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Pregnancy, Rheumatoid Arthritis, and Lupus

by Bonnie L. Bermas, MD

The good news is that RA itself does not have a negative impact on the baby. RA does not increase the rate of miscarriage, and it does not cause any problems in the baby.

If you have lupus

The situation is more complicated if you have systemic lupus erythematosus. Lupus can affect many parts of the body, including the skin, joints, kidneys, blood cells, heart, and lungs. Common symptoms are a rash on the face, pain and swelling in the joints, and fever. Kidney disease is among the most serious symptoms. Lupus is more common in women than in men and usually appears when people are between the ages of 15 and 45.

In years past, doctors often counseled women with lupus against becoming pregnant. This recommendation was based on the idea that pregnancy would always cause lupus flares — potentially very serious flares — and that the babies would not fare well. These are still valid concerns. But a better understanding of lupus and its treatment has made pregnancy a realistic and safe option for most women with lupus.

The data on lupus flares during pregnancy are conflicting. Several studies have shown that pregnancy increases the risk of flares. Other studies have found that it does not. Part of the confusion lies with how different researchers measure and define a flare. Moreover, during any nine-month period a woman with lupus may have a flare or flares whether she is pregnant or not. So flares during pregnancy are not necessarily related to the pregnancy. Furthermore, pregnancy itself can bring on fatigue, headaches, shortness of breath, and joint pain, all symptoms of a lupus flare. What is most likely is that there is a slightly increased risk of flare-ups in women with lupus. But in many women, the flares can be readily managed with medicine.

The woman most likely to flare and do poorly during pregnancy is the woman whose lupus is active when she conceives. This is especially the case if the lupus affects her kidneys. (Pregnancy also stresses the kidneys.) Doctors generally recommend that a woman not try to become pregnant until she has been in remission from kidney disease and active lupus for six months.

Ideally, the woman with lupus who wants to become pregnant will see her rheumatologist ahead of time so the doctor can do blood tests that will assess how active the lupus is. The blood tests will also establish a baseline that the doctor can refer to later during the pregnancy if there are problems. (If these tests aren’t done before a woman becomes pregnant, they should be done soon after.) The woman should also consult early on with an obstetrician who has experience caring for women with lupus or an obstetrician who specializes in high-risk pregnancies. It also helps if, when a woman becomes pregnant, she is taking medicines to control her lupus that she can continue to take safely during her pregnancy. (Although many women with RA can stop taking their medicines during pregnancy, this may not be the case for women with lupus.) She and her rheumatologist also need to plan for what medicines she can use if she has a flare during the pregnancy.

If blood tests show that the woman has antibodies called anti-Ro (SSA) or anti-La (SSB), she has a small risk of having a baby born with a rare condition called neonatal lupus. The main symptom of neonatal lupus is a skin rash, and the lupus usually disappears within six months. However, a very small percentage of babies with neonatal lupus (2% to 5%) develop heart block, which causes the heart to beat abnormally. When a woman is known to have anti-Ro or anti-La antibodies, she will probably have an ultrasound at 18 to 24 weeks into the pregnancy to see if there is heart block. If there is, the doctor may prescribe a corticosteroid in an attempt to treat it (although the research has not shown a clear benefit of doing this). Sometimes it will be necessary to deliver the baby early. Most babies born with heart block need to have a pacemaker implanted, either at birth or later in life.

As I noted earlier, if blood tests show that a woman with lupus has antiphospholipid antibodies, she has an increased risk of blood clots. This is in addition to the increased risk of clots caused by pregnancy itself. She also has an increased risk of miscarriage (thought to be caused at least in part by blood clots in the placenta that stop it from functioning properly). Roughly 40% of people with lupus have these antibodies, but a much smaller percentage will have complications during pregnancy. In pregnant women with the antibodies who have already had miscarriages or blood clots, treatment with the drug heparin can lower the risk of blood clots and miscarriage. (However, a woman won’t be treated just because she has the antibodies unless she has had miscarriages, pregnancy complications, or blood clots.)

Other pregnancy complications of lupus include preeclampsia, premature rupture of the membranes (which usually means that the baby is born prematurely), and low-birth-weight babies. In preeclampsia, or pregnancy-induced hypertension, a pregnant woman has high blood pressure and retains fluid, among other symptoms. Preeclampsia is thought to be more common among women with lupus. Often, it can be difficult to distinguish between preeclampsia and lupus flares. If it is not treated appropriately, preeclampsia can damage a woman’s kidneys and liver. It can also increase the risk of miscarriage and premature birth or cause the baby to be very small. If you have preeclampsia, your doctor may recommend that you deliver the baby early, either by induced labor or a cesarean section.

Last Reviewed on September 3, 2010

Bonnie L. Bermas is Assistant Professor of Medicine at Harvard Medical School and Director of the Lupus Center at Brigham and Women’s Hospital in Boston.

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