Pregnancy and Lupus, possible complications and treatments

Things to consider before looking for a baby

Systemic lupus erythematosus (also known by its acronym SLE or simply as lupus) is an autoimmune disease in which the body’s own defence system attacks the tissues of one or more organs. It is a chronic condition, i.e. it is a lifelong condition, although it is common to find periods of flare-ups when symptoms worsen. As is common in most autoimmune diseases, women are more commonly affected (10:1 ratio) and symptoms usually start between the ages of 20-30 years old.

For women with SLE who wish to have children, it is very important to plan pregnancies in advance so that medication can be changed if necessary and the patient’s condition can be re-evaluated with blood tests. This is because pregnancy may not be recommended if there is significant damage to vital organs due to the risk it could pose to the mother-to-be and the baby. It is advisable to be at least 6 months stable and without outbreaks to start the gestational search and thus reduce risks.

Not all medication used to treat lupus is prohibited in pregnancy and the rheumatology specialist will be in charge of assessing the best treatment plan for pregnancy. In general terms, we can confirm that:

• The use of Leflunomide, Metrotexate and Mycophenolate mofetil is contraindicated because of the risk of miscarriage and teratogenicity.
• The use of aspirin and hydroxychloroquine should be continued.
• Of the commonly used immunosuppressants, Azathioprine and Tacrolimus are compatible. If on other medication they should be changed 6 weeks to 3 months in advance.
• Low doses of prednisone have not been associated with pregnancy complications. Information on high doses is more controversial and may influence hormone production and ovulation and may make it difficult to achieve spontaneous pregnancy.

Systemic lupus erythematosus and fertility.

Regarding fertility, there are two distinct issues: ovarian reserve and problems in achieving or maintaining pregnancy.

Regarding ovarian reserve, although there are studies with different results, it seems that women with lupus are at a higher risk of having a low ovarian reserve, especially if they have previously used cyclophosphamide. In addition, trying to find the best chance of the disease to conceive may delay the time to seek pregnancy, which is also related to the decrease in ovarian reserve and oocyte quality. In these cases, it is important to consider the possibility of freezing eggs in order to plan a future pregnancy.

On the other hand, not all patients diagnosed with lupus have difficulty in having children, as most will go on to have pregnancies naturally. That said, there are exceptions such as the diagnosis of Antiphospholipid Syndrome or APS (a common occurrence in this disease) which does carry a higher risk of repeated miscarriages. This is why it is recommended to assess the level of related antibodies before gestational screening.

Another particular case would be women who have anti-Ro/anti-La antibodies. In these women the risk comes from the effect of these antibodies on the foetus as they can interfere with the normal heart rhythm and confer an increased risk of so-called ‘neonatal lupus’. This is due to the passage through the placenta of antibodies that can attack the newborn’s skin and cardiovascular system.

Approximately 10% of women with SLE will also have thyroid problems, so thyroid screening prior to pregnancy is of utmost importance.  All this leads us to the same recommendation to plan the ideal time for pregnancy after a general evaluation.

What to do if I suffer from lupus and I don’t get pregnant?

If pregnancy does not occur after 6-12 months of searching, depending on the case and age, it is advisable to consult a fertility specialist and start with a basic study to try to find the cause or simply to find out what the situation is. Patients with systemic lupus erythematosus can undergo fertility treatment during their periods of remission, although special care should be taken as they have a higher risk of thrombosis, so they should take specific medication and use protocols that ensure the lowest possible level of oestrogens.

Possible complications during pregnancy when you have Lupus 

• Disease flare: most body systems are not at increased risk of disease flare in pregnancy with the exception of the renal system, so this should be closely monitored during pregnancy.
• Gestational diabetes: increased risk in pregnant women with lupus, especially if they use corticosteroids. This medication in many cases cannot be avoided in pregnancy and is important to keep the disease under control, but it has the side effect of making it more difficult to metabolise carbohydrates and thus increasing the risk of diabetes in pregnancy.
• Pre-eclampsia: in the general population, the risk of this complication is between 5-8%, while in patients with lupus it is 15-35%, which is why it is recommended that blood pressure be taken at least once a month to detect it as early as possible. On the other hand, and like other pregnant women, in the first trimester the so-called ‘pre-eclampsia screening’ will be carried out to identify patients at risk and thus take the necessary measures to try to reduce it.
• The increased risk of repeated miscarriages in those with antiphospholipid syndrome.
• Premature birth and premature rupture of membranes.
• Intrauterine growth retardation.

What happens if I’m pregnant and suffer from lupus?

In these cases, the pregnancy will be monitored more closely by both the obstetrics and rheumatology departments, with frequent check-ups to ensure that the pregnancy runs smoothly. Each pregnant woman with lupus has a unique situation and there are no general measures; the number of check-ups will depend on the evolution of each case, although at least once a month.

Another important time is the postpartum period, when there is an increased risk of both a disease flare and the risk of thrombosis, so women with lupus with an added risk factor should use heparin after giving birth. The duration of this treatment will be decided on a case-by-case basis.

After childbirth the medication should be maintained and breastfeeding is not contraindicated as most of the drugs do not pass into the milk, but each case will have to be individualised.

Dr Maria Martínez (03/2870742), Gynaecologist specialising in Reproductive Medicine at Instituto Bernabeu.