Lupus and pregnancy: planning and care

We know that pregnancy is a time of many demands and prohibitions for women. But how is pregnancy for those who suffer from Systemic Lupus Erythematosus? According to the rheumatologist at Imuno Brasil, Dr. Ricardo Amaro Noleto Araujo, the keyword is planning, and he explains the main precautions and care that doctor and patient should take at this time.

It is unlikely that Lupus poses a risk to the life of the mother or the baby during pregnancy, however, it is necessary to consider the following aspects:

Planning: It is recommended that the patient with Lupus make a plan to get pregnant, as the ideal is that the disease has been in remission for at least 6 months so that she can get pregnant and go through the gestational period with more tranquility. This phase is achieved through appropriate treatment, symptom control, and laboratory tests that assess disease activity. It is important to emphasize that if the pregnant woman has another associated comorbidity such as Hypertension, Hypothyroidism and Diabetes, these diseases must also be controlled for a safe pregnancy, and multidisciplinary follow-up is very important in these cases.

Drugs: Another concern of pregnant women is regarding the schedule of drug treatment: “during pregnancy, it is possible that the patient with Lupus will have to modify her medication in use”, explains Dr. Ricardo Amaro Noleto Araujo. The treatment must be adapted to the needs of each patient, in order to choose the right medicine to treat the mother without harming the baby. 

Most immunosuppressants are contraindicated during pregnancy, which makes the therapeutic approach difficult when the disease is active during pregnancy. In general, the use of antimalarial drugs such as hydroxychloroquine is well tolerated, has a lower profile of side effects than any other drug available for the treatment of SLE, and is recommended throughout pregnancy as a way to keep the disease under control and out of activity. Other medications such as methotrexate, mycophenolate, cyclosporine must be modified due to the profile of side effects and risks to the health of the fetus. Some cases may require the use of corticosteroids to control the disease during pregnancy, with the dose and duration of use defined according to each manifestation

Risks: Among the complications that can occur during the pregnancy of patients with lupus are neonatal lupus, which can affect the baby in different ways and severity, such as cutaneous manifestations that develop between the first 3 months of birth, to more serious situations, such as hemocytopenia (hemolytic anemia, leukopenia and thrombocytopenia), hepatobiliary manifestations or heart disease, the latter of which can be fatal. It is important to highlight the need to research some antibodies that may have a higher gestational morbidity among patients with Lupus, congenital heart block may occur in up to 2% of children born to mothers with positive anti-Ro/SSA and anti-La/SSB antibodies, with a recurrence rate of 12-20%.

In these cases, “Early intrauterine diagnosis is essential for treatment, and it is recommended to perform an echocardiogram between the 16th and 25th weeks of gestation, a period of greater transplacental passage of maternal antibodies and greater risk of alteration of the fetal cardiac conduction system”.

Pregnancy can also trigger other manifestations or aggravate certain aspects of the disease. Lupus nephritis, for example, occurs when Lupus attacks the kidneys. The condition, characterized as a clinical challenge, can occur postpartum or be pre-existing, hence the importance of pregnancy planning. Active nephritis leads to a greater risk of miscarriage and complications during pregnancy, and prior treatment is of paramount importance.

The Antiphospholipid Antibody Syndrome (APS) is considered more dangerous, as it is characterized by the existence of venous and arterial thrombosis in the presence of antiphospholipid antibodies, resulting in high rates of severity during pregnancy. This condition can cause problems for the fetus to grow and even important complications such as eclampsia. It is important to recognize this syndrome during prenatal care in order to institute treatments that reduce these risks.

We emphasize the need to individualize the treatment and exams for each pregnant woman, it is always indicated that she is accompanied by a multidisciplinary team, including the rheumatologist and the obstetrician. A better outcome occurs when decisions are taken in a shared and aligned way between the teams.Sobre o Dr Ricardo Amaro Noleto Araujo: Rheumatologist from Universidade Federal de São Paulo (UNIFESP). Master in Vasculitis from UNIFESP. Professor and researcher in Autoimmune Diseases at Faculdade Santa Marcelina.