Lupus and pregnancy: Can women with this autoimmune disease get pregnant and will their babies be healthy?
For women who have autoimmune diseases like lupus, concerns about conceiving and carrying a baby to term are common. While having lupus can be challenging during pregnancy, motherhood is still possible. CNA Women finds out more about the common misconceptions.
An autoimmune disease such as lupus is classified as one where the body can’t tell the difference between viruses, bacteria and the body’s own healthy cells – and attacks these healthy cells instead of the germs. Lupus symptoms include muscle and joint pain, rashes, hair loss, light sensitivity, extreme fatigue, blood clotting and anaemia.
Women are nine times more likely than men to be diagnosed with lupus, or systemic lupus erythematosus (SLE). Typically, a diagnosis happens during the child-bearing ages of 15 through 45 years.
For women suffering from lupus, the big question that weighs on their minds is: Can I have children with an autoimmune disease like SLE?
IT STARTS WITH FAMILY PLANNING
It’s possible, said Adjunct Associate Professor Faith Chia, senior consultant at Tan Tock Seng Hospital’s Department of Rheumatology, Allergy & Immunology. She added that many women who suffer from SLE have gone through pregnancies safely – and are mothers to healthy children.
“In fact, I have a patient (with lupus) who is delivering her second child after an uncomplicated pregnancy this month,” the rheumatologist said.
However, for a smooth pregnancy to happen, Assoc Prof Chia said that women must have their lupus symptoms under control with no flare-ups for at least six months prior to conceiving.
Family planning is a critical conversation to have with your healthcare team if you have lupus.
“The risks of complications during pregnancy increase when you have lupus, so it is important for patients to work with their doctors – both their rheumatologist and their obstetrician-gynaecologist (ob-gyn) to work towards a safe pregnancy.”
HIGH-RISK PREGNANCIES NEED INTEGRATED CARE
In Singapore, the one-STop Obstetric high RisK Centre or STORK at KK Women’s and Children’s Hospital (KKH), provides integrated care for women with complex and high-risk pregnancies.
Here, they can receive obstetric care from several multi-disciplinary medical specialists who collaborate to support women with high-risk pregnancies.
“We believe strongly in pre-pregnancy counselling and optimisation to achieve the best possible maternal and neonatal outcomes,” said Associate Professor Tan Lay Kok, the head of the Department of Maternal Fetal Medicine at KKH. “Women with lupus must recognise that their pregnancies are high-risk pregnancies.”
The obstetrician-gynaecologist also emphasised that women with lupus must plan for their pregnancies. “This allows for time to assess the extent and severity of the lupus, and to ensure that the disease enters remission because for the best outcomes, it must be inactive.”
Assoc Prof Tan, who was involved in a Singapore study of 75 pregnant women who had lupus and had their symptoms managed over a 16-year period at Singapore General Hospital (SGH), said the number of lupus patients who get pregnant works out to “four to five patients” a year.
PREGNANCY RISKS WITH LUPUS
Because lupus symptoms can manifest in different organs, Assoc Prof Tan said awareness is key. Some pregnancy complications arising from lupus include:
- Foetal growth restriction, where the baby does not grow well
- Superimposed pre-eclampsia where the mother suffers a specific high blood pressure disorder during pregnancy at an early stage
- Deep vein thrombosis where blood clots develop in the lower limbs
- Pulmonary embolism where blood clots develop in the lungs
- Pre-term labour such as the water bag bursting prematurely
- Premature newborns
A mother whose lupus is active could suffer from significant inflammation, with antibodies that can cross the placenta and affect the pregnancy greatly.
For example, in Antiphospholipid Antibody Syndrome (APS), the antiphospholipid antibodies attack phospholipids, a type of fat in the body. “That results in a spectrum of adverse outcomes ranging from recurrent miscarriages, poor foetal growth, an increased risk of developing pre-eclampsia and stillbirth,” said Assoc Prof Tan.
Lupus nephritis happens when the mother’s immune system attacks her kidneys, resulting in inflammation and organ damage. “This form of active SLE, especially with renal involvement of the kidneys, puts the mother at greater risk,” says Dr Tan Wei Ching, Senior Consultant, Obstetrics & Gynaecology at the Singapore General Hospital (SGH).
There are risks for the unborn baby too. Assoc Prof Tan pointed out there is an antibody which attacks Ro, a protein found in the control centre of the cell. “The anti-Ro antibody crosses the placenta and targets the baby’s heart (in the womb), causing a congenital heart block or a slowdown of the baby’s heartbeat.”
He said this affects 2 per cent of babies of mothers with lupus. If there was a previously affected baby, it rises by 20 per cent for the second child and to 40 per cent for the third child, Assoc Prof Tan added.
Other autoimmune diseases that affect women:
COMMON MISCONCEPTIONS DISPELLED
IF I HAVE LUPUS, WILL I PASS IT TO MY BABY?
According to The Centers for Disease Control and Prevention in the United States, babies born to mothers with lupus are mostly healthy.
Dr Tan of SGH said only 2 per cent of babies born to mothers with SLE may have neonatal lupus, a rare condition that occurs in babies who were exposed to certain lupus antibodies in the womb.
At birth, it can present as a rash on the skin and low blood count. For most babies, this is temporary and resolves over time as the level of antibodies decreases as they grow.
One rare manifestation of neonatal lupus is congenital heart block and, like the rashes, will resolve with close monitoring. Only in very severe cases will it require a pacemaker.
WILL I HAVE A MISCARRIAGE BECAUSE THE BODY SEES THE FOETUS AS A FOREIGN OBJECT?
No. Lupus is an autoimmune disease in which the body’s immune system attacks its own tissues, leading to inflammation and damage in organs and tissues.
Women with lupus who have APS can have an increased risk of blood clotting, affecting the blood flow in the placenta, potentially leading to miscarriage.
Dr Tan of SGH said: “Lupus is associated with a higher risk of blood clotting disorders and that increases the risk of miscarriage, not the foetus.”
WILL CONTINUING MY LUPUS MEDICATION HARM THE BABY’S GROWTH?
While there are risks for every medication, Assoc Prof Tan of KKH said: “There is excellent and comprehensive guidance available now, published by international scientific bodies and associations, on the various medications that can be used for lupus. They detail risks and side effects, which are important to dispel common misconceptions.”
He cited one example for the steroid prednisolone, used for inflammation. It was previously associated with babies born with cleft lip and palate although these were animal studies from many years ago.
“Most of the prednisolone is metabolised or processed by the placenta, so little of it reaches the baby,” Assoc Prof Tan said. “Many mothers with lupus (who believed the misconceptions) needlessly denied themselves this medication and ended up compromising their own welfare and that of their babies too.”
MANAGING YOUR PREGNANCY IF YOU HAVE LUPUS
In SGH, women with lupus are referred to the Rheumatology Obstetric Clinic (ROC) at the Centre for High Risk Pregnancies (CHiRP). Much like KKH’s STORK, the doctors and medical team work together to manage pre-existing complications and disease activity.
Doctors recommend that the pregnant mother with lupus do the following:
1. Schedule frequent doctor visits to your specialists
Visit both your rheumatologist and your ob-gyn to ensure your pregnancy is on track, with symptoms managed. Both these specialists will work closely together throughout the pregnancy to delivery and in the immediate post-partum period.
Assoc Prof Chia of TTSH said that expectant mothers with lupus should consult their rheumatologist every two to four weeks, especially in the last trimester. “Each visit, they will have blood and urine tests, a complete history and physical examination plus a review of their medications."
Dr Tan of SGH said: “SLE mothers are kept on close surveillance at joint clinics like the ROC and CHiRP. For example, blood pressure and urine tests for proteins are done at each visit. Regular monitoring of the baby’s heart during ultrasound scans ensures optimal foetal growth and can detect signs of heart block.”
2. Recognise your symptoms
Because the body changes during pregnancy, Assoc Prof Chia also observed that women may find it hard to distinguish these changes from their lupus symptoms. Common examples are fatigue, joint aches, breathlessness, and swollen feet or ankles.
The best course of action is to flag your doctors if anything out of the ordinary happens.
3. Manage your medications with your medical team
Dr Tan of SGH said continuing medication prescribed is key to keeping flares at bay, especially if the mother is still experiencing symptoms.
She added: “Doctors will have to weigh the risks and benefits in their choice of medications to ensure minimal adverse effects to the growing baby while keeping the mother’s disease under optimal control.”
Assoc Prof Chia said: “Women with lupus can go on to lead normal lives. Many of our patients are working, mothers to one or more children, and have rich and fulfilling lives while managing the disease.
“If they work with their medical team, monitor themselves and take their medications prescribed, they can enjoy the best pregnancy outcomes.”
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