Pregnancy can be a major concern for women living with an autoimmune disease. How will it affect baby? How will if affect mommy? If you so happen to be one of those women and you thought that pregnancy was out of the question for you because of your illness… think again.
Pregnancy with an autoimmune disease
Pregnancy with an autoimmune disease requires careful planning. First, it’s extremely important to have an open and honest discussion with your rheumatologist before thinking about conceiving, preferably 6 to 12 months before. In fact, you should have a similar discussion with everyone on your care team: primary care provider, hematologist, nephrologist, pulmonologist, cardiologist, etc. It’s also important to establish care with a high-risk OB-GYN, preferably someone who has experience caring for people with your condition and who delivers in a hospital staffed by rheumatologists.
During this time your care team plan will work with you to:
- Make sure your disease is well controlled on a stable regimen for at least 6 months.
- Remove medications that could potentially cause problems for your baby and replace them with safe alternatives.
- Identify and anticipate for potential risks that could negatively affect your pregnancy.
High risk medications
Because it would be completely unethical to conduct a randomized controlled study on pregnancy outcomes and exposure to disease modifying agents (DMARDs), the vast majority of evidence regarding the safety of medications during pregnancy comes from animal models and registries such as OTIS: autoimmune diseases in pregnancy project. The following are considered safe to use during pregnancy:
- Hydroxychloroquine
- Azathioprine
What about biologics?
Again, available data is limited due to the fact that you can’t recruit people into studies to answer these sort of questions. Mounting evidence suggests that TNF-inhibitors are probably safe. However, if I were to choose one biologic, I would probably go with certolizumab for the simple reason that very little if any of it crosses the placenta.
Follow this link from the American College of Rheumatology regarding medication safety during pregnancy.
What about breastfeeding?
The NIH maintains a database called LactMed that contains information about medications and how they affect breastfeeding. The information is free and available to the public.
What does it mean to be high-risk?
- Previous pregnancy with complications
- Kidney disease
- Heart disease
- Lung disease (including pulmonary hypertension), very high risk
- Flare of a rheumatic illness
- A history of previous blood clot
- Presence of SSA and SSB antibodies
- Presence of antiphospholipids
- IVF (in vitro fertilization)
- Pregnancy with twins, triplets, etc.
- Mother being over 40
SSA and SSB antibodies
SSA and SSB increase the risk of neonatal lupus. The risk is small, 1-2% of cases but the risk significantly increases in women who have already borne a child with neonatal lupus.
Children that are born with neonatal lupus may have a rash, liver problems, and low blood cell counts but thankfully, these symptoms disappear completely after about six months. Having neonatal lupus does NOT increase the risk systemic lupus erythematosus (SLE).
The most dreaded complication of neonatal lupus is complete heart block, which typically occurs at weeks 20 – 22. Your high risk OB-GYN will conduct frequent fetal cardiac tests during the “high risk period” +/- a few weeks. While it’s currently not recommended to use prophylactic steroids to prevent this from happening, if congenital heart block does occur, your doctor will most likely use steroids and in utero pacing.
Antiphospholipid antibodies
There are three types of antiphospholipids: lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoproteins. The presence of these antibodies, particularly at high titers, are associated with something called the antiphospholipid syndrome. People that have this condition have a higher risk of developing blood clots. Hence, they tend to get DVTs and pulmonary embolisms. Moreover, women tend to get miscarriages, stillbirths, pre-term deliveries, and preeclampsia. Since antiphosplipid antibodies increase the risk of clots, to prevent complications, women that have antiphospholipids should take “pregnancy-safe” blood thinners.
How does pregnancy affect disease activity?
It all depends on the disease. Typically SLE becomes more active during pregnancy, whereas rheumatoid arthritis and psoriatic arthritis tends to improve.
Lupus nephritis
HOWEVER, there are a few notable circumstances where pregnancy is risky for both the mother and the child. It’s generally not safe to conceive during a period of very high disease activity. This includes lupus nephritis. It’s generally discouraged to conceive when lupus nephritis is active, but when things are controlled it’s okay with very close monitoring. Patients with lupus nephritis commonly flare, are at higher risk of preeclampsia, and HELLP syndrome.
Pulmonary hypertension
Another very important high risk situation is pulmonary hypertension. This happens in systemic sclerosis, SLE, myositis, mixed connective tissue disease, Sjogren’s syndrome, and rheumatoid arthritis. When pulmonary hypertension is caused by an autoimmune disease, we call it connective tissue disease-related pulmonary arterial hypertension. Symptoms include:
- Shortness of breath, particularly with exertion
- Fatigue
- Dizziness, passing out.
- Chest pain
- Swollen legs or swollen abdomen (ascites)
- Palpitations
- Bluish color
So why is this especially important for pregnancy-related matters?
A study by Qian et al. aimed to evaluate the survival of patient with SLE-associated pulmonary arterial hypertension. This was a systematic review and meta-analysis. They identified 6 studies which included a total of 323 patients. They found that 1-, 3-, and 5-year survival rates were 88%, 81%, and 68% respectively. The more severe the pulmonary hypertension, the worse the outcome.
However, high pulmonary hypertension peripartal mortality is not an isolated incident related to SLE alone. It is elevated for all connective tissue disease-related caused of pulmonary arterial hypertension.
Conclusion
In conclusion, we’ve come a long way when it comes to rheumatic diseases and pregnancy. Way back when, it was generally discouraged in practically all circumstances. But things have changed. With careful planning and monitoring, many women with autoimmune diseases can now have safe pregnancies.
Medical Disclaimer
This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.
References
Kelley and Firestein’s Textbook of Rheumatology, tenth edition
American College of Rheumatology
Pasut G. Pegylation of biological molecules and potential benefits: pharmacological properties of certolizumab pegol.BioDrugs. 2014 Apr;28 Suppl 1:S15-23.
Moroni G, et al. Maternal outcome in pregnancy women with lupus nephritis. A prospective multicenter study. J Autoimmun. 2016 Nov;74:194-200.
Thakkar V, Lau EM. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol. 2016 Feb;30(1):22-38.
Qian J, et al. Survival and prognostic factors of systemic lupus erythematosus-associated pulmonary arterial hypertension: A PRISMA-compliant systematic review and meta-analysis. Autoimmun Rev. 2016 Mar;15(3):250-7.