Top 10 Series: Lupus and Pregnancy

Top Ten Points to Optimize the Outcome

Aeshita Pearl Dwivedi, MD
Research Volunteer, Mary Kirkland Center for Lupus Care, Hospital for Special Surgery


Doruk Erkan, MD, MPH

Doruk Erkan, MD, MPH

Associate Attending Rheumatologist, Hospital for Special Surgery
Associate Professor of Medicine, Weill Cornell Medical College
Associate Physician-Scientist, Barbara Volcker Center for Women and Rheumatic Disease


1. Is it possible for lupus patients to have a successful pregnancy?

Many lupus patients can have a successful pregnancy. To increase your chance of a successful pregnancy, it is essential to seek advice regarding the right time to conceive and to educate yourself about ways in which you can optimize the pregnancy outcomes.

Lupus patients are more likely to develop pregnancy complications compared to the general population. Thus, it is important to consult your rheumatologist and an obstetrician experienced in managing high-risk pregnancies prior to becoming pregnant. Additionally, you should plan your delivery at a hospital that has a Neonatal Intensive Care Unit as well as other advanced facilities to provide the specialized care that you and your baby may require.

Apart from the medical aspects, it is also important that you discuss your pregnancy plans with your partner or close family members. Pregnancy and a newborn often demand changes in your personal and professional life; seeking timely support from family and friends makes it easier to cope with these changes.


2. When is it the right time to conceive and what should you do after becoming pregnant?

The right time to conceive is when the lupus disease activity is fully under control and you are in your best health. The healthier you are before your pregnancy, the greater are your chances of having a healthy pregnancy and a healthy baby. It is strongly recommended that you avoid pregnancy until at least six months after the lupus disease activity, especially kidney disease, has been completely brought under control.[1] Pregnancy places an added burden on your kidneys and active kidney disease can even lead to pregnancy loss.

After your pregnancy test is positive, you should visit your rheumatologist and obstetrician at your soonest possible convenience. The purpose of these visits is to assess the state of your health and lupus disease activity by means of a complete physical examination and blood tests.


3. Can pregnancy lead to the worsening of lupus?

Although the risk of a lupus flare is not increased in pregnant women when compared to non-pregnant women, lupus flares can occur during pregnancy or immediately following delivery.[2] Fortunately most of these flares are not life threatening to the mother or the baby and can be treated with steroids.

Women who conceive at least six months after the lupus disease activity has been brought under control are less likely to experience a lupus flare than those who conceive while their lupus is active.[1]


4. How can you identify the symptoms of lupus flare during pregnancy?

Most patients flaring during pregnancy report fatigue, body aches, fever, butterfly shaped redness across the nose and cheeks, or patchy hair loss. Joint pain and joint swelling are also commonly reported. In case of heart or lung involvement, patients report symptoms such as chest pain or breathing problems.

At times, common discomforts of pregnancy can mimic the symptoms of lupus flare. These include:

  1. Swelling of joints (during pregnancy joint swelling occurs because the ligaments which hold your joints loosen up).
  2. Joint pain (especially in the lower back).
  3. Swelling of hands, feet, or ankles (during pregnancy your body tends to retain more fluid).
  4. Redness over the face, also known as “pregnancy blush” (due to increased blood flow to the skin during pregnancy).
  5. Loss of hair.
  6. Fatigue.
  7. Shortness of breath (this occurs because your diaphragm shifts upwards during pregnancy to make more space for the baby).

Nevertheless, if you experience any of the symptoms mentioned above, you should immediately report them to your physician. Lupus flares detected early are easier to treat and in turn cause less harm to the mother and the baby.


5. What are the complications that can occur in pregnant lupus patients?

Lupus patients are at a higher risk for pre-eclampsia (increased blood pressure occurring after 20 weeks of pregnancy in a previously normal woman), HELLP syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets), hypertension, renal insufficiency, urinary tract infections, and diabetes. Diabetes and hypertension occur more commonly in women taking steroids during pregnancy. Blurry vision, headaches, abdominal pain, and decreased frequency of urination could indicate a rise in your blood pressure.

Pregnancy loss (or miscarriages) may occur in approximately one-fifth of lupus pregnancies.[3] They are more likely to occur in women with high blood pressure, active lupus disease, active kidney disease, or antiphospholipid antibodies (aPL). Antiphospholipid syndrome (APS) is an autoimmune disorder caused by aPL attacking vascular structures in the body. As a result, this disorder leads to an increased tendency to form abnormal blood clots in the veins and arteries of the legs, lungs, or placenta. For this reason, it is important for lupus patients to be screened for aPL (especially those women who have experienced a miscarriage previously). Women with a history of miscarriage(s) and antiphospholipid antibodies are commonly prescribed aspirin and a blood thinner (heparin) to prevent recurrence.[2]

Finally, lupus patients are at a higher risk for delivering before completing 37 weeks of pregnancy (preterm delivery) and about one-third of lupus mothers deliver preterm.[5] Preterm deliveries are more likely to occur in patients with pre-eclampsia, aPL, and active disease.[4,5] Lupus patients should be watchful for symptoms of premature labor which include backache, pelvic pressure, blood or clear fluid leaking from the vagina, abdominal cramps, and contractions occurring every 10 minutes before 37 completed weeks of pregnancy.


6. What effects can lupus have on the baby?

Most lupus patients give birth to healthy babies. Babies born to lupus patients have no greater chance of birth defects or mental retardation than those born to women without lupus.

Among lupus patients with anti-Ro/SSA or anti-La/SSB antibodies, the risk that the baby will have neonatal lupus erythematosus is 25%.[6] Neonatal lupus consists of a temporary red, raised rash (usually around the eyes and scalp) and abnormal blood counts; the disease usually disappears by 6 to 8 months of age and does not recur.

Among lupus patients with anti-Ro/SSA or anti-La/SSB antibodies, the risk that the baby will have congenital heart block is less than 3%.[6] Thus, if you carry these antibodies, your obstetrician will regularly check the baby's heartbeat starting at around your 16th week of pregnancy. Depending of the type of heart disease your baby has, your doctor may prescribe steroids to you in order to improve the outcome of your baby.

Babies of lupus patients are also prone to intrauterine growth retardation (IUGR) and low birth weight. This is more likely to occur in pregnancies where the mother is either taking steroids or suffering from pre-eclampsia, hypertension, or active disease. Therefore, it is important to undergo regular ultrasound monitoring to detect IUGR in time and manage it appropriately.


7. Which lupus medications can be safely used during pregnancy?

If possible, it is best to avoid taking any medication during pregnancy (except for pre-natal vitamins). Some medications are safe during pregnancy while others are not. At times, your doctor may substitute safe medications for the unsafe ones if you are required to continue your treatment during pregnancy. It is unwise to discontinue medications on your own because doing so may lead to worsening of your lupus and cause damage to your baby. Selected medications are discussed below but you should always review your medication list with your physician during the pregnancy planning phase. 

  1. Selected medications causing minimal to no harm to your baby during pregnancy include:
    1. Steroids: Steroids such as prednisone, prednisolone, and methylprednisolone can be safely used during pregnancy because they do not cross the placenta and hence they do not affect the baby.[2] Even though they are considered safe, they should be used at the lowest possible dose. Dexamethasone and betamethasone DO cross the placenta and are specifically used when it is necessary to treat the baby as well. For example, in the event of a preterm delivery, steroids help the baby’s lungs to mature faster.

      Although considered safe for the baby, steroid use may be associated with side effects like diabetes, increased blood pressure, pre-eclampsia, kidney problems, breaking of the water early, low birth weight babies, and intra-uterine growth retardation.

      If you are required to take steroids during pregnancy, the side effects can be minimized by: (a) consuming a low salt diet (to prevent high blood pressure); (b) taking calcium and vitamin D (to prevent bone loss); and (c) exercising regularly (to prevent bone loss and excessive weight gain). 
    2. Hydroxychloroquine (Plaquenil®): Hydroxychloroquine can be safely continued during pregnancy. It is commonly used to prevent lupus flares and improve the outcome for mothers with lupus kidney disease.[7,8] In fact, women who discontinue hydroxychloroquine during pregnancy are more likely to have exacerbation of lupus disease activity and usually require higher doses of steroids. 
    3. Azathioprine: Azathioprine may be used cautiously in patients suffering from severe disease which has not responded to other medications during pregnancy.
    4. Heparin (blood thinner): Heparin is safe for use during pregnancy but it should be stopped prior to the delivery to decrease the risk of bleeding (especially if a caesarian section is required). 
    5. Aspirin and Non-steroidal anti-inflammatory drugs (eg. Advil®, Aleve®): Low dose aspirin (less than 160 mg/day) can be safely used during pregnancy in patients with antiphospholipid syndrome. Non-steroidal anti-inflammatory drugs (NSAIDs) can be safely used at moderate doses from the time of a positive pregnancy test until the beginning of the 28th week (or the third trimester) of pregnancy. They should be avoided during the third trimester as they can affect your baby’s blood flow, prolong the duration of your labor, or increase the blood loss during delivery.[2] Acetaminophen (Tylenol®) is a better alternative for alleviating pain as it can be safely used throughout the course of pregnancy. 
  2. Selected medications to be absolutely avoided during pregnancy include:
    1. Cyclophosphamide
    2. Methotrexate (should be stopped at least three months before you consider becoming pregnant) 
    3. Mycophenolate Moeftil
    4. Leflunomide
    5. Warfarin


8. Is it possible for lupus patients to have a normal vaginal delivery?

Decision regarding the method of delivery is usually made taking into account the health of the mother and the baby at the time of labor. If the mother and the baby are healthy at the time of labor, many lupus patients are able to have a successful vaginal delivery. However, if the mother/baby is under stress, or in the event of preterm labor, a caesarian section might be the safest and the fastest method of delivery.

Women taking steroids usually require an increased dose (also known as a stress dose) during labor. The increased dose of steroids helps the body cope with the additional physical stress your body experiences during labor.


9. What should mothers with lupus do after the delivery of the baby?

After the delivery, it is essential to follow up regularly with your doctor for the monitoring of the normal changes in your body as it transitions to its pre-pregnant state.

Lupus flares following delivery are treated similarly to those in a non-pregnant patient. However, if you are breast feeding you may have to stop doing so, depending on the type and the dosage of medications you require for your treatment.

Make sure you discuss the options for birth control with your doctor. Please remember that breastfeeding is not a reliable method of birth control.

Since lupus patients might face complications following delivery, it is important to arrange in advance for someone who will provide proper care to your baby (e.g., your spouse or your parents) while you are undergoing treatment.


10. Is it possible for a mother with lupus to breastfeed her baby?

Yes, most women with lupus are able to breastfeed their babies. Be patient, as it often takes time for the mother and baby to learn how to breastfeed. Do not hesitate to seek help from your doctor or nurse if you face trouble while breastfeeding. Nonetheless, lupus mothers may face the following challenges with regard to breastfeeding:

  1. If the baby is born prematurely, the baby might not be strong enough to suckle and draw the breast milk. Under such circumstances, you may express the breast milk yourself by using a pump and feed it to the baby until the baby is strong enough to suckle.
  2. At times the mother might not be able to produce enough milk. This usually occurs in the event of a preterm delivery or if the mother is on a steroid medication.
  3. Some medications can transfer through the breast milk into your baby. Non-steroidal anti-inflammatory medications, acetaminophen, hydroxychloroquine, low-dose prednisone (less than 15 to 20 mg/day), warfarin, and heparin are safe during breastfeeding. If the daily dose of prednisone exceeds 20 mg, you should wait for about 4 hours before nursing your baby.[9] You should avoid breastfeeding if you are on azathioprine, cyclosporine, cyclophosphamide, methotrexate, or mycophenolate moeftil. Regardless, if you are on any kind of medication, it is best to consult you doctor regarding the safety of breastfeeding before initiating it.

Learn more about the Mary Kirkland Center for Lupus Care

*The information above is intended to provide general education for lupus patients considering pregnancy. Use of this site does not establish a physician-patient relationship. The information provided above does not constitute medical or health care advice for any individual and is not a substitute for medical or other professional advice and service. Patients or individuals should always consult their health care providers for any specific lupus and/or pregnancy-related questions. Please refer to HSS Website Terms of Use for further information.

References

1. Petri M, Howard D, Repke J: Frequency of lupus flare in pregnancy: the Hopkins Lupus Center experience. Arthritis Rheum 1991,34:1538-1545.

2. Lockshin MD, Salmon J, Erkan D. Pregnancy and Rheumatic Disease. In: Creasy and Resnik’s Maternal-Fetal Medicine, 6th Edition. Eds: Creasy RK, Resnik RR, Iams JD, Lockwood CJ, Moore TR. Elsevier, Philadelphia 2008; p1079-1088.

3. Clark CA, Spitzer KA, Laskin CA. Decrease in Pregnancy Loss Rates in Patients with Systemic Lupus Erythematosus Over a 40-year Period. J Rheumatol 2005;32:1709-1712.

4. Hayslett JP. Maternal and fetal complications in pregnant women with systemic lupus erythematosus. Am J Kidney Dis 1991;17:123-126.

5. Clark CA, Spitzer KA, Nadler JN, Laskin CA. Preterm deliveries in women with systemic lupus erythematosus. J Rhematol 2003;30:2127-2132.

6. Buyon JP, Clancy RM: Neonatal lupus: review of proposed pathogenesis and clinical data from the US-based Research Registry for Neonatal Lupus. Autoimmunity 2003, 36:41-50.

7. Kasitanon N, Fine DM, Haas M, Magder LS, Petri M. Hydroxychloroquine use predicts complete renal remission within 12 months among patients treated with mycophenolate mofetil therapy for membranous lupus nephritis. Lupus 2006;15:366–370.

8. A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group. N Engl J Med 1991;324:150–154.

9. Petri M. Immunosuppressive drug use in pregnancy. Autoimmunity 2003; 36:51-56

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