Ask the Expert: Dr. Jane Salmon, Rheumatologist, Answers Your Questions About Pregnancy & Lupus
Q1. Is it possible to have a successful pregnancy and deliver at full term?
Although lupus patients usually have healthy pregnancies, they have a small but significant increased risk of complications to mother and baby. Clinical studies, including our own, have shown that the likelihood of good outcomes is increased if patients conceive at a time when lupus disease activity is under control. I recommend pre-pregnancy discussions with your rheumatologist to advise you when it is safe to try to become pregnant and to assess the safety of your medications during pregnancy. It is important to visit a high-risk obstetrician as soon as you know you are pregnant. The obstetrician and rheumatologist will form the team to closely monitor your pregnancy.
Q2. Will pregnancy cause my lupus to worsen?
Flares of lupus can occur during pregnancy, but if you conceive when your disease is inactive, flares are uncommon. In general, they are mild and can be safely treated with steroids.
Q3. I have read about your work on connecting problems with a women’s immune system to developing preeclampsia in pregnancy and having a miscarriage. When do you think it will be possible to test whether I am likely to develop preeclampsia when I am pregnant?
Preeclampsia affects up to 4 percent of pregnancies. It occurs in 10 percent of women with lupus, more commonly in those with kidney disease. Preeclampsia is diagnosed by the onset of high blood pressure and the appearance of protein in the urine, which may be signs of active lupus as well as preeclampsia. Because the cause of preeclampsia is unknown, there are no reliable means to predict its occurrence and no satisfactory prevention or treatment; when preeclampsia becomes life-threatening the only option is to deliver the baby pre-term. Studies in animal models suggest that preeclampsia may be triggered by immune mechanisms and inflammation. We followed 250 SLE patients through their pregnancies and found genetic variations in proteins that regulate a specific inflammatory pathway only in lupus patients who developed preeclampsia. Our results suggest new targets for treating preeclampsia and raise the possibility that tests to identify women at increased risk for preeclampsia can be developed. We are studying more genes in this pathway and measuring circulating proteins in blood early in pregnancy with the goal of developing a risk profile to guide patients and physicians, but this will take more years of research.
Q4. Will lupus medications harm a developing fetus? Must I stop taking these drugs if I get pregnant?
It is best to review your medications with your physician if you are planning to become pregnant. If your pregnancy is unplanned, contact your rheumatologist as soon as possible and avoid discontinuing or changing your medications on your own. Some medications, such as hydroxychloroquine, are safe and are used to prevent flares of lupus during pregnancy. Other medications, such as cyclophosphamide, methotrexate and warfarin, are potentially dangerous to the fetus and should be avoided.
Q5. Can women with lupus take birth control pills?
Birth control issues are very important in women with lupus, as poorly timed pregnancies pose health risks to mother and fetus. Historically, doctors were reluctant to prescribe oral contraceptives to patients with lupus because older studies suggested an increased risk of disease flares and estrogens were thought to promote lupus-like disease in animal experiments. Recent studies have definitively shown that that oral contraceptive use does not increase the risk of lupus flare or overall disease activity in women with mild lupus. Oral contraceptives containing lower doses of estrogen are probably safe in women with mild lupus. They should be avoided in women at increased risk of clotting, including women with antiphospholipid antibodies or nephrotic syndrome (lupus kidney involvement with high levels of urinary protein).
Dr. Jane Salmon is Co-Director of theMary Kirkland Center for Lupus Research, Director of the SLE APS Center of Excellence, Director of the FOCIS Center of Excellence, and Director of the Lupus Registry and Repository. Dr. Salmon’s research has focused on elucidating mechanisms of tissue injury in lupus and other autoimmune diseases. Her basic and clinical studies have expanded our understanding of pregnancy loss and organ damage in SLE and the determinants of disease outcome in lupus patients with nephritis, pregnancy, and cardiovascular disease.