The Lupus Book: A Guide for Patients and Their Families, Third Edition (46 page)

the other hand, there are circumstances when a pregnancy presents increased

risks. This chapter attempts to confront and clarify misconceptions and notions often held by both patients and doctors.

DOES LUPUS ALTER THE ABILITY TO CONCEIVE?

The ability to procreate, or fertility, is usually normal in SLE. Discoid lupus and drug-induced lupus per se are not associated with fertility problems. But

several specific circumstances relevant to SLE may affect fertility. These include disease activity, dialysis, and drugs.

Patients with very active disease frequently have irregular periods or none at

all. This is the body’s reaction to stress; menstrual regularity is restored when the disease is under adequate control. Thirty percent of patients with SLE have significant kidney disease, and 10 to 20 percent of them evolve end-stage renal disease, necessitating dialysis over a 10-year observation period. Dialysis is associated with scanty or no menstrual cycles. A successful kidney transplant

obviates the need for dialysis and may restore regular periods. Finally, certain chemotherapy drugs interfere with ovulation (Chapter 27). Cyclophosphamide

causes premature menopause in 25 to 50 percent of the women in their twenties

who receive it for at least a year and in 80 percent of the women who take it

in their later thirties. Azathioprine, cyclosporine A, methotrexate, and nitrogen

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The Management of Lupus Erythematosus

mustard are not associated with loss of periods in women with SLE. Investi-

gational studies under way would enable women who need to take cyclophos-

phamide to be made hormonally ‘‘prepubertal’’ with leuprolide (Lupron), the

equivalent of having their eggs removed and stored for later use.

What about male fertility? Sperm counts (but not libido) decrease in men who

take chemotherapies. Although sterility is uncommon, I urge males with SLE

who require chemotherapy to bank (store) their sperm before starting treatment.

THE MOTHER: WHAT WILL GO ON INSIDE OF HER?

The Overall View

Our group conducted a survey and chart review of 307 women with SLE who

had 634 pregnancies and were seen in our office between 1980 and 1990. Eighty

patients (26 percent) never conceived; this is three times the national average.

Of the 634 pregnancies, 439 (69 percent) resulted in live births, 106 (17 percent) in therapeutic abortions, and 95 (15 percent) in spontaneous abortions. These

patients fell into low-risk, high-risk, and moderate-risk categories.

Low-Risk Mothers

Those who fall into this group have nothing to worry about, since their risk of a problem pregnancy is the same as that in the general population (5 to 10

percent). These women include those with discoid lupus, drug-induced lupus,

and women with SLE who have mild disease and are in remission, off all med-

ication, and lack the Ro (SSA) antibody and anticardiolipin antibody.

High-Risk Mothers

A small group of women face an extremely high risk of fetal demise and ma-

ternal organ failure if they become pregnant. Overall, up to 3 percent of high-

risk pregnant women with SLE die. This group includes patients with active

lupus myocarditis, active lupus nephritis with an elevated serum creatinine, severe and uncontrollable high blood pressure, and those who need to receive

chemotherapy during their pregnancy. Myocarditis is usually aggravated during

pregnancy and leads to heart failure. Many lupus patients with active nephritis and an elevated serum creatinine will require dialysis, and that hikes the risk of fetal demise to over 80 percent. Preexisting hypertension is aggravated during

most pregnancies, and, if not well controlled, can lead to strokes. Finally, most chemotherapies other than cyclosporine A or azathioprine have an unacceptably

high risk of causing fetal anomalies, malformations, and maternal infections.

Despite these odds, I continuously come across brave women who wish to ex-

ercise their biological prerogative and don’t care that the odds are greatly stacked
Can a Woman with Lupus Have a Baby?

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against them. About 20 percent of the mothers make it through, have a normal

baby, and come out unscathed. Most mothers with these risk factors miscarry;

the remaining 20 percent develop serious complications. Lupus patients with

serious, organ-threatening disease who wish to have children should be encour-

aged to consider adoption.

Moms Who Should Proceed with Caution

Patients who are not at especially high risk but for whom a pregnancy might

well present problems fall into the category that most of my young female

patients fit into. This section provides a clear road map to follow.

What Will Happen to the Lupus?

Patients whose lupus is mild or moderately active at the time of conception have a 40 percent chance of having no change in their disease, a 40 percent chance

of flaring, and a 20 percent chance of improving. The fetus makes cortisone,

and by the second trimester, mild disease may improve as the mother receives

this extra dose of steroids. However, various chemicals released in pregnancy

can also promote inflammation. Most flares are mild and easy to manage. Serious flares rarely occur in this group, but mild cutaneous or musculoskeletal postpartum flares are common, especially between the second and eighth weeks after

delivery. The withdrawal of fetal steroids from the body may have something

to do with this. Although few rheumatologists do this, I routinely give SLE

patients an injection of 60 milligrams of triamcinolone (Kenalog) intramuscu-

larly 7 to 10 days postpartum to block the flare.

What Lupus Medications Can Patients Take During a Pregnancy?

Regular-dose aspirin or other NSAIDs
are not advisable during a pregnancy since they may induce bleeding, which leads to miscarriage, prolongs labor, and causes early closure of the opening between the pulmonary artery and descend-ing aorta near the fetal heart. However, these dangers are not applicable to

patients taking low-dose aspirin who have antiphospholipid antibodies. A patient who is pregnant and has inadvertently taken an NSAID on a short-term basis

and has not miscarried has no cause for concern, since fetal malformations do

not occur.

Historically,
antimalarials
were not advisable in pregnancy, and the manufacturers list pregnancy as a contraindication. The administration of chloroquine is associated with a very small risk of causing blindness or deafness in the fetus.

Several reports of congenital malformations with quinacrine have appeared. In

my experience, however, hydroxychloroquine (Plaquenil) appears to be safe and

several large scale recent studies have confirmed this. Some investigators have continued the drug and noted less lupus activity.

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The Management of Lupus Erythematosus

Moderate or low-dose
corticosteroids
(less than 40 milligrams of prednisone a day) appear to be relatively innocuous and free of significant problems in

pregnancy. This is probably because they are natural hormones made by both

mother and fetus. A steroid preparation called betamethasone (sometimes in-

jected into joints as Celestone) crosses the placenta particularly well and is used by obstetricians to improve the maturity of fetal lungs in mothers who show

signs of delivering prematurely.

The use during pregnancy of any of the agents discussed in this paragraph is

not advised by the manufacturers.
Azathioprine
rarely, if ever, causes fetal abnormalities and has been taken during pregnancies by patients who have had

kidney transplants. Occasional reports of fetal immune deficiencies for the first months have appeared. Two transplant antirejection agents,
cyclosporine A
, and Cell Cept are probably not advisable.
Cyclophosphamide, methotrexate, nitrogen
mustard
, and
chlorambucil
are all capable of causing fetal malformations and should be avoided unless the life of the mother is at stake and she wishes to

continue the pregnancy.

Plasmapheresis
and
intravenous gamma globulin
are safe to use in pregnancy.

How Can Complications Related to the Antiphospholipid Syndrome

Be Prevented?

The antiphospholipid syndrome (Chapter 21) is associated with an increased risk of fetal death and miscarriage. One-third of those with SLE have antiphospholipid antibodies (especially anticardiolipin), and in these patients the risk of spontaneous abortion ranges from 20 to 50 percent.
Antiphospholipid antibodies
cross the placenta and promote clots in it, which results in fetal death. I usually screen all newly pregnant patients for antiphospholipid antibodies if they have not been tested previously. Occasionally, doctors come across a patient who is

antiphospholipid-negative but becomes positive only during the pregnancy.

There is no agreed upon way to manage pregnant women with antiphospho-

lipid antibodies. If the antibody is present, I prescribe one baby aspirin a day (81 milligrams) during the pregnancy until the 35th week, when it is stopped

to allow the baby’s heart channel to close. There is a much greater risk that IgG

antibodies to cardiolipin will induce abortion than that IgM or IgA antibodies

will do so, and the IgG antibodies can be tested for easily. If the mother mis-

carries in spite of baby aspirin therapy, the next time she conceives, I initiate therapy with subcutaneous heparin, a blood thinner injected or low molecular

weight heparin daily under the skin, like insulin. Oral warfarin (Coumadin),

which is usually used when patients with these antibodies have systemic blood

clots while taking baby aspirin, is not advised in pregnancy. Many respected

practitioners use moderate doses of prednisone (20 to 40 milligrams daily) along with baby aspirin, and still others occasionally use plasmapheresis in patients
Can a Woman with Lupus Have a Baby?

[247]

(wash their blood to filter out the antibody) weekly or give intravenous immu-

noglobulin. My success rate with baby aspirin—and if needed, subcutaneous

heparin—is over 50 percent.

What Should Patients Who Carry the Ro (SSA) Antibody Do?

Between 20 and 30 percent of those with SLE carry the Ro (SSA) antibody.

Many of these patients also carry the La (SSB) antibody; the presence of this

antibody by itself is very rare. Anti-Ro and anti-La can cross the placenta and induce two syndromes: neonatal lupus and congenital heart dysfunction or block.

(Both are discussed in detail in Chapter 23.) These antibodies present no risk

to the mother. The chance of developing either of these syndromes is very small, and cutaneous neonatal lupus is a mild, self-limited process. Even though congenital heart block in the infant is found in less than 5 percent of pregnancies of Ro-positive mothers, pregnant women should be screened for it with a fetal

echocardiogram (ultra-sound of the heart) at week 18 and 24. The administration of betamethasone, a steroid that crosses the placenta, may be useful.

What about Patients with Active Kidney Disease?

Renal disease present at the beginning of pregnancy is associated with a 50

percent flare rate, a 25 percent incidence of preeclampsia (pregnancy-related

hypertension), and a 25 percent risk of kidney failure requiring dialysis during the pregnancy. Patients who have normal renal function (creatinines of less than 1.5 milligrams per deciliter) should be closely monitored, with doctor visits

approximately every 2 weeks. Rigid blood pressure control, salt restriction, and increased doses of steroids if renal function worsens or serum complements fall are desirable. Patients with elevated serum creatinines are at an even greater risk and must follow these precautions. If the nephritis was well controlled prior to conception, only 10 percent of patients have serious flareups during pregnancy.

How Should Pregnant Patients Feel and What Should They Do?

Pregnant patients with lupus behave and feel like most healthy pregnant women.

There is no reason why they cannot work or exercise if they wish to and are

able. No special dietary considerations apply. There is a chance that if they have mild to moderate disease, their lupus symptoms could worsen during the first

trimester. The fetus’ adrenal gland starts making cortisone during the second

trimester, and the mother will probably start feeling better at that time. The

child’s father should be included on the health-care team so that he can help

and support the mother when she needs rest or doesn’t feel up to doing things.

Flareups can be treated with acetominophen (Tylenol) if fever or musculoskel-

etal aching is involved and with steroids if they are more serious.

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The Management of Lupus Erythematosus

What Laboratory Tests Should Be Obtained During a Lupus Pregnancy?

When a patient tells me she is pregnant, I ask her (and the father) to come into my office so I can explain the situation and answer many of the questions raised in this chapter. In addition to examining the patient, I also perform baseline

laboratory studies. These include a complete blood count, platelet count, blood chemistry panel, urinalysis, anticardiolipin antibody, lupus anticoagulant, complement studies, anti-DNA, electrocardiogram, and anti-Ro (SSA) and anti-La

(SSB) antibodies. The Westergren sedimentation rate is falsely elevated in all

normal pregnancies and is not reliable. I try to see my pregnant lupus patients once each trimester and more often if necessary. Blood pressures and weight