From the Archives: Fall 2003 Issue of Lupus Now
Q: What should be done if lupus becomes active in a woman who is pregnant?
A: First, consider what is meant by lupus activity. During pregnancy, there can be some confusion about whether to attribute certain problems to lupus or to the pregnancy itself.
For example, otherwise healthy women can be quite fatigued in their first trimester. Facial rashes may be related to pregnancy, not lupus. There is a tendency to run lower red blood cell counts during normal pregnancy. An increase in protein spillage into the urine may be caused by increased blood flow to the kidneys (which happens in normal pregnancies) and does not necessarily mean that lupus is attacking the kidneys. The blood tests generally used by health care providers to follow a person with lupus—such as those that measure complement levels—also may show higher results during a normal pregnancy and, thus, mask the drop one might usually see during a flare.
Nevertheless, certain problems—such as massive protein in the urine, a reduction in the filtering system of the kidneys, brain disease, severe arthritis, fluid around the heart or lungs or severe ulcers in the mouth or nose—are likely due to lupus. If the flare is very severe, such as major central nervous system disease or obvious kidney deterioration— and these problems happen before the twelfth week of pregnancy—it may be prudent to advise termination of the pregnancy, and in some cases, to give cyclophosphamide (a chemotherapy drug that can also act as an effective immunosuppressant in cases of SLE).
When problems occur in the second trimester, a similar course of action may be required. But again, to suggest termination is an extreme measure and should be considered on an individual basis. One thing to keep in mind is that a pregnant woman with lupus who exhibits a severe kidney flare before 20 weeks often loses the baby. Once she gets past 26 weeks, the baby is viable, so a different treatment approach may be required.
It is always a priority to try to keep the fetus inside until 30 weeks, when chance for having a healthy baby is about 80 percent. However, if the mother develops a disease such as preeclampsia, with high blood pressure, more protein in the urine and evidence of liver problems, delivery is required for the health of the mother.
—Jill Buyon, M.D.
Q: I have been looking into getting LASIK surgery and I see a lot of warnings about people with lupus. Can you explain why this might be a concern?
A: LASIK (laser-assisted in situ keratomileusis) surgery permanently changes the shape of the cornea and is intended to reduce a person’s dependency on eyeglasses or contact lenses.
People with systemic lupus should be cautious about undergoing LASIK, because certain complications occur more frequently in people with autoimmune diseases. These include: corneal inflammation (diffuse keratitis), dry eyes, post-operative inflammation, microbial complications, and delayed wound healing.
Therefore, it is imperative that a person’s rheumatologist, internist or primary care physician be involved in the decision to have LASIK surgery. In terms of treatments, corneal inflammation can be treated with topical therapy. And if a person develops an infection after surgery, both topical and systemic antibiotics can help. Other, less common complications can usually be managed by a skilled ophthalmologic surgeon.
—Oscar S. Gluck, M.D.
Jill Buyon, M.D. is the vice chair of the Department of Rheumatology at the Hospital for
Special Surgery, New York, NY, and professor of medicine at the New York University School of Medicine
Oscar S. Gluck, M.D. is the director of the Arizona Rheumatology Center, and clinical professor in the Department of Medicine at the University of Arizona School of Medicine.