Lupus and Pregnancy

In general, healthy babies are born to healthy mothers. Before any pregnancy it is best to make sure you are as healthy as you can be.

Talk with your rheumatologist when pregnancy planning in order to ensure you have the best possible experience. It is best to make sure your disease is stable for 6 months on meds safe in pregnancy before trying to get pregnant.

Did you know that 30-50% of pregnancies are unplanned? It’s important to talk to your rheumatologist if you are planning a family or considering pregnancy. Planned pregnancies are key to optimal maternal and fetal outcomes.

Are you having trouble getting pregnant? Some women with lupus have antibodies that can result in increased miscarriages. Talk to your doctor if you have a history of recurrent miscarriages.

How does Pregnancy affect Lupus?

Lupus can range from mild to severe, but all lupus pregnancies are considered high risk. Many patients with lupus, especially those in remission, have no complications.

If you have severe lupus, pregnancy may not be advised because it can put strain on your heart, kidneys, and lungs. For most, it’s safe to proceed. Talk to your rheumatologist.

There are changes to the immune system and hormone levels that occur during pregnancy that can increase the risk of lupus flares. There is a trend towards flare in the third trimester.

This risk is lower when lupus is controlled. The risk of a flare can be predicted by how active your lupus is in the 6-12 months before you become pregnant.

The risk of flares is highest in those who were flaring before becoming pregnant, in those who stop hydroxychloroquine, and in women with active kidney disease. For this reason, it is important to have good disease control leading up to and throughout pregnancy.

How can Lupus affect Pregnancy?

Some women with lupus have a higher risk of complications during their pregnancy.

Lupus, especially when it is active, can increase the risk of early delivery, high blood pressure, kidney issues (protein in the urine called preeclampsia), bleeding before or after delivery, infection, blood clots, and rarely seizures (eclampsia).

Some women with lupus need to see other experts including specialized obstetricians, hematologists (blood doctors), and nephrologists (kidney doctors).

The presence of kidney disease (from any cause) is a significant risk factor for complications during pregnacy. Women with kidney involvement have a 2-3 times higher chance of flare when compared to those without kidney involvement. Active lupus affecting the kidney is associated with early delivery, high blood pressure, and preeclampsia.

Will Lupus Affect my Baby?

Mothers with lupus may have antibodies that can cross the placenta. Only 1-2% (a very small number) of mothers with these antibodies will have babies with neonatal lupus or heart conduction issues.

If these antibodies are present, the mother will undergo fetal heart ultrasound between 16-28 weeks gestation. This will be done with your obstetrician.

Neonatal lupus most commonly presents with a rash. This resolves at 6 months when mom’s antibodies have cleared from their baby. Lupus can increase the risk of early birth, small babies, and rarely loss of the baby.

Miscarriages and Lupus

Although 40% of lupus patients have antiphospholipid antibodies only 4% will have clinical manifestations. If you are positive for these antibodies and have had recurrent miscarriages or a blood clot, you may require ASA or a blood thinner to carry your baby to term. Talk to you rheumatologist if this applies to you.

Medications and Pregnancy

Pregnancy, whether planned or a pleasant surprise, brings with it important concerns about prescription and over the counter medications.

Not every medication poses a risk to your unborn baby; however, some do. It is important to talk to your doctor.

Safe Medications

The following medications can be used safely throughout pregnancy and breast feeding:

• Prednisone
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
• Hydroxychloroquine (Plaquenil)
• Azathioprine (Imuran)
• Cyclosporin
• Tacrolimus

NSAIDs can be used up to 28 weeks, but should be avoided if you are having trouble getting pregnant.

Medications to AVOID

Mycophenolate is not safe in pregnancy or breastfeeding.

The safety of rituximab and belimumab are unknown. Rituximab does not affect fertility and may be a reasonable alternative to cyclophosphamide in some cases, but it is recommended to avoid pregnancy for 12 months after.

Contraception

Oral contraceptives do not increase the risk of flares in women with mild, stable lupus.

Estrogen-containing contraceptives are avoided in women with antiphospholipid antibodies, smokers, and patients with active kidney diseases due to increased risk of blood clots.

All Intrauterine devices are safe.