Pregnancy in Lupus

by Dr Neil Buchanan MB ChB FRCP (Glasgow & Edinburgh)

(First printed in Lupus UK News & Views, Winter 1997 Number 53.)

Lupus is predominantly a disease of young women and therefore tends to afflict those members of society with potential to become pregnant. In fact over a third of women with lupus who become pregnant do so after the first symptoms of disease have appeared. this means that for the lupus sufferer and specialist alike, lupus in pregnancy is a common and important issue. I shall consider the mother first with the important question of how pregnancy may affect lupus.

Sometimes symptoms usually suggestive of lupus flare occur in unaffected women in pregnancy. These include hair fall and redness of the cheeks and palms. swelling of the ankles and fingers may occur in normal pregnancy. Lupus activity may be greater during pregnancy and worsening is certainly common shortly after delivery of the baby.

With careful treatment, the greater activity of the disease can generally be satisfactorily and safely controlled. It used to be considered that kidney involvement was contraindication to pregnancy in the lupus patient but now appears that pregnancy does not usually pose a great threat to kidney function, even in those with pre-existing kidney disease.

For greater safety, I would recommend that kidney disease has been under control for 6 moths before pregnancy is considered. Pregnancy is still not advised in patients with active nervous system involvement from lupus.

On the whole, specialised care and treatment can make pregnancy safe and rewarding experience from the mother's point of view, but how does lupus in the mother affect the baby? Active lupus in pregnancy, especially active kidney disease, is associated with an increase in the chance of a miscarriage or a premature baby. Careful specialist management can reduce these risks to relatively low level. There are special sub-groups of patients in whom the baby has special risks and in whom pregnancy presents a need for extra special medical care. people in the first sub-group often have skin rashes on exposure to the sun and may have dry eyes and mouth, a condition known as Sjögren's Syndrome (see Sjögren's Syndrome).

These patients have circulating antibodies in their blood called Ro and sometimes antibodies called La. These antibodies can cross the placenta from mother to baby and cause a mild lupus face rash for several weeks after birth. This rash clears without treatment and does not cause scarring. Extremely rarely these babies can have problems with the conducting system which controls the heart beat. It should be emphasised that this condition is very rare in the sub-group who have Ro and La antibodies. The second sub-group of patients needing special attention show a tendency to have blood clots in the arteries and veins and are prone to miscarriages, especially in the middle three months of pregnancy.

These patients have special blood test abnormalities called the lupus anticoagulant and anticardiolipin antibody (see Hughes' Syndrome). Again appropriate treatment can greatly can greatly help with these pregnancies. before pregnancy is attempted, I would recommend a visit to the lupus specialist clinic to discuss the problems a potential mother might face.

Patients and non-specialist doctors are sometimes surprised to learn that many of the drugs normally used in lupus are considered safe for use in the lupus pregnancy. These include Prenisolone, azathiaprine (Imuran), hydroxychloroquine (Plaquenil) and low dose (baby/junior) aspirin. For ladies with a clotting tendency and anticardiolipin antibodies or lupus anticoagulant, we sometimes use self-injected low dose heparin. Patients find these injections fairly straight forward to learn.

Of crucial importance in the treatment programme is the obstetrician. regular ultrasound scan assessments are undertaken as are Doppler tests to measure blood flow to the placenta and to the baby. These tests, in skilled hands, can guide the obstetrician in deciding changes to treatment and when the baby is delivered. Overall, with care and a good partnership between the lupus sufferer and specialist, pregnancy can be a safe and rewarding experience.