Pregnancy and Lupus |
Michael D. Lockshin, M.D. |
Since lupus primarily affects young women, pregnancy often becomes a crucial question. Years ago, all medical texts said that lupus patients could not have children, and if they became pregnant, they should have therapeutic abortions. Clearly, these early conclusions are wrong. Currently, 50 percent of all lupus pregnancies are completely normal, and 25 percent deliver normal babies prematurely. Fetal loss, due to spontaneous abortion (miscarriage), or death of the baby accounts for 25 percent. While not all of the problems of pregnancy with lupus have been solved, pregnancies are possible, and normal children are the rule. While it is certainly possible for lupus patients to have children, pregnancy may not be easy. It is important to note that although many lupus pregnancies will be completely normal. all lupus pregnancies should be considered "high risk." "High risk" is a term commonly used by obstetricians to indicate that solvable problems may occur and must be anticipated. Pregnant lupus patients should be managed by obstetricians who are thoroughly familiar with high risk pregnancies and work in close concert with the women's primary physician. Delivery should be planned at a hospital that has access to a unit specializing in the care of premature newborns. SLE mothers should not attempt home delivery, or be overly committed to "natural" childbirth, since treatable complications during delivery are frequent. However, under close observation, the risk to the mother's health is lessened, and healthy babies can be born. WILL PREGNANCY FLARE MY LUPUS? Although older medical texts suggest that SLE flares are common in pregnancy, recent studies indicate that flares are uncommon and are usually easily treated. In fact, 6-15 percent of lupus patients will actually experience an improvement in lupus symptoms during pregnancy. FLares most often occur during the first or second trimester, or during the two months immediately after delivery. Most of the flares tend to be mild. The most common symptoms of these flares are arthritis, rashes and fatigue. Approximately 33 percent of lupus patients will have a decrease in platelet count during pregnancy, and about 20 percent will have an increase in or new occurrence of protein in the urine. Women who conceive after 5-6 months of remission are less likely to experience a lupus flare than those who get pregnant while their lupus is active. Lupus nephritis befroe conception also increases the chance of experiencing a lupus flare during pregnacy. It is important to distinguish the symptoms of a lupus flare from the normal body changes that occur during pregnancy. For example, because the ligaments that hold the joints together normally soften in pregnancy, fluid may accumulate in the joints, especially in the knees, and cause swelling. Although this may suggest an increase in inflammation due to lupus, it may simply be the swelling that occurs during a normal prenancy. Similarly, lupus rashes may appear to worsen during pregnancy, but this is usually due to an increased blood flow to the skin that is common in pregnancy (the 'blush' of a pregnant woman). Many women also experience new hair growth during pregnancy, followed by a dramatic hair loss of hair after delivery. Although hair loss os certainly a symptom of active SLE, this again is most likely a result of the changes that occur during a normal pregnancy. WHEN IS THE BEST TIME TO GET PREGNANT? The answer is simple: when you are at your healthiest. Women in remission have much less trouble than do women with active disease. Their babies do much better, and everyone worries less. Good health rules are essential: eat well, take medications as prescribed, visit your doctor(s) regularly, don't smoke, don't drink, and cerntainly don't use 'recreational' drugs. WHY ARE FREQUENT DOCTOR VISITS SO IMPORTANT IN A LUPUS PREGNANCY? Frequent doctor visits are important in any high risk pregnancy because many conditions which may occur can be prevented, or treated more easily, if found early. About 20 percent of lupus patients will have a sudden increase in blood pressure, protein in the urine, or both during pregnancy. This is called toxemia of pregnancy (or pre-eclampsia, or pregnancy-induced hypertension). It is a serious condition, and will require immediate treatment and usually immediate delivery. Toxemia is more common in older women, in black women, in women with twins, in women with kidney disease, in women with high blood pressure, and in women who smoke. Serum complement and blood platelet count may be abnormal in these cases. Since complement levels and blood platelet counts are also abnormal during SLE flares, it may be difficult for the doctor to be certain that a flare is not causing these symptoms. If toxemia is promptly treated the woman should be in no danger, but there is a high risk that the baby will die if it is not rapidly delivered. If toxemia is ignored, both the woman and her baby are in danger. As pregnancy progesses it is often wise for the doctor to check the baby's growth with sonograms (which are harmless). The doctor should also regularly check the baby's heart beat. Abnormalities in either the baby's growth or heart beat may be the first signs of trouble that can be treated. CAN I TAKE MEDICATIONS DURING PREGNANCY? It is always unwise to take unnecessary medications during pregnancy. However, necessary medications should not be discontinued. Most medications commonly taken by SLE patients are safe to use during pregnancy. Prednisone, Prednisolone, and probably methylprednisolone (Medrol) do not get through the placenta and are safe for the baby. Specifically, dexamethasone (Decadrol, Hexadrol) and betamethasone (Celestone) do reach the baby and are used ONLY when it is necessary to treat the baby as well. For example, these medications might be used to help the baby's lungs mature more rapidly if the baby will be premature. Aspirin is safe; it is often used to protect against a complication known as toxemia of pregnancy. Preliminary reports suggest that azathioprine (Imuran) and hydroxychloroquine (Plaquenil) do not harm babies, but the final word is not yet in on these. Cyclophosphamide (Cytoxan) is definitely harmful if taken during the first three months of pregnancy. WHAT ABOUT 'PROPHYLACTIC' (PREVENTATIVE) TREATMENT WITH PREDNISONE? A few doctors feel that all pregnant women with lupus should take small doses of Prednisone to prevent early abortion. However, there are no confirmed data that is necessary. Similarly, some physicians feel steroids should be given or increased after the baby is born to prevent 'post partum flare.' Again, there is no evidence that this is necessary in most cases either. For patients recently on steroids, however, 'stress' steroid is usually given during labor to supplement what the mother can't make herself. WHAT ARE ANTI-PHOSPHOLIPID ANTIBODIES AND WHY ARE THEY IMPORTANT? About 33 percent of lupus patients have antibodies that interfere with the function of the placenta. These antibodies are called antiphospholipid antibodies, the lupus anticoagulant or anti-cardiolipin antibodies. These antibodies may cause blood clots, including blood clots in the placenta, that prevent the placenta from growing and functioning normally. This usually occurs during the second trimester. Since the placenta is the passageway for nourishment from the mother to the baby, the baby's growth slows. The baby can be delivered at this time and will be normal if it is big enough. Treatment for lupus patients who have these antibodies is still being tested. Aspirin, Prednisone, Heparin, and plasmapheresis have all been suggested as possible therapies. However, even with the use of such medications, these antibodies may still lead to miscarriage. WILL MY BABY BE NORMAL? Prematurity is the greatest danger to the baby. About 50 percent of lupus pregnancies end before 9 months, usually because of the complications previously discussed. Babies born after 30 weeks or over 3 pounds usually do well. Premature babies may have difficulty breathing, may develop jaundice, and may become anemic. In modern neonatal units, these problems can be easily treated. Babies weighing more than 3 pounds at birth grow normally. Even babies as small as 1 pound, 4 ounces have survived and have been healthy in every way; but the outcome is uncertain for babies of this size. There are no congenital abnormalities that occur only to babies of lupus patients (except as described below), and no unusual frequentcy of mental retardation. WILL MY BABY HAVE LUPUS? About 33 percent of lupus patients have an antibody known as anti-Ro or anti-SSA antibody. About 10 percent of women with Anti-Ro antibodies, or about 3 percent of all lupus women, will have a baby with a syndrome known as neonatal lupus. Neonatal lupus is not SLE. Neonatal lupus consists of a transient rash, transient blood count abnormalities, and a special type of heart beat abnormality. If the heart beat abnormality occurs, which is very rare, it is treatable; but it is permanent. Neonatal lupus is the only type of congenital abnormality found in children of mothers with lupus. For babies with neonatal lupus who do not have the heart problem, there is no trace of disease by 3-6 months of age, and it does not recur. Even babies with the heart beat abnormality problem grow normally. If a mother has had one child with neonatal lupus, there is about a 25 percent chance of having another child with the same problem. WILL I HAVE TO HAVE A CAESARIAN SECTION? Very premature babies, babies showing signs of stress, babies of mother with low platelets, and babies of mothers who are very ill are almost always delivered by Caesarion section. This is often both the safest and fastest method of delivery in these cases. Usually the decision about type of delivery is not made in advance because the specific circumstances at the time of delivery are the determining factors. CAN I BREAST-FEED? Although breast feeding is possible for lupus patients, breast milk may not come if the baby is born very prematurely because very premature babies are not strong enough to suckle, and thus, cannot draw the milk. However, milk can be pumped from the breast to feed a premature baby if the baby is not strong enough to suckle and the mother wishes to do this. Plaquenil and the cytotoxic drugs (Cytoxan, Imuran) are passed through the milk to the baby. Some medications, such as Prednisone, amy prevent milk from being produced. If you are taking any medication it is best not to breast feed; but if your doctor approves, you may. WHO WILL CARE FOR THE BABY? Prospective parents often do not ask what will happen after the baby is born if the mother is ill and unable to care for the child. Since it is likely that a lupus patient will have future periods of illness, it is wise to think of this possibility in advance and to have plans for alternate child-care (spouse, grand-parent, etc.) if needed. |
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