Lupus and Contraception, Pregnancy and HRT

This site is intended for healthcare professionals as a useful source of information on the diagnosis, treatment and support of patients with lupus and related connective tissue diseases.

Contraception

Fertility is usually normal in lupus patients. However, disease activity, end-stage renal disease and some of the drugs (i.e. cyclophosphamide) used to treat active lupus can contribute to a reduction in fertility. There is an increased risk of deep venous thrombosis in lupus women using oral contraceptives compared with the general population and this risk increases further in those with antiphospholipid antibodies (anticardiolipin antibodies and/or lupus anticoagulant). It is advised to convert women to progesterone only oral contraceptive pills as oestrogen is considered to flare lupus.

Pregnancy

Women with lupus can have healthy pregnancies and successful outcomes for both mother and baby. However, they should always plan wherever possible, pregnancy during inactive phases. This should be within a 6 month period of inactivity and when medication is stable, following cessation of any teratogenic products.

The frequency of flares in pregnant lupus women is slightly higher than the frequency in non-pregnant lupus patients. These flares often appear during the second and third trimesters of pregnancy and most commonly shortly after delivery of the baby. In general, flares are mild, mainly with joint and skin symptoms. In some women with pre-existing stable lupus nephritis, pregnancy does not jeopardise renal function in the long term, although lupus nephropathy may manifest for the first time in pregnancy. Flares may be difficult to diagnose during pregnancy since many features such as hair-loss, oedema, facial erythema, fatigue, anaemia, raised ESR and musculoskeletal pain also occur in normal pregnancy

The differentiation between renal flares and pre-eclampsia is critical. Both entities share clinical features such as oedema, hypertension and proteinuria. The presence of other features of active lupus, the reduction in C3 and C4 proteins and the presence of cellular casts in the urinary sediment favour the diagnosis of a lupus flare.

Active lupus is associated with an increased risk in pre-term deliveries and small-for-gestational-age babies. Renal disease may predispose to pre-eclampsia and intra-uterine growth retardation and, if active, lead to more frequent fetal losses. These maternal and fetal factors support the need for treatment of flares.

Pregnancy and antiphospholipid syndrome (APS)

APS is a clinical syndrome and has been reported to be associated with the presence of circulating antibodies against phospholipids. One of the major features of the syndrome in women is pregnancy loss, most typically in the second trimester. The mechanism which leads to fetal loss is unknown. This is most likely to be related to placental vessel thrombosis and treatment aimed at anticoagulation has significantly improved pregnancy outcome in these patients. It is now known that the most important risk factor for pregnancy loss in lupus patients is the presence of antiphospholipid antibodies.

Patients and non-specialist doctors are sometimes surprised to learn that many of the drugs normally used in lupus are considered safe in pregnancy. These include Prednisolone, Azathioprine, Hydroxychloroquine, and low-dose aspirin. For women with anticardiolipin antibodies or lupus anticoagulant, low-dose heparin is used, which does not cross the placenta. Women on Warfarin are converted to Heparin throughout the pregnancy.

Pregnancy care is best undertaken in combined clinics where physicians and obstetricians can regularly monitor lupus disease activity, as well as fetal growth parameters, uterine artery Doppler blood-flow examination at 20-24 weeks, and umbilical artery blood flow from 24 weeks. These tests, in skilled hands, can guide the obstetrician in deciding when the baby ought to be delivered.

The risks of neonatal lupus and congenital heart block

This illness of the foetus and neonate is considered a model of passively acquired autoimmunity, in which antibodies (anti-Ro) produced by the mother, in crossing the placenta, are thought to have the potential to cause skin rashes and to injure foetal heart conduction tissue. Neonatal lupus was so termed because the cutaneous lesions of the neonate resembled those seen in lupus. These skin lesions usually appear 2-3 weeks after birth and resolve without treatment after approximately 6 months. In very rare cases these babies can have a congenital heart block and it is usually irreversible. Most babies with this condition require a pacemaker. It should be emphasised that, although anti-Ro antibodies occur in about 25% of all lupus patients, the risk of congenital heart block is small (less than 2%).

Breastfeeding

Breastfeeding is rarely contra-indicated in lupus patients. Women are always encouraged to breastfeed and prior to the birth, the specialist rheumatology team should discuss with the patient whether or not breastfeeding is planned. Often drugs like Azathioprine and Hydroxychloroquine are continued throughout pregnancy especially in those women who are at risk of serious flare should the drug be withdrawn. The risks and benefits of the drugs should be closely discussed and decisions made according to the risk/benefit of active disease if the drug is withdrawn in order to enable breastfeeding.

Heparin (used frequently to treat patients with thrombosis associated with antiphospholipid antibodies) is a safe drug for the nursing mother.

Hormone Replacement Therapy (HRT)

There is a clear connection between lupus and accelerated atherosclerosis which is increased in women who need to take HRT. Caution is recommended when considering prescribing HRT as risks of heart disease are as high in lupus women as in diabetics. If the agreement between patient and prescriber is that HRT is required, it should be used for the shortest time possible to reduce potential risk to long term health.