Lupus and Pregnancy
Systemic lupus erythematosus, more often just called lupus, is a chronic, inflammatory disease that may affect the skin, joints and multiple internal organs, such as the lungs, kidneys, heart or brain.
Lupus is an autoimmune disease that typically involves more parts of the body than RA or PsA. The body’s immune system attacks healthy tissues and organs by mistake, and inflammation can rage out of control.
Lupus most often affects young women who are in their childbearing years. Decades ago, women with lupus were once advised to avoid pregnancy. Now, effective treatments allow women with lupus to better control their disease activity and have safe, healthy pregnancies.
Women with lupus are more likely to have a flare during pregnancy, experience pregnancy loss or preterm birth, or experience other complications if they have any of these health problems: pre-existing or current hypertension (high blood pressure), history or current kidney disease, history of preeclampsia during pregnancy, history of blood clots or low blood platelets, or antiphospholipid antibodies.
In addition to your rheumatologist, you will likely need to see a maternal-fetal specialist during your pregnancy. This is an obstetrician who specializes in managing high-risk pregnancies. Women with lupus need to follow their doctors’ instructions carefully, watch for any signs of health problems or pregnancy complications, get enough rest and exercise, eat a healthy diet, and take any prescribed medications as directed.
You’ll need to get regular tests like these during your pregnancy to check for possible complications:
- Complete blood count (CBC)
- Kidney and liver function tests
- Antiphospholipid antibody tests
- Anti-SSA/Ro and anti-SSB-La antibody tests
- Anti-DNA antibody tests
- Complement tests (C3 and C4)
- Fetal ultrasounds
Pregnant women with lupus should see their rheumatologist about once every trimester, although your doctor may recommend more frequent appointments. If you have a flare during pregnancy, you may need to see your rheumatologist more often.
Controlling lupus during pregnancy, and avoiding flares, is the best way to have a safe pregnancy and healthy baby. Your rheumatologist can prescribe treatments like hydroxychloroquine (Plaquenil), azathioprine (Imuran), or prednisone during pregnancy to control your lupus.
Women with lupus are more likely to have a preterm delivery, meaning the baby is born more than three weeks before the due date. In some cases, the baby is born a month early and is very healthy, but perhaps a bit small. In other cases, the baby is born several months early and is in the hospital for many weeks and can suffer life-long complications. Very active lupus, particularly in the kidneys, is the most common cause for a very early delivery.
Unfortunately, women with lupus are at increased risk for miscarriages and stillbirths. Previous miscarriages and/or high levels of antiphospholipid antibodies are the most worrisome risk factors for this outcome. Women who have active lupus nephritis (lupus that involves the kidneys) at the time they conceived, or women who test positive for high protein levels in the urine, antiphospholipid antibodies or lupus anticoagulant; or have hypertension or high serum creatinine levels during pregnancy may also be at higher risk for losing their baby.
Lupus can increase the risk of certain serious pregnancy complications. That’s why regular visits with your maternal-fetal specialist for blood and urine tests are so important. These complications include:
- Preeclampsia, or pregnancy-induced hypertension: This used to be called toxemia, and is caused by problems with the baby’s placenta. The placenta is an organ attached to the uterine wall and connected by the umbilical cord to the fetus that allows for the flow of blood, oxygen, and nutrients. Preeclampsia occurs after 20 weeks, and causes sudden high blood pressure, high levels of protein in your urine, and can cause severe headaches, blurred vision, and seizures. Preeclampsia is a serious complication that could arm you and your baby, so it requires emergency medical treatment. Your doctors are looking for early signs of preeclampsia when they check your urine and blood pressure at every visit.
- HELLP syndrome, which stands for hemolysis, elevated liver enzymes and low platelets: This is a somewhat rare syndrome, but can occur in 10% to 20% of women with preeclampsia.
- Intrauterine growth restriction: This can cause your baby to be very small and may be due to hypertension, antiphospholipid antibodies or high lupus disease activity, especially if you have kidney involvement.
- Kidney problems: Active lupus can cause reduced kidney function. Extra protein can seep into your urine. This can cause swollen feet, legs or ankles. Pregnant women may think swollen ankles are normal, but if you have lupus, it could be due to impaired kidney function.
Once again, most women with well-controlled lupus can have safe, healthy pregnancies, and give birth to healthy children with no development problems. It’s important to see your rheumatologist and maternal-fetal specialist regularly, notify them about any possible problems or signs of complications, and take medications as they direct to control flares.
Rarely, women with lupus could have a baby with neonatal lupus. Neonatal lupus is NOT the same as SLE; babies born with neonatal lupus are very unlikely to develop chronic lupus later in life. Neonatal lupus is caused by a reaction in the infant to the mother’s anti-SSA/Ro antibodies. About 10% of babies will be born with a skin rash that will go away on its own over the first few months of life and won’t come back. Occasionally, the infant might have abnormal liver tests or low blood cell counts, but this is also temporary and babies do not need to be specifically tested for these blood tests at birth
In about 1-2% of cases, fetuses exposed to anti-Ro antibodies will develop a congenital heart block, which slows the heartbeat and requires a pacemaker. This happens before the baby is born. Once a baby is born with a normal heart rhythm, there is not a risk of developing this condition.