The Risks of Pregnancy for Women With Lupus
A woman with lupus can have a successful pregnancy, but there are some risks and possible complications.
Lupus is a disease that most commonly affects women during their childbearing years. In the past, women with lupus were advised not to get pregnant because it was thought to be too dangerous for both mother and baby. Although pregnancy with lupus is still considered high risk, most women with lupus who want to have children will be able to have safe, successful pregnancies.
How Does Lupus Affect Pregnancy?
Lupus doesn't affect a woman's ability to get pregnant, but it does increase the risk of some pregnancy complications. "Although most pregnancies go well, there is an increased risk of miscarriage and premature birth. Women with lupus are at risk for renal [kidney] complications including renal failure if pregnancy occurs during a phase of active renal disease," notes Ignacio Sanz, MD, a rheumatologist at the University of Rochester Medical Center in Rochester, N.Y., and chair of the research committee for the Lupus Foundation of America. Here's what you need to know about the risks of pregnancy in different stages:
- First Trimester. Miscarriage during the first trimester is sometimes associated with active lupus symptoms. About 10 percent of pregnancies in women with lupus end in miscarriage, while nearly 15 percent of all pregnancies in the United States result in miscarriage.
- Second Trimester. Pregnancy complications in the second trimester may be due to a lupus antibody known as the antiphospholipid antibody. These antibodies are present in the blood of about 36 percent of women with lupus and are associated with the formation of blood clots that can cause miscarriage.
- Late-term complications. Pre-term birth occurs in about 25 percent of lupus pregnancies. Women with lupus are also more likely to develop high blood pressure and retain body fluid during pregnancy, a condition called preeclampsia, which can cause the placenta to rupture.
Maternal Risks of a Lupus Pregnancy
"The main concern for women with lupus has always been that pregnancy will cause their lupus to flare up. We have learned that although many women do have a flare [during pregnancy], they are not as severe as we once feared," says Dr. Sanz. "However, this sense of safety only applies to pregnancies that occur when lupus has been well controlled for several months."
Flares occur in about 18 percent of pregnant women with lupus. They are likely due to increased estrogen production that takes place in the body during pregnancy, stimulating the immune system to react. Flares are more common in women who have kidney involvement with their lupus before or during the pregnancy.Fetal Risks of Lupus
There are certain risks to the baby if the mother has lupus during her pregnancy. These include:
- Small baby. Babies of mothers with lupus have a higher risk for a condition called intrauterine growth retardation (IUGR), meaning that the baby remains much smaller than is normal. IUGR occurs in about 15 percent of lupus pregnancies. IUGR may be more likely if the mother has preeclampsia, antiphospholipid antibody, or was treated with steroids during pregnancy.
- Neonatal lupus. In rare cases, the baby can be born with lupus antibodies that cross the placenta. In 95 percent of these cases, the antibody is a type called anti-Ro. Even when the mother has anti-Ro antibody, neonatal lupus occurs in only about one percent of cases. Most of the symptoms of neonatal lupus are mild and go away in a few months, but there is one serious complication called congenital heart block. In these cases the baby does not have a normal heart rhythm and may need a pacemaker.
Managing Lupus During Pregnancy
"If we need to treat lupus during pregnancy we can still use many of the same drugs we used before pregnancy," says Sanz. Prednisone, Plaquenil (hydroxychloroquine), and the immunosuppressive drug Imuran (azathioprine) can all be used if needed to control lupus during pregnancy.
In women who have tested positive for antiphospholipid antibody, especially if they have a previous history of pregnancy complications, a combination of aspirin and the blood thinner heparin can be given to prevent blood clotting that can cause a second trimester miscarriage. 
How to Prepare for a Lupus Pregnancy
If you want to become pregnant with lupus, you should talk to your doctor first. "We advise women not to get pregnant if they have active lupus. This is especially important if the activity involves the kidneys or central nervous system. We would like to see their lupus in good control for about six months before they become pregnant," advises Sanz.
Once you get the okay to get pregnant, you should be tested for antiphospholipid and anti-Ro antibodies. The doctor who treats your lupus can recommend an obstetrician who has experience with high risk pregnancies. It is wise to be monitored by your treatment team once a month. Monitoring should include blood work and urine testing to detect any increase in lupus activity as early as possible.
In women who are at risk of transferring anti-Ro lupus antibodies to the baby or of having premature births, regular fetal heart monitoring and ultrasound exams of the fetus and the placenta should be done.
With proper timing and careful management, most women with lupus can have safe and successful pregnancies. Although a lupus pregnancy is still considered high risk, doctors know how to monitor for complications and how to treat complications when they develop. The days of counseling women with lupus not to get pregnant have passed.