibodies, as a woman with lupus you should realize that compared with other women you have a significantly higher-than-normal risk of preterm delivery or of requiring a Caesarean section. For these reasons, you'd be well advised to receive your care from an obstetrician experienced in high-risk pregnancies and lupus. Your other doctors will work with your obstetrician to monitor you and your baby carefully throughout pregnancy.
Other than the risks associated with preterm delivery, babies born to mothers with lupus generally do not have any special health problems and are not significantly more likely to have birth defects than other babies. About 3 percent of women with lupus may have infants with a temporary form of the disease called "neonatal lupus" that usually disappears by age 6 months. These babies have rash, low blood counts and/or heart problems. In rare cases, this can be associated with a permanent abnormality of the baby's heartbeat called "congenital heart block." The risk of neonatal lupus and heart block is higher among women who have antibodies in their blood called "anti-Ro." These antibodies cross the placenta during fetal development and seem to mediate the disease in infants. Knowing whether or not these antibodies are present in persons with lupus can be helpful so that their babies can be more intensively monitored during their development.
It is possible, though unproven, that corticosteroid therapy can prevent complications of neonatal lupus, including heart block. That's why some women with lupus and anti-Ro antibodies are treated with corticosteroids early in pregnancy, especially if they've previously had a baby with neonatal lupus. Steroids, however, have many potential risks, so the decision to begin steroid treatment should be made only after a thorough review of its potential risks and benefits.
Breast-feeding is safe for infants born to women with lupus, but the possible transmission of medications to breast milk should be reviewed with your doctor.
For additional information, contact the Lupus Foundation of America at:
Lupus Foundation of America, Inc.
2000 L Street, N.W., Suite 710
Washington, DC 20036
1-800-558-0121 (Information request line)
1-800-558-0231 (Para información en Español)