Pregnancy and Lupus
Twenty years ago, medical textbooks said that women with lupus could not get pregnant because of the risks to both the mother and unborn child. Today, most women with lupus can safely become pregnant. With proper medical care, you can decrease the risks associated with pregnancy and deliver a normal, health baby. Michael D. Lockshin, M.D., a member of the Lupus Foundation of America’s Medical-Scientific Advisory Council, has provided information on your questions and concerns about your lupus and pregnancy.
Since lupus primarily affects young women, pregnancy often becomes a crucial question. Years ago, all medical texts said that women with lupus could not have children, and if they became pregnant, they should have therapeutic abortions. We now know that these early conclusions were wrong. Currently, more than 50 percent of all lupus pregnancies are completely normal. Twenty-five percent of women with lupus deliver normal babies prematurely. Fetal loss, due to spontaneous abortion (miscarriage) or death of the baby, accounts for less than 20 percent. Not all of the problems of pregnancy with lupus have been solved, but pregnancies are possible, and normal children are the rule.
While it is certainly possible for women with lupus to have children, pregnancy may not be easy. It is important to note that although many lupus pregnancies will be completely normal, all lupus pregnancies should be considered "high risk." "High risk" is a term commonly used by obstetricians to indicate that solvable problems may occur and must be anticipated. A pregnancy in a woman with lupus should be managed by obstetricians who are thoroughly familiar with high risk pregnancies and who work closely with the woman’s primary physician. Delivery should be planned at a hospital that has access to a unit specializing in the care of premature newborns. Lupus mothers should not attempt home delivery, or be overly committed to "natural" childbirth, since treatable complications during delivery are frequent. However, under close observation, the risk to the mother’s health is lessened, and healthy babies can be born.
Will Pregnancy Flare My Lupus?
Although older medical texts suggest that lupus flares are common in pregnancy, recent studies indicate that flares are uncommon and are usually easily treated. In fact, some women with lupus will actually experience an improvement in disease symptoms during pregnancy. Most of the flares tend to be mild. The most common symptoms of these flares are arthritis, rashes, and fatigue. Approximately 33 percent of women with lupus will have a decrease in platelet count during pregnancy, and about 20 percent will have an increase in or new occurrence of protein in the urine. These abnormalities may be due to pregnancy rather than to lupus. These levels usually recover after delivery.
Women who conceive after five-six months of remission are less likely to experience a lupus flare than those who get pregnant while their lupus is active. The presence of lupus nephritis before conception also increases the chance of having complications during pregnancy.
It is important to distinguish the symptoms of a lupus flare from the normal body changes that occur during pregnancy. For example, because the ligaments that hold the joints together normally soften in pregnancy, fluid may accumulate in the joints (especially in the knees) and cause swelling. Although this condition suggests inflammation due to lupus, it may simply be the swelling that occurs during a normal pregnancy. Similarly, lupus rashes may appear to worsen during pregnancy, but this is usually due to increased blood flow to the skin that is common in pregnancy (the "blush" of a pregnant woman). Many women also experience new hair growth during pregnancy, followed by a dramatic loss of hair after delivery. Although hair loss is certainly a symptom of active lupus, this again is most likely a result of the changes that happen during a normal pregnancy.
When is the Best Time to Get Pregnant?
The answer is simple: when you are at your healthiest. Women in lupus remission have much less trouble than do women with active disease. Their babies do much better, and everyone worries less. Good health rules are essential: eat well, take medications as prescribed, visit your doctor(s) regularly, don't smoke, don't drink, and certainly don't use "recreational" drugs.
Why Are Frequent Doctor Visits So Important in a Lupus Pregnancy?
Frequent doctor visits are important in any high risk pregnancy because many conditions which may occur can be prevented, or treated more easily, if found early. About 20 percent of women with lupus will have a sudden increase in blood pressure, protein in the urine, or both during pregnancy. This is called toxemia of pregnancy (or pre-eclampsia or pregnancy-induced hypertension). It is a serious condition that requires immediate treatment and often immediate delivery of the baby. Toxemia is more common in older women, in black women, in women with twins, in women with kidney disease, in women with high blood pressure, and in women who smoke.
Serum complement and blood platelet count may be abnormal in these cases. Since complement levels and blood platelet counts are also abnormal during lupus flares, it may be difficult for the doctor to be certain that a flare is not causing these symptoms. If toxemia is promptly treated the woman should be in no danger, but there is a high risk that the baby will die if it is not rapidly delivered. If toxemia is ignored, both the woman and her baby are in danger.
As pregnancy progresses it is often wise for the doctor to check the baby’s growth with sonograms (which are harmless). The doctor should also regularly check the baby’s heart beat. Abnormalities in either the baby’s growth or its heart beat may be the first signs of trouble that can be treated.
Can I Take Medications During Pregnancy?
It is always unwise to take unnecessary medications during pregnancy. However, necessary medications should not be discontinued. Most medications commonly taken by those with lupus are safe to use during pregnancy: prednisone, prednisolone, and probably methylprednisolone (Medrol®) do not get through the placenta and are safe for the baby. But others, specifically dexamethasone (Decadrol®, Hexadrol®) and betamethasone (Celestone®) do reach the baby and are used ONLY when it is necessary to treat the baby as well. For example, these medications might be used to help the lungs mature more rapidly if the baby will be premature. A small dose of aspirin is safe. Most physicians now hold that azathioprine (Imuran®) and hydroxychloroquine (Plaquenil®) do not harm babies, but the final word is not yet in on these. Cyclophosphamide (Cytoxan®) and methotrexate are definitely harmful if taken during pregnancy. Mycophenolate mofetil (CellCept®) is also unsafe.
What About Prophylactic (Preventive) Treatment With Prednisone?
Doctors once felt that all pregnant women with lupus should take small doses of prednisone to prevent early abortion. This is generally not necessary. Similarly, physicians once felt that steroids should be given or increased after the baby is born to prevent "post-partum flare." Again, this is unnecessary in most cases. For women recently on steroids, however, a "stress" steroid is usually given during labor to supplement what the mother cannot make herself.
What Are Antiphospholipid Antibodies and Why Are They Important?
About 33 percent of women with lupus have antibodies that interfere with the function of the placenta. These antibodies are called antiphospholipid antibodies, the lupus anticoagulant, or anti-cardiolipin antibodies. These antibodies may cause blood clots, including blood clots in the placenta, which prevent the placenta from growing and functioning normally. This usually occurs during the second trimester. Since the placenta is the passageway for nourishment from the mother to the baby, this condition will slow the baby’s growth. However, the baby can be delivered at this time and will be normal if it has developed enough.
Treatments for pregnant women with lupus who have these antibodies are still being tested. Heparin in various forms is recommended. Some doctors add a small dose of (baby) aspirin. With the use of such medications, about 80 percent of the women will not miscarry.
Will My Baby Be Normal?
Premature birth is the greatest danger to the baby. About 50 percent of lupus pregnancies end before nine months (40 weeks), usually because of the complications previously discussed (births before 36 weeks are considered premature). Babies born after 30 weeks or weighing more than three pounds usually do well and grow normally. Premature babies may have difficulty breathing, may develop jaundice, and may become anemic. In modern neonatal units, these problems can be easily treated. Even babies as small as one pound, four ounces have survived and have been healthy in every way; but the outcome is uncertain for babies of this size. There is one congenital abnormality that occurs only to babies of lupus mothers (described below), and no unusual frequency of mental retardation.
Will My Baby Have Lupus?
About 33 percent of people with lupus have an antibody known as anti-Ro, or anti-SSA, antibody. About 10 percent of women with anti-Ro antibodies -- about three percent of all women with lupus -- will have a baby with a syndrome known as neonatal lupus. Neonatal lupus is not lupus. Neonatal lupus consists of a transient rash, transient blood count abnormalities, and sometimes a special type of heart beat abnormality. If the heart beat abnormality occurs, which is very rare, it is often treatable but it is permanent. Neonatal lupus is the only type of congenital abnormality found in children of mothers with lupus. For babies with neonatal lupus who do not have the heart problem, there is no trace of the disease by three-six months of age, and it does not recur. Most babies with the heart beat abnormality problem grow normally, but some need pacemakers. If a mother has had one child with neonatal lupus, there is about a 25 percent chance of having another child with the same problem. The chance that the child will develop lupus later in life is very, very low.
Will I Have to Have a Caesarian Section?
Very premature babies, babies showing signs of stress, babies of mothers with low platelets, and babies of mothers who are very ill are almost always delivered by Caesarian section. This is both the safest and fastest method of delivery in these cases. Usually the decision about type of delivery is not made in advance because the specific circumstances at the time of delivery are the determining factors.
Can I Breast-Feed?
Although breast feeding is possible for women with lupus, breast milk may not come if the baby is born very prematurely. Very premature babies are not strong enough to suckle, and thus cannot draw the milk. However, milk can be pumped from the breast to feed a premature baby if the mother wishes to do this. Plaquenil and the cytotoxic drugs (Cytoxan, Imuran®) are passed through the milk to the baby. Some medications, such as prednisone, may prevent milk from being produced. Many drugs, including warfarin (Coumadin®), heparin, and low doses of prednisone, are safe. If you are taking any medication it is best not to breast feed; but if your doctor approves, you may.
Who Will Care For the Baby?
Prospective parents often do not ask what will happen after the baby is born if the mother is ill and unable to care for the child. Since it is likely that a woman with lupus will have future periods of illness, it is wise to think of this possibility in advance and to have plans for alternate child care (spouse, grandparent, etc.) if needed.
Related Information
Reproductive Health and Lupus
October 2008 webchat transcript with Dr. Bonnie Bermas
Pregnancy and Lupus
August 2007 webchat transcript with Dr. Rosalind Ramsey-Goldman
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