Having a child is possible for individuals with systemic lupus erythematosus (SLE), but it requires careful preparation and management. Medical advancements have improved outcomes for both the mother and the baby. A healthy pregnancy is achieved when the disease is well-controlled and managed proactively by a specialized medical team, starting before conception.
Pre-Conception Planning for Lupus Patients
The most impactful step toward a safe pregnancy is achieving sustained disease inactivity, or remission, ideally for at least six months before attempting conception. Conceiving during active lupus significantly increases the likelihood of flares, posing risks to the mother and fetus. The rheumatologist must assess disease stability, focusing particularly on organ systems like the kidneys.
A thorough review of all current medications must happen before trying to conceive, as many standard lupus treatments can cause severe birth defects. Drugs like methotrexate, mycophenolate mofetil (MMF), and cyclophosphamide are teratogenic and must be stopped well in advance, sometimes up to six months. These are replaced with safer alternatives, such as azathioprine or hydroxychloroquine, which have established safety profiles for use during pregnancy.
Pre-conception testing also includes screening for specific autoantibodies that can directly impact the fetus. Testing for anti-Ro/SSA and anti-La/SSB antibodies is necessary, as they can cross the placenta. The presence of these antibodies carries a small but significant risk (one to two percent) of causing congenital heart block in the baby, a serious condition affecting the fetal heart’s electrical system. Screening for antiphospholipid antibodies is standard, as these are associated with an elevated risk of blood clots and pregnancy loss.
Potential Complications for Mother and Baby
Lupus makes a pregnancy high-risk, raising the potential for specific complications for the mother. The immune system changes of pregnancy can sometimes trigger a lupus flare, characterized by symptoms like joint pain, rashes, or kidney problems. Hypertension, or high blood pressure, is also a concern, as lupus patients have an increased chance of developing preeclampsia, a serious condition that can harm the mother’s organs.
Distinguishing between a kidney-related lupus flare and preeclampsia can be challenging, as both may present with hypertension and protein in the urine. Prompt diagnosis is necessary because management strategies for the two conditions differ. The presence of antiphospholipid antibodies further increases the mother’s risk of developing blood clots throughout the pregnancy.
The fetus faces several distinct risks when the mother has lupus, including an increased chance of miscarriage or stillbirth, especially if the disease is active at conception. The baby may also experience complications like fetal growth restriction or preterm birth, which is delivery before 37 weeks of gestation. When anti-Ro/SSA and anti-La/SSB antibodies are present, they can lead to Neonatal Lupus, which often appears as a temporary skin rash or, more seriously, as congenital heart block.
Specialized Care During Pregnancy
Management of a lupus pregnancy requires a specialized, collaborative approach involving a multidisciplinary medical team. This team should include the patient’s rheumatologist and an obstetrician with expertise in high-risk pregnancies, known as a Maternal-Fetal Medicine (MFM) specialist. The MFM specialist is trained to manage the complexities of concurrent maternal disease and fetal well-being.
Monitoring frequency is increased throughout pregnancy, often involving monthly or bi-monthly appointments with both the rheumatologist and the MFM specialist. Frequent laboratory testing includes monthly checks of complete blood counts, kidney function, and lupus disease activity markers. This regular testing helps the medical team quickly identify potential issues, such as a flare or the onset of preeclampsia.
Fetal surveillance is a routine part of this specialized care and includes regular ultrasounds to monitor the baby’s growth and the health of the placenta. Starting around 26 weeks, or sometimes earlier, fetal well-being is assessed with non-stress tests and biophysical profiles. If anti-Ro/SSA or anti-La/SSB antibodies are present, the baby will also undergo specialized fetal echocardiograms starting in the second trimester to screen for heart block.
Medication management remains a focus during pregnancy to maintain remission and prevent complications. Hydroxychloroquine is continued throughout the entire pregnancy, as it helps decrease the risk of lupus flares and preeclampsia. Low-dose aspirin (81 mg) is routinely recommended for all lupus patients, typically starting at the beginning of the second trimester to reduce the risk of preeclampsia.
Delivery and Postpartum Recovery
The timing and method of delivery for a lupus pregnancy are determined by the health of both the mother and the baby. Most lupus pregnancies reach term, or near-term, though delivery may be scheduled slightly before 40 weeks of gestation if there are concerns about placental function or fetal growth. A cesarean section is not automatically required, but the rate of surgical delivery is higher compared to the general population due to complications like severe preeclampsia or fetal distress.
The immediate period following childbirth carries a heightened risk for disease activity. Hormonal shifts after delivery can trigger a lupus flare, making the postpartum period vulnerable. Close monitoring by the rheumatologist must continue for several months to manage this elevated risk.
Breastfeeding is safe for mothers with lupus, as the majority of maintenance medications are compatible with nursing. Drugs like hydroxychloroquine, azathioprine, and low-dose steroids transfer into breast milk in minimal amounts. Mothers should discuss their medication regimen with their rheumatologist to confirm compatibility and establish a plan for safely transitioning back to full maintenance therapy.