BY ADEY BERHANU, MD, FACR, RHMSUS
Lupus is an autoimmune condition characterizedby dysregulation of the immune system resulting in widespread inflammation that can affect different organ systems. Autoimmune diseases, including lupus, are more common in women during their childbearing years. As such, special considerations for lupus patients during pregnancy are reviewed in this article.
In the past, pregnancy in lupus patients was associated with increased fetal loss. The good news is that pregnancy loss in lupus patients has now dropped to mirror the rates of healthy women without autoimmune disease. Increased planning prior to conception, screening, and close monitoring are the driving forces behind improved maternal-fetal
outcomes in lupus.
With lupus, it is important to plan conception when the symptoms of lupus are well-controlled. Six months of lupus disease remission is recommended before attempting conception because active lupus is associated with increased obstetricrisks, including fetal growth restriction, preterm labor, preeclampsia, and miscarriage. A large study has shown that disease remission or low lupus activity at time of conception was associated with an 81% chance of uncomplicated pregnancy (1). Therefore, for a lupus patient with new or active lupus involvement, it is advised to delay pregnancy until the lupus has been treated and well-controlled for at least six months before trying to conceive
Women with lupus should undergo further autoimmune screening prior to
pregnancy. Specifically, lab work to check for coexisting autoimmune diseases such as antiphospholipid or Sjogren’s antibodies should be performed and, if present, may require additional monitoring during pregnancy or use of prophylactic treatment during pregnancy. The use of aspirin or blood thinners may be recommended as antiphospholipid antibodies are associated with increased likelihood of blood clots.
The Sjogren’s antibodies known as SSA or SSB can be transmitted from the mother to the fetus causing heart block or lupus rash. The initial risk of heart block is 2-3% and fetal heart ultrasounds are performed routinely and Plaquenil is recommended for preventive treatment (2).
Medication review is essential prior to conceiving as there are several medications used in the treatment of lupus that are teratogenic (harmful) to the fetus and must be discontinued prior to pregnancy. Teratogenic medications include anti-hypertensive medications known as ACE inhibitors (i.e., Lisinopril), CellCept, and Cytoxan. Discontinuation of such medications and a washout period of up to three months is recommended prior to conception. Adjustments can be made to medications that are safe and commonly used in lupus pregnancies, including hydroxychloroquine (Plaquenil), azathioprine, and prednisone. A great resource for medication safety profiles and use during pregnancy is MotherToBaby.
A multidisciplinary treatment team is recommended because pregnancy during lupus is complex and can be higher risk. Therefore, a maternal-fetal medicine specialist obstetrician and rheumatologist should co-manage pregnant women with lupus as they plan conception and during pregnancy.