Until recently, pregnant women with lupus faced significant health risks, both to themselves and their unborn babies. Researchers have learned more about the nature of the disease, and with the availability of new approaches to treating and managing the condition, as well as better understanding of the specific factors that increase risk for lupus pregnancies, most women with lupus are able to have successful pregnancies.
The key to a successful pregnancy for women with lupus is to plan in advance, with the help of an obstetrician and a rheumatologist. Women with severe organ damage or very active lupus are more likely to experience problems in their pregnancies, and risk overall remains somewhat greater for lupus patients than for the general population. Pregnancy almost always has a better outcome for both mother and child when lupus has been quiet or stable for about six months prior to conception.
Here I discuss different pregnancy risk factors every woman with lupus should understand, and the appropriate steps for modifying her disease management when planning to become pregnant.
Important factors that have been shown to increase risk of complications for mother and/or baby include:
- Severe organ damage related to prior disease
- Active/uncontrolled lupus at the time of or during the six months prior to conception
- History of lupus kidney involvement
- Presence of certain autoantibodies
Experts have identified several autoantibodies present in about 1/3 of women with lupus that are associated with a greater risk for problems during pregnancy. Women with lupus should be checked for these antibodies prior to or early in pregnancy. Antiphospholipid antibodies increase the risk of miscarriage, premature delivery, and other complications. Another type of autoantibodies found in both lupus and other rheumatic diseases are anti-Ro/SSA and anti-La/SSB antibodies. These may be associated with development of inflammation in the baby that can very rarely cause damage to the child’s heart. The results of these tests can help doctors better monitor and treat their patients.
Even with improvements in management over the years, women with lupus are more likely to experience pregnancy-related complications than those without the disease. These complications may include:
- Premature delivery
- Low-birth-weight babies
- Lupus flares that may damage the mother’s organs
Pregnant women with lupus also have higher-than-average risks for other complications during pregnancy:
- Preeclampsia, marked by high blood pressure during pregnancy, high protein in the urine, and, in some cases, kidney and liver damage or dysfunction.
- Eclampsia, which causes seizures and can lead to organ failure and other life-threatening problems.
Modifications to Disease Management
While many medications are safe to take during pregnancy, certain treatments have been linked to an increased risk of birth defects, which include:
- Mycophenolate mofetil or mycophenolic acid
Patients on these medications are usually tapered off or switched to treatments that are considered compatible with pregnancy. They are then monitored by their doctor for several months to assure that the new therapies are effective and well-tolerated before a pregnancy is attempted.
Medications that are considered safe throughout pregnancy, and while breastfeeding are:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), except for the third trimester, when they are prohibited
- Nonfluorinated steroids such as prednisone
- The immunosuppressive agents azathioprine, cyclosporine and tacrolimus
- The biologic agents rituximab and belimumab may be continued until the time of conception but are then generally discontinued due to lack of data on use during pregnancy
Steroids are considered safe for the developing baby and may be taken during pregnancy. However, prolonged use of the drugs can cause side effects including pregnancy-induced high blood pressure, gestational diabetes and osteoporosis. As a result, patients should take these medications for as short a time and in as low a dose as possible.
Pregnancy outcome is optimized if pregnancy is planned for times of stable or quiet disease and while on pregnancy compatible medications. Therefore, safe and effective contraception is an important aspect of optimizing lupus pregnancy outcome. Open communication between patients and their physicians is critical. Both the rheumatologist and the obstetrician should follow the patient, working together with the patient as a team. Continued research and education should lead to even better outcomes in the years to come.
For information on this topic and more, visit the HSS Lupus and APS Center of Excellence page.
Lisa R. Sammaritano, MD, is a rheumatologist at HSS and has developed a clinical practice geared towards patients with Systemic Lupus Erythematosus (SLE) and Antiphospholipid Antibodies, and combines this with clinical and basic research in these areas. She is the lead author of the upcoming 2019 American College of Rheumatology Guideline on Reproductive Health for Patients with Rheumatic and Musculoskeletal Diseases and she is establishing a new Reproductive Health Center within the Barbara Volcker Center for Women and Rheumatic Disease at HSS to help guide patients and their physicians in this important area.