Systemic lupus erythematosus and pregnancy

Source: Lev Dolgachev / Alamy / IPA

Yes it can be done.

The first message to send to women with systemic lupus erythematosus - an autoimmune disease that was considered an absolute contraindication to pregnancy until a few decades ago - is that having a baby is possible. The vast majority of women with this syndrome can calmly face the search for a child, with a very good chance of being able to make his dream come true.

But be careful, and this is the second important message: “For this to happen we must put yourself in the right conditions"He warns Laura Andreoli, rheumatologist of the Civil Hospitals of Brescia and one of the authors of the European recommendations for the management of pregnancy in case of lupus or antiphospholipid antibody syndrome. On the occasion of World Lupus Day, which is celebrated on May 10, let's see what conditions it is, with the advice of Andreoli and the gynecologist Andrea , another author of the recommendations and referent of the obstetrics unit 1 always at the civil hospitals.

Systemic lupus erythematosus: identikit of the syndrome

Lupus is one chronic autoimmune disease, in which the immune system "attacks" the organism itself. “In reality it is a syndrome characterized by a kaleidoscope of manifestations affecting different organs and tissues” explains Andreoli. Symptoms and clinical pictures can also be very different from patient to patient.

Among the most common symptoms are:

  • tiredness and general malaise
  • intermittent fever;
  • photosensitivity, i.e. sensitivity to sun exposure, which can cause skin manifestations. Very typical is the so-called butterfly erythema, which affects the nose and cheeks;
  • stiffness e articolar pains.

The disease can also involve the kidneys (causing nephritis), lungs (with pleurisy), blood system (with anemia, low platelets or other) and other organs.

Lupus is more frequent in women - the ratio is 9 to 1 compared to men - and often begins to manifest itself in childbearing age. The trend is generally fluctuating, that is, moments in which the disease is active alternate, and the symptoms are felt, and moments in which it is silent: the experts say in remission. “Another feature is that it can change over time: the same person affected can have different manifestations over the years ".

Lupus cannot be cured, at the moment there is no therapy that can definitively defeat it. There are several though drugs that allow you to keep it under control, considerably attenuating its manifestations and reducing the moments of activity. "Among these, for example, thehydroxychloroquine - considered drug of choice in pregnancy - i corticosteroids, taken by mouth in maintenance therapy or even intravenously if the disease reignites, or immunosoppressori classics such as cyclosporine ”explains the rheumatologist.

Lupus, antiphospholipid antibodies and pregnancy: where the problem lies

A lupus that is not adequately controlled can result in an augmentation risk of miscarriage and obstetric complications such as preeclampsia, the more severe the earlier it occurs, fetal growth retardation, low birth weight, premature birth.

“All risks that they have strictly to do with vascular problems"Clarifies. “This is because lupus, like all autoimmune diseases, involves inflammation of the blood vessels (experts speak of vasculitis) and can therefore undermine the vascular organ par excellence of pregnancy, the placenta ".

The risk picture is worse if, in addition to lupus, they are also present antiphospholipid antibodies.

The antiphospholipid antibody syndrome

This is another autoimmune disease that is also often heard about lupus. It is a syndrome characterized by the combination of a clinical picture with thrombosis and recurrent miscarriages and presence in the blood of so-called antiphospholipid antibodies and can be either isolated or associated with other autoimmune diseases such as lupus.

"As for the pregnancy front, the forms of lupus with antiphospholipid antibodies are generally more complicated and require more attention," he stresses.

On the other hand, there is no particular effect of pregnancy on the course of the disease: if the therapy is adequate, the risk of exacerbation during pregnancy is limited. "But if there is an exacerbation, there is no need to despair: it can be faced with drugs compatible with pregnancy" reassures Andreoli.

What to do if you want to become pregnant

"The fundamental thing to know is that for women with lupus, pregnancy is not an impossible goal, but an achievable goal as long as it must be planned well", the rheumatologist immediately clarifies. By specifying that "planning" means get on the lookout for a child with a disease under control, therefore not in the activity phase, thanks to treatments tailored to each individual patient.

Pregnancy with lupus: a routine with some extra control

Assuming that the ideal is to wait for the right time to seek pregnancy, once this part is automatically considered at risk. "A variable risk, higher in some cases and lower in others, because the manifestations of the disease can be very different, but that must be monitored carefully" she clarifies.

Thus, women with lupus face a few more checks: for example blood tests to assess the state of activity of the disease - approximately once a month - or investigations on fetal well-being. Among these, the flowmetry or doppler, which allows to evaluate the circulation at the level of the fetus and the placenta and to understand how things are going. “If everything is normal at 20-24 weeks, most likely there will be no problems and the pregnancy will come to term, with a good baby,” she says.

When fetal echocardiography is needed

In some cases, women with lupus who are expecting a baby are advised to do fetal echocardiography between 16 and 24 weeks of pregnancy. “It happens when the disease is characterized by the presence of some particular autoantibodies called anti-ENA antibodies (such as anti-Ro or anti-La) which, passing the placenta, can reach damage the heart tissue of the fetus, causing a congenital heart block ”explains Dr. .

If this happens, not much can be done - except monitoring the situation - while the baby is in utero. Since the severity of the block is very variable, however, in these cases the outcome is not necessarily bad, on the contrary: most children with a congenital block will be born and will be well, but will need some therapy or intervention aimed at the birth. . "The meaning of fetal echocardiography is precisely this: to know in advance that there may be this problem and to prepare accordingly, for example planning the birth in a center specialized in neonatal cardiology".

Therapies in pregnancy

While it is important that the disease is quiescent when looking for a baby, it is equally important that it be kept under control during pregnancy itself. In this regard, many women fear that the drugs to be taken could harm the child, but Andreoli is very reassuring on this point: "There are drugs absolutely compatible with pregnancy, and then also with breastfeeding, so the woman can rest assured ".

"If the woman is fine, then the baby will be fine too, and if drugs are needed to achieve this goal, they are welcome."

If the pregnancy starts, drugs for the control of lupus are usually added to others to promote the formation and growth of the placenta and fetal growth: "It is theaspirinetta and low molecular weight heparin if antiphospholipid antibodies are also present ”explains the gynecologist.

Read also: Aspirinetta in pregnancy: what it is for, when to take it, when to stop it


And what about the mode of delivery? “Hopefully, there are no contraindications to the vaginal one,” she explains. If, on the other hand, there is any complication, it will be assessed on a case-by-case basis whether it is more appropriate to proceed with a caesarean section. “Even in the absence of problems, however, it is generally preferred to avoid exceeding the term e induce delivery between 38 and 40 weeks, depending on the situation ”concludes the gynecologist.

Who to trust

The ideal would be to be followed by a center that has amultidisciplinary team specialized in the management of the pregnancy of women with lupus, just like it happens at the Civil Hospitals of Brescia. If this is not possible, the important thing is to contact experienced specialists (in the case of the gynecologist it must be a specialist experienced in high-risk pregnancies) well willing to cooperate with each other even if they belong to different hospitals.

Lupus and breastfeeding

"Medicines that are compatible with pregnancy in general are also compatible with breastfeeding, so there is usually no need to suspend or modify them," says Andreoli.

After the arrival of the baby, the problem is rather the fact that, even understandably, the mother tends to concentrate all on him and to neglect herself, perhaps ignoring the signs of a disease that is rekindling itself - such as a certain stiffness in the morning. - or skipping blood tests or checkups with the rheumatologist.

“Instead it is a lot It is important that the mother does not forget that she has a chronic illness, which must be followed with a certain consistency by specialists ”underlines Andreoli. "My advice is not to be shy in asking for help to deal with this aspect of her life, for example by having someone accompany you to the hospital check-ups, in order to have a hand in managing the baby during the visit or the exams".

Lupus and contraception

Not only pregnancy: for a long time women with lupus were also advised against any form of hormonal contraception, as well as the spiral. This is because the disease carries a thrombotic risk, which - it was thought - can be added to that brought by the pill.

“Even in this case, however, there have been great changes and today this is no longer the case,” he says. "If the disease is well controlled and there are no antiphospholipid antibodies, the woman with lupus can safely use the pillola with estroprogestinici. Or the minipillola, with progestogens alone, if there is any minor complication. AND green light, always, to the spiral. In the presence of antiphospholipid antibodies, on the other hand, the pill and minipill are to be avoided, while there is no problem with the spiral ”.

Other sources for this article: Lupus article on Medscape

  • lupus
  • the
  • antiphospholipid antibodies
  • heparin in pregnancy
  • aspirin in pregnancy
  • breastfeeding
  • weeks 1-13
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