Pregnancy and Lupus Q and A

Lupus and Pregnancy
By Rodanthi C. Kitridou, M.D., FACP, FACR
Lupus has important implications for the lifestyle and quality of life of the woman who has it. Pregnancy is one
of the milestones in the life of women (and men) and the interface between lupus and pregnancy leads to some special situations. Women with lupus frequently ask: 
Q: Am I able to get pregnant?
A: Absolutely yes. There is no problem with fertility in women with lupus. They can conceive as easily as any woman except in about 5%, which is the infertility rate of the general population. Any problems with fertility should
be investigated in both partners by an obstetrician-gynecologist who specializes in infertility. 
Q: Is there a best time to get pregnant?
A: Very much so. A good general rule is, to be free of lupus activity, in a remission, for 6 months or more. The chances of a flare are only about 10%. If pregnancy happens without a long lasting remission, flares can happen in half of the patients. 
So, planning the pregnancy is very important in lupus. Although, during a flare the menstrual period may stop, there can be conception. That is why good contraception is necessary. A flare, especially a severe one, is a very difficult time for the non-pregnant patient with lupus. It can be twice as difficult in pregnancy, because the fate of the baby has to be considered too. 
Q: What type of contraception is best for a lupus patient?
A: Oral contraceptives (the pill) are, in general, the most effective, when taken properly. In the 60’s 70’s and 80’s, when the pill contained a relatively large dose of estrogen (a female hormone), almost half the lupus patients who took it flared. For this reason, a study across the nation is being done to evaluate how safe the newer “mini-pills” are, that contain less estrogen. (Some of the women with lupus, who are in a remission, are able to take the modern “mini-pills” without flares). Until the results of the study are in, in 2-3 years, here are some good choices:
Progestational contraceptives contain the female hormone, progesterone, and are available as tablets, as injections that protect for 3 months, and as implants. A progesterone implant is a small tube with progesterone that is placed under the skin and can prevent pregnancy for up to 5 years. There is a slight risk of local infection. A side effect of the progestational contraceptives is that there can be spotting and breakthrough in some patients. 
The intrauterine device, IUD, is inserted in the uterus and prevents pregnancy. Currently used IUDs are improved from those of 20 years ago. There is a slight risk of unwanted pregnancy with IUD and some potential side effects: bleeding and infection. Barrier methods of contraception include the diaphragm with spermicide, and condom with spermicide. The risk of unwanted pregnancy is about 10-14%. “Rhythm” methods do not work. 
Q: I have been in a remission for 6 months now. If I go ahead and try to get pregnant, what are the risks to me?
A: Lupus flares could happen even after a long remission, during pregnancy, or in the 2 months after delivery, but are usually mild-joint pain, rashes, fatigue. That is not to say that other types of flares are excluded. Pleuritis, pericarditis, hemolytic anemia, cerebritis, vasculitis, and other flares can occur. In women who have had lupus nephritis, it too could flare, and this could be serious. New involvement with nephritis can occur during pregnancy, and sometimes be mistaken for pregnancy-induced hypertension or preeclampsia. Not treating lupus nephritis during pregnancy can have dire consequences for mother and baby, such as loss of kidney function, loss of the baby. If there has been high blood pressure in the past (hypertension), there is a 40% chance that it will recur during pregnancy. 
First time pregnant women with lupus may experience, in the second half of pregnancy, preclampsia which is hypertension with protein in the urine, that mimics lupus nephritis. Distinguishing between lupus nephritis flare and preeclampsia can be difficult. Laboratory tests can help: complement is low and anti-DNA is high in lupus flare, and there may be other systems involved by the flare. These lab tests should be done once a month, to monitor lupus activity. Antiphospholipid antibodies are linked to the causation of preeclampsia. Baby aspirin, taken once a day, has helped prevent preeclampsia. 
Q: Are there any risks to the baby? 
A: Yes, there are some. Again, knowing ahead of time the possibilities helps counter potential problems. Certain autoantibodies are linked to fetal risks. 
Special lab tests that should be done before pregnancy, even at the onset of lupus, are: Antiphospholipid antibodies, anti-Ro/SSA and anti-La/SSB. Antiphospholipid antibodies are against cell membrane constituents (phospholipid) and could cause blood clotting inside arteries or veins. Three such antibodies are usually tested for in the blood, anticardiolipins, lupus anticoagulant, and false positive VDRL. If one or more of these are present, there can be risk of clotting. Clotting can occur in a leg vein (phlebitis), sometimes “travels” to lung veins (pulmonary embolus), or can happen in the blood vessels of the placenta (the afterbirth). The placental blood vessels are extremely important in the circulation of the baby, and any clotting would lessen the nutrients brought to the fetus. In fact, several fetal problems have been linked to the presence of IgG antiphospholipid antibodies that can cross the placenta and cause clotting. Low birth weight of the baby from malnutrition in the uterus, and even miscarriage (fetal death), usually in the second half of the pregnancy. Some women with high levels of one or more antiphospholipid antibodies may have several miscarriages, known as “recurrent abortions”. Baby aspirin is effective in the prevention of low birth weight and some miscarriages, while recurrent aborters do better with heparin treatment. Both treatments lower the clotting ability of the blood.
Premature birth (before the 36th week of pregnancy) is common in lupus, about in 30% of pregnancies, and has been linked to premature rupture of the membranes (breaking of the water). 
A third fetal problem is the neonatal lupus erythematosus syndrome (NLE), linked to anti-Ro/SSA and anti-La/SSB antibodies, and rarely, to anti-RNP antibodies. About 30% of SLE patients have anti-Ro/SSA, and very few have, anti-La/SSB (5-15%). NLE can be manifested as a skin rash that disappears in 4-6 months, or as congenital heart block, that persists through life and may need a pacemaker. 
Because of the potential problems to the mother and baby, a team of physicians is needed: a rheumatologist with experience in lupus, a high-risk obstetrician and a neonatologist. 
Q: What drugs are safe to take during pregnancy? 
A: In general it is best to give as little medication as possible. Most flares are managed with steroids, without any unwanted effected on the baby. Prednisone, prenisolone, and methylprenisolone (Medrol) can be used as needed to treat the mother’s SLE. A small dose of prednisone (10 mg per day), may help prevent flares. Hydroxychloroquine (Plaquenil) and azathioprine (Imuran) are well tolerated with little or no risk for fetal malformations. Methotrexate or cyclophosphamide (Cytoxan) should not be used, because they have been linked to malformations. However, a severe nephritis flare during pregnancy may require intravenous Cytoxan, if the kidney function is being compromised. Certain drugs for hypertension (ACE inhibitors) can cause malformations and renal failure in the fetus and should not be used in pregnancy. 
Q: What drugs are safe while breastfeeding?
A: It is best not to breastfeed if the mother needs medications for lupus, except for small doses of prednisone, up to 15-20 mg per day. Trace amounts of all drugs are found in maternal milk and could cause problems in the baby, whose metabolic system is still immature. 
In closing, I would like to emphasize that lupus pregnancies are more successful than ever before, with the advances in SLE treatment by rheumatologists, aggressive follow-up and early diagnosis of fetal distress by obstetricians, and superior treatment by neonatologists, with increased survival of premature babies. Careful planning, a team of seasoned physicians, and loving support by the husband family are the essential ingredients of successful childbearing in lupus.