Pregnancy and Rheumatic Disease

For years, women with potentially serious systemic autoimmune diseases have been advised not to get pregnant. We now know that, with careful medical and obstetric management, most of these women can have successful pregnancies. Successful, however, does not mean uneventful. Doctors and patients must be ready to deal with possible complications for both mother and child. Further, women should not consider getting pregnant until their rheumatic disease is under control.

What are the effects of pregnancy on rheumatic diseases?

The effects of pregnancy on rheumatic diseases vary by condition. Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and APS typically are modified by pregnancy. For instance, symptoms of RA often improve in pregnant patients, frequently resulting in a reduced need for medication, but may flare up after delivery.

The relationship between lupus activity and pregnancy is more debated. In general, there is a tendency for mild to moderate flares, especially during the second half of pregnancy and the post-partum period. However, most of these flares do not endanger the mother's or the baby's life, nor do they substantially alter the long term prognosis of lupus. A prolonged period of clinical remission before conception decreases the chance of a flare during pregnancy.

Antiphospholipid syndrome (APS), increases the risk of clots in veins and arteries as well as obstetric complications such as miscarriage, prematurity or hypertension (high blood pressure) during pregnancy. When combined with kidney disease, the possibility exists for pre-eclampsia. Pre-eclampsia and eclampsia are conditions that may damage the mother’s kidneys and liver and also increase the risk of prematurity or death of the fetus. Thus, for women with APS, pregnancy—especially the time around delivery—is a particularly dangerous period and dictates special care.

Pulmonary hypertension, which complicates some rheumatic diseases (SLE, APS, Sjögren’s and, particularly, scleroderma), also warrants mention. Because this severe disease frequently is worsened during pregnancy—especially in the post-partum period—pregnancy isconsidered inadvisable.

Other diseases such as scleroderma (in the absence of pulmonary hypertension or lung fibrosis), polymyositis, dermatomyositis and vasculitis do not seem to be particularly influenced by pregnancy. However, it is still recommended that you consider pregnancy only when these diseases are under control and with the care of your rheumatologist.

What are the effects of rheumatic diseases on pregnancy?

During pregnancy, the effects of inflammation when rheumatic disease becomes active as well as the then necessary anti-inflammatory and/or immunosuppressive drugs can cause problems. Those diseases with the potential to affect the kidney and, especially, APS are more likely to affect pregnancy outcome than others.

Patients who have or have had kidney disease, due to vasculitis, scleroderma or, more frequently, lupus, in general are at increased risk of severe hypertension and pre-eclampsia. If renal function and blood pressure prior to pregnancy are normal and the disease is inactive at the time of conception for a period of at least six months, the outcome is likely to be good. Conversely, women with severely impaired renal function, uncontrolled hypertension and/or active kidney involvement usually are advised against getting pregnant.

APS probably has the greatest impact on pregnancy. It is related to both early and late miscarriage, prematurity and low-weight babies, as well as thrombosis and pre-eclampsia. Thus, pregnancy in women with APS should always be considered as high risk, and be the subject of close medical and obstetric monitoring. Therapy is based on low-dose aspirin and heparin.

Finally, a rare condition named congenital heart block can occur in 2% of children born to mothers with anti-Ro antibodies (most frequently seen in patients with LUPUS and Sjögren’s syndrome). Anti-Ro antibodies can gain access to the fetal circulation and produce disturbances in the baby's heart, which result in a slow heart rate. These babies may need a permanent pacemaker. Thus, women with anti-Ro antibodies also should be closely monitored including fetal heart scans during pregnancy.