Lupus and Pregnancy
Wondering, “Can I have a baby if I have lupus?” As technology and medicine have advanced over the years, pregnancy has become a possibility for women who have lupus. Close monitoring by your maternal-fetal medicine and Rheumatology specialists is key for a successful pregnancy and subsequent delivery.
Preparing for pregnancy in advance
Planning a pregnancy when you have lupus requires careful coordination and intention, but many women with lupus are able to have children without complication.
Because those who have lupus often take over-the-counter and prescription medications daily, consulting with your doctor before you begin trying to conceive is essential for the best outcome. You’ll work closely with both a maternal-fetal medicine specialist and a rheumatologist to ensure your risk (and the risk to the fetus) are managed and minimized throughout the pregnancy. Their recommendations will likely include discontinuing medications that are not safe to take during pregnancy, like methotrexate, prednisone, CellCept, cyclophosphamide, and other medications. They’ll most likely encourage you to continue taking hydroxychloroquine because the benefits of that medication, even during pregnancy, generally outweigh the risks.
They’ll also review with you the state of your health to make recommendations about timing. Whenever possible, women who have lupus should avoid conceiving during flares or periods of active disease. It’s safest for you and your unborn child if you’re in remission at the time of conception and ideally throughout the duration of pregnancy. Drugs like hydroxychloroquine can help prevent a flare during pregnancy without harming the fetus.
Factors that increase the risk of complications
Certain factors increase your risk of complications during pregnancy and/or fetal demise. Knowing your risk factors can help guide your discussions with your maternal-fetal medicine provider and rheumatologist before and during pregnancy.
If you have any of the following – at present or historically – be sure to discuss ways to mitigate risk with your healthcare team prior to becoming pregnant:
- Hypertension (high blood pressure)
- Kidney disease
- Low platelets
- Blood clots
- Antiphospholipid antibodies
The sooner your provider is aware of these risk factors, the better they can prepare for potential complications and mitigate the risk of harm to yourself or your unborn child.
What to expect during your pregnancy
A healthy pregnancy requires careful collaboration between you, your maternal-fetal medicine specialist, and your rheumatologist. Here’s what to expect.
Your responsibility in a healthy pregnancy
In order to ensure the best possible outcome for your unborn child, you should take measures to prevent pregnancy when your disease is active and seek guidance from your healthcare team when you’re ready to conceive.
During your pregnancy, you’ll need to schedule a Rheumatology appointment at least once per trimester and more frequently if you notice signs or symptoms of a lupus flare while you’re pregnant. You’ll be responsible for showing up for your appointments (including lab draws) as well as discontinuing and taking all medications that are recommended by your healthcare team.
Taking care of your body will be essential to avoid a flare. Manage stress levels, get plenty of sleep, don’t take recreational drugs, avoid alcohol, quit smoking (or don’t start), and let your healthcare team know right away if something doesn’t feel right to you.
By being an active participant in your pregnancy, you can improve your likelihood of a safe and successful pregnancy.
The provider's role in your pregnancy
Your healthcare providers also play a very important role in your pregnancy. They’ll be responsible for monitoring you for signs and symptoms of a flare or other complications that could have consequences for you or your baby.
You’ll need to find a maternal-fetal medicine specialist who is comfortable overseeing pregnancy in a patient with lupus. Your OBGYN or rheumatologist might have recommendations for you. Between your maternal-fetal medicine specialist and your rheumatologist, you should have the following tests done throughout your pregnancy to monitor lupus activity and the function of your vital organs:
- Complement levels
- Anti-SSB/La and Anti-SSA/Ro antibodies
- Anti-DNA bodies
- Blood chemistry levels
- Complete blood count
- Antiphospholipid antibodies
These tests will give your healthcare team insight into your body and the health of the baby, allowing them to make proactive decisions to keep you as healthy as possible.
Knowing your risk factors and the complications that are most likely to arise during pregnancy can empower you to identify problems early and seek help at the first sign of trouble. Remember, many women with lupus have healthy pregnancies and deliveries and never experience any of these complications.
First, review the risk factors listed earlier and note which apply to you. Discuss those risks with your provider early. Then, be aware of these common complications and notify your provider immediately if you notice the signs or symptoms.
Antiphospholipid antibodies are a group of antibodies that, when present in the body, can interfere with a healthy pregnancy by causing blood clots that inhibit the function and growth of the placenta. This can increase the risk of miscarriage and slow the growth of the fetus, so if your doctor identifies antiphospholipid antibodies, he or she may recommend early delivery depending on a number of factors.
Antiphospholipids are diagnosed through blood tests, not particular signs and symptoms, so early diagnosis and intervention rely on routine blood tests.
Fetal demise isn’t reserved for mothers who have lupus, but they are at slightly higher risk than mothers who don’t have lupus. Your risk of fetal loss is higher if you have experienced miscarriage or stillbirth in the past; you had lupus nephritis at the time you conceived; and your lab results show protein in your urine, high serum creatinine, or the presence of antiphospholipid antibodies or lupus anticoagulant.
If you think you might be experiencing fetal demise (cramping, bleeding, or in later months, lack of movement), seek emergency medical attention.
Women who have lupus are at higher risk of developing HELLP syndrome before in the week following delivery, which stands for hemolysis, elevated liver enzymes, and low platelets. Although this condition is rare, it increases the risk of severe complications like pulmonary edema, respiratory distress, placental abruption, and hemorrhage during delivery. If you develop HELLP Syndrome during or after pregnancy, you’ll likely require hospitalization and intervention to protect yourself and your baby.
Signs and symptoms include blurry vision, headache, nausea, chest pain, and swelling.
Impaired kidney function
Because lupus can impact and damage the kidneys in the absence of pregnancy, it continues to pose a risk to your kidneys – and therefore your pregnancy – during pregnancy. If lupus is impairing your kidney’s overall function, you may experience proteinuria (protein in the urine) and fluid retention in the feet and ankles.
Intrauterine growth restriction
As the name suggests, intrauterine growth restriction refers to the slow or delayed fetal growth and low birthweight. Intrauterine growth restriction can occur on its own but is often related to another condition in pregnancy like lupus-related kidney disease or antiphospholipid antibodies.
The goal during pregnancy is to prevent or limit lupus flares altogether, which is most likely if you wait until you’ve been in remission or inactive for at least 5 or 6 months before conceiving. Identifying a flare during pregnancy can be challenging because some of the signs and symptoms of pregnancy are similar to the signs and symptoms of a flare. For this reason, routine labs are important in identifying the markers of a flare early and then intervening as appropriate to drive the best outcome for both mom and baby.
Symptoms of a flare include unexplained fever, rash, and pain, and swelling in the joints.
On rare occasions, the mother’s antibodies can impact the fetus leading to a condition called neonatal lupus, characterized by liver problems, rash, low blood cell counts, and sometimes, congenital heart block. Neonatal lupus is generally resolved by the time the infant is six months old with no lasting effects at all.
Those infants who suffer from congenital heart black related to neonatal lupus sometimes need a pacemaker.
It’s important to note that neonatal lupus is not a lifelong disease; infants with neonatal lupus typically move through life without ever developing another form of lupus during their lifetime.
A problem with the placenta or a change in your body’s immune response to the placenta can lead to a complication called pre-eclampsia, characterized by high blood pressure and protein in the urine. Pre-eclampsia can occur at any time in the last twenty weeks of pregnancy and in rare cases, in the days following delivery.
Signs and symptoms of preeclampsia include fluid retention, headache, and blurry vision and you should seek immediate medical attention if you experience these symptoms.
Babies delivered between 37 and 40 weeks gestation are considered full-term and have the least likelihood for underdevelopment at birth. Mothers with lupus are at higher risk of giving birth prior to 37 weeks, so it’s important to be prepared early, ensure you’re near the services you and your baby will need, and work with your provider to monitor for signs of impending labor.