Pregnancy And Lupus
Michael D. Lockshin, M.D.
Since lupus primarily affects young women, pregnancy often becomes a
crucial question. Years ago, all medical texts said that lupus
patients could not have children, and if they became pregnant, they
should have therapeutic abortions. Clearly, these early conclusions
are wrong. Currently, 50 percent of all lupus pregnancies are
completely normal, and 25 percent deliver normal babies prematurely.
Fetal loss, due to spontaneous abortion (miscarriage), or death of the
baby accounts for the remaining 25 percent. While not all of the
problems of pregnancy with lupus have been solved, pregnancies are
possible, and normal children are the rule.
While it is certainly possible for lupus patients 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. Pregnant lupus patients should be managed by
obstetricians who are thoroughly familiar with high risk pregnancies
and work in close concert 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. SLE 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 SLE flares are common in
pregnancy, recent studies indicate that flares are uncommon and are
usually easily treated. In fact, 6-15 percent of lupus patients will
actually experience an improvement in lupus symptoms during pregnancy.
Flares most often occur during the first or second trimester, or
during the two months immediately after delivery. Most of the flares
tend to be mild. The most common symptoms of these flares are
arthritis, rashes and fatigue. Approximately 33 percent of lupus
patients 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.
Women who conceive after 5-6 months of remission are less likely to
experience a lupus flare than those who get pregnant while their lupus
is active. Lupus nephritis before conception also increases the
chance of experiencing a lupus flare 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 may suggest an increase in
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 an 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 SLE, this again is
most likely a result of the changes that occur during a normal
pregnancy.
When is the Best Time to Get Pregnant?
The answer is simple: when you are at your healthiest. Women in
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 lupus patients 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, and will require immediate
treatment and usually immediate delivery. 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 SLE 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 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 SLE patients are safe to use during
pregnancy. Prednisone, Prednisolone, and probably methylprednisolone
(Medrol) do not get through the placenta and are safe for the baby.
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 baby's lungs mature more rapidly if the baby will be
premature. Aspirin is safe; it is often used to protect against a
complication known as toxemia of pregnancy. Preliminary reports
suggest that azathioprine (Imuran) and hydroxychloroquine (Plaquenil)
do not harm babies, but the final word is not yet in on
these. Cyclophosphamide (Cytoxan) is definitely harmful if taken
during the first three months of pregnancy.
What About 'Prophylactic' (Preventative) Treatment with Prednisone?
A few doctors feel that all pregnant women with lupus should take
small doses of Prednisone to prevent early abortion. However, there
are no confirmed data that this is necessary. Similarly, some
physicians feel steroids should be given or increased after the baby
is born to prevent 'post partum flare.' Again, there is no evidence
that this is necessary in most cases either. For patients recently on
steroids, however, 'stress' steroid is usually given during labor to
supplement what the mother can't make herself.
What are Anti-Phospholipid Antibodies and Why are they Important?
About 33 percent of lupus patients have antibodies that interfere with
the function of the placenta. These antibodies are called
antiphospholidid antibodies, the lupus anticoagulant or
anti-cardiolipin antibodies. These antibodies may cause blood clots,
including blood clots in the placenta, that 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, the baby's growth slows. The
baby can be delivered at this time and will be normal if it is big
enough.
Treatment for lupus patients who have these antibodies is still being
tested. Aspirin, Prednisone, Heparin, and plasmapheresis have all
been suggested as possible therapies. However, even with the use of
such medications, these antibodies may still lead to miscarriage.
Will My Baby Be Normal?
Prematurity is the greatest danger to the baby. About 50 percent of
lupus pregnancies end before 9 months, usually because of the
complications previously discusssed. Babies born after 30 weeks or
over 3 pounds usually do well. Premature babies may have difficulty
breathing, may develop jaundice, and may become anemic. In modern
neonatal units, these problems can be easily treated. Babies weighing
more than 3 pounds at birth grow normally. Even babies as small as 1
pound, 4 ounces have survived and have been healthy in every way; but
the outcome is uncertain for babies of this size. There are no
congenital abnormalities that occur only to babies of lupus patients
(except as described below), and no unusual frequency of mental
retardation.
Will My Baby Have Lupus?
About 33 percent of lupus patients have an antibody known as anti-Ro
or anti-SSA antibody. About 10 percent of women with Anti-Ro
antibodies, or about 3 percent of all lupus women, will have a baby
with a syndrome known as neonatal lupus. Neonatal lupus is not SLE.
Neonatal lupus consists of a transient rash, transient blood count
abnormalities, and a special type of heart beat abnormality. If the
heart beat abnormality occurs, which is very rare, it is 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 3-6 months of age, and it does not recur. Even babies
with the heart beat abnormality problem grow normally. 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.
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 often 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 lupus patients, breast milk
may not come if the baby is born very prematurely because 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 baby is not strong enough to suckle and 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. 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 lupus patient 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.
lupus@piper.hamline.edu
Last modified: 1996-07-30