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 (DVT) in women with lupus using combined oral contraceptives compared with the general population and this risk increases further in those with antiphospholipid antibodies (anti-cardiolipin antibodies and/or lupus anticoagulant). The progesterone-only pill or Mirena coil is preferred to oestrogencontaining treatments to reduce the chance of future flares in patients with moderate or severe disease.

Pregnancy

Years ago women with lupus were advised not to become pregnant. Thankfully we are now at a very different time and place, and just like the wider female population, pregnancy (or not) is an individual’s choice. Women with lupus can have healthy pregnancies and successful outcomes for both mother and baby. Pregnancy should be planned for and during inactive phases, after a 6 month period of lupus quiescence and when medication is stable, on drugs suitable for pregnancy.

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 in the 12 weeks after delivery of the baby. In general, flares are mild, mainly with joint and skin
symptoms. Lupus 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.

Active lupus is associated with an increased risk in pre-term deliveries and small-for-gestational-age babies (“small for dates” babies). Renal disease may predispose to pre-eclampsia and intra-uterine growth restriction and, if active, lead to more frequent foetal losses. These maternal and foetal factors support
the need for appropriate treatment of flares during pregnancy.

Women with lupus nephritis need careful additional monitoring as there are increased risks of complications, though pregnancy does not jeopardise renal function in the long term as long as estimated glomerular filtration rate (eGFR) is less than or equal to 50 mL/min/1.73m before pregnancy. All pregnant lupus women should be monitored for renal symptoms as nephropathy may manifest for the first time during pregnancy and can be confused with pre-eclampsia.

The differentiation between renal flares and pre-eclampsia is critical. Both entities share clinical features such as oedema, hypertension and roteinuria. 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.

Much work has occurred with BSR (British Society of Rheumatology) to produce robust current guidelines (in 2 parts) on appropriate treatment compatible with pregnancy, including lupus, and these reports are invaluable in their advice and guidance.

Full report,
Part 1 -
READ HERE
Part 2 -
READ HERE

Executive summary,
Part 1 -
READ HERE
Part 2 -
READ HERE

When considering subsequent pregnancies, we as clinicians are in a unique position of support. It can be a difficult balance between what can be a very strong maternal drive, and the very real impact pregnancy can have on a woman’s health and life day to day. We may even need to raise the difficult point that some women don’t make it through pregnancy (e.g. with pulmonary hypertension, severe heart or kidney disease). Pregnancy is always an individual’s choice, however keeping an objective view of how their health was during a previous gestation and immediately after may be significant.

For instance;
• consider how much support family and friends were able to give and
whether this will alter in the intervening time.
• would this be able to continue with an additional baby or child?
• how much care and support the older child or children need?
• would a larger age gap help?
• whether there are any confounding factors with their lupus such as with
extra renal stress.

Pregnancy and antiphospholipid syndrome (APS)

One of the major features of APS in women is pregnancy loss. About half of all pregnancy losses for all women are in the first trimester; later losses from APS are more strongly associated in the second and third trimester. The mechanism which leads to foetal loss is unknown, but 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 compatible with pregnancy. These include prednisolone, azathioprine, hydroxychloroquine, and low-dose aspirin. For women with anti-cardiolipin antibodies or lupus anticoagulant, lowdose heparin is used, which does not cross the placenta. Women who have been
on warfarin prior to conception are switched to heparin within 6 weeks of the first day of their last menstrual cycle and then throughout the pregnancy.

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

Neonatal lupus and congenital heart block

Neonatal lupus is due to the transmission of anti-Ro and/or anti-La antibodies crossing the placenta from about 16 weeks of gestation, and this is why it so important to check antibodies in advance. Neonatal lupus was so termed because the cutaneous lesions of the neonate resembled those seen in lupus. These skin lesions appear from 2-3 weeks after birth onwards and resolve without treatment after approximately 6 months but the lupus antibodies can also cause heart block, liver abnormalities or low platelets.

Very rarely babies can have a congenital heart block which is usually irreversible, with babies requiring a pacemaker but which only occurs in about 1% of all pregnancies to women with anti-Ro and anti-La antibodies. Most major abnormalities occur no more frequently in stable, treated SLE women than in the wider population when taking pregnancy suitable medication (e.g. prednisolone, hydroxychloroquine, and azathioprine).

Breastfeeding

Women are nearly always encouraged to breastfeed and prior to the birth, the specialist rheumatology team should discuss with the patient whether or not breastfeeding is planned. Breastfeeding is very rarely contra-indicated in lupus patients. Often drugs like azathioprine and hydroxychloroquine are continued throughout pregnancy and breastfeeding especially in those women who are at risk of serious lupus flare if these were withdrawn. The risks and benefits of the drugs should be closely discussed and decisions made according to the risk/benefit to mother and baby of continuing or stopping therapy and the risk to the baby of disease flare in the mother. Heparin and warfarin are used frequently to treat patients with thrombosis associated with antiphospholipid antibodies, and are compatible drugs for the nursing mother.

Assisted conception and IVF

Fertility in lupus patients is reported as the same as the wider population.Therefore this means that some women who wish to become pregnant need some additional assistance. Conception assistance can be successful in SLE patients however there are risks that they should be aware of due to the necessary drugs. A detailed conversation before starting any treatment should be encouraged and facilitated, preferably in a specialist pre-pregnancy obstetric/rheumatologycombined clinic.

As in any other pregnancy lupus stability and inactivity with stable medication is very important, ideally for 6 months before starting treatment. Ovulation stimulation, which can be required to enable ovarian egg removal, can be associated with lupus flare and/or blood clots. For patients with APS and SLE infertility treatment has further higher risks due to their anti-coagulation needing very careful management.

Hormone Replacement Therapy (HRT)

Most lupus women can be encouraged to go through their menopause by knowing that SLE tends to settle significantly (due to the lack of monthly hormone surges), and that HRT just delays the signs and symptoms they are feeling. If patient and prescriber agree HRT is required, it should be used for the shortest time possible to reduce risk of lupus flare and potential risk to long term health which may be associated with oestrogen therapy.