How Having Lupus and RA Affects Pregnancy

What you need to know about risks and treatment

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If you have systemic lupus erythematosus (lupus) or rheumatoid arthritis (RA), you are likely already well-acquainted with how your immune system's attack on healthy tissues can negatively affect your body. It may, then, come as no surprise that you would be considered "high risk" if you become pregnant.

Pregnant women with lupus or RA have more pregnancy complications (e.g., hypertension, premature birth) and longer childbirth-related hospital stays than other women. Having both diseases can complicate matters.

Thankfully, with planning, proper treatment, and careful monitoring, most women with these diseases have successful pregnancies.

A pregnant woman discusses medication use with doctor

Adam Hester / Getty Images

Disease Activity During Pregnancy

How these diseases will impact you during pregnancy is hard to predict, as women's experiences vary considerably.

Pregnancy can cause a change in disease activity that can lead to an increased risk of complications for both you and your unborn child. And if your lupus or RA is not well-managed going into this period, the concern is even greater.

One certainty? Low disease activity before conception makes for a healthier pregnancy and better outcomes.

Planning for pregnancy with the help of your rheumatologist can help. They can help you set a timetable for getting pregnant and advise you as to how to best get your diseases under control before conceiving.

Then, if you do get pregnant, your rheumatologist—in partnership with a perinatologist (an obstetrician/gynecologist specially trained in high-risk pregnancies)—should work together to manage your care.

Lupus Activity

Most lupus flares aren't considered a threat to either you or your baby. However, a flare does make your body more susceptible to damage from the disease and put you at greater risk for complications that can affect you and your baby.

With this in mind, the best time to get pregnant is when your disease is fully controlled—especially if you have kidney involvement.

Research is split as to whether pregnancy actually changes lupus activity or makes flares more common, but evidence suggests it may increase the risk of them in the first two trimesters and in the three months postpartum. Those with active disease at conception are even more prone to flares.

In contrast, and according to research published in 2020, when lupus is stable and mild at conception, flares are typically mild and do not appear to increase in frequency during pregnancy.

Treatment with Plaquenil (hydroxychloroquine) appears to significantly lower your risk of a flare during pregnancy and the postpartum period.

RA Activity

Research from 2019 suggests that in 60% of women with RA, symptoms improve during pregnancy, most likely due to pregnancy-related changes in the immune system.

Healthcare providers can't predict which women will see an improvement in symptoms during pregnancy. Your disease activity may stay the same, or you may have flares and remissions.

As with lupus, a postpartum RA flare is somewhat common, happening about 47% of the time. This could occur because the immune system returns to its normal function at this time.

Planning for Pregnancy

Healthcare providers often recommend that women with lupus don't try to conceive until they've gone six months without lupus activity.

With rheumatoid arthritis, the outcomes for both mothers and babies appears to be better in those who have had well-controlled disease for between three and six months before trying to get pregnant.

Possible Complications

There is a two-way street to consider: Lupus and RA—and, in some cases, their treatment—have the potential to affect your body and your pregnancy, and pregnancy itself may impact your disease.

Both of these play into the overall potential for complications including:

  • Hypertension (high blood pressure)
  • Premature delivery
  • Newborn health concerns
  • An increased risk of miscarriage

You're at further risk of these complications if you have a history of preeclampsia in other pregnancies, a history of blood clots or low platelets, or tests reveal the presence of antiphospholipid antibodies.

These complications can lead to more frequent hospitalizations during pregnancy, more frequent Cesarean deliveries, and longer hospital stays after delivery.

The key to avoiding these once you are pregnant is to manage your disease well and in a way that is safe for your developing baby.

It may be difficult to tell pregnancy symptoms from the early warning signs of an RA or lupus flare. Be sure to contact your healthcare provider right away if you suspect a flare is coming on so you can manage it and minimize risks.

High Blood Pressure

High blood pressure is a common problem in lupus even without pregnancy, as it's a side effect of long-term treatment with steroids and/or non-steroidal anti-inflammatory drugs (NSAIDs). Kidney disease associated with some cases of lupus also can increase blood pressure.

High blood pressure during pregnancy is concerning because it can be associated with preeclampsia/eclampsia and placental abruption.

Preeclampsia/Eclampsia

Marked by high blood pressure, elevated protein in the urine, and inflammation, untreated preeclampsia and the more serious version, eclampsia, can be fatal for both mother and child.

The risk of preeclampsia is 14% higher in women with lupus and is especially a concern for those with active disease or pre-existing kidney disease. The risk is also higher with RA, with some studies showing a twofold increase.

Eclampsia is more likely to involve seizures and can lead to coma. This condition used to be considered a progression of preeclampsia, but healthcare providers now recognize that some people develop eclampsia without ever having preeclampsia symptoms other than high blood pressure.

In babies, preeclampsia/eclampsia is a leading cause of premature birth. The condition reduces the amount of blood flowing through the placenta, which leads to malnourishment, poor growth, and, less often, stillbirth.

If it's late enough in the pregnancy to do so safely, healthcare providers may induce labor, as the condition will go away once you're no longer pregnant. If it's too early for the baby to come, you may be given corticosteroids to help accelerate lung development and make early delivery safer.

Other treatment often involves:

  • Bed rest or hospitalization
  • Blood pressure medications
  • Anti-seizure medications, as a precaution

Regular check-ups and home monitoring can help you and your healthcare provider catch preeclampsia or eclampsia early so it can be treated and complications can be prevented.

Those at higher risk for developing preeclampsia and its related complications may be advised to take daily low-dose aspirin starting after 12 weeks of pregnancy.

Placental Abruption

In a placental abruption, all or a portion of the placenta pulls away from the uterus after the 20th week of gestation. Preeclampsia/eclampsia can cause this, but some researchers also believe your immune system—and especially antiphospholipid antibodies—can interfere with how the placenta functions.

Placental abruption can lead to stillbirth or preterm delivery. Symptoms of placental abruption can include:

  • Vaginal bleeding
  • Frequent contractions
  • Abdominal pain or tenderness

In a serious abruption, involving more than 50% of the placenta, blood loss may be severe and the baby may need to be delivered by emergency C-section. In less serious cases, when there's no immediate risk, the mother may be hospitalized or put on bed rest and monitored closely.

As with preeclampsia, you may be given steroids to help the baby's lungs mature more quickly and increase the odds of survival should early delivery become necessary.

Vaginal bleeding is not always present in placental abruptions, so call your healthcare provider about any of the symptoms right away just to be sure. Any vaginal bleeding in the second or third trimester warrants an immediate call to your obstetrician.

Prematurity

In addition to the above conditions that increase the risk of premature birth in women with lupus and RA, some research suggests that the diseases themselves may cause a statistically greater chance of prematurity.

Lupus may cause premature birth due to the water breaking before you've reached full term—what's called premature rupture of membranes.

In RA, healthcare providers suspect this is due to inflammatory chemicals involved in the disease that may promote uterine contraction.

However, RA research thus far has been inconsistent, with some studies showing less risk than others and some showing no increased risk at all. The risk may be greater for women with active disease or who are taking corticosteroids.

Newborn Health Concerns

RA is linked to full-term or nearly full-term babies with low birth weight or who are small for their gestational age. Researchers believe this could be due to problems with placental function that can result from immune-system abnormalities and/or treatment with prednisone.

Some small or premature babies are healthy and need very little extra care, but others may face complications. These potential health concerns include:

Depending on their level of development, gestational age, and specific needs, the baby may need to spend time in the neonatal intensive care unit (NICU) on oxygen and/or a feeding tube. Your baby may need to be monitored more closely both in the hospital and after you're discharged.

The earlier your baby is born, the more likely they are to need the NICU and the longer they're likely to be there.

You may find it comforting to know that there's no evidence that either lupus or RA is associated with an increased risk of birth defects.

Miscarriage

Lupus has long been known to increase the risk of miscarriage. In fact, healthcare providers used to recommend that women with lupus not get pregnant at all. That is no longer the case and, thanks to improvements in care, the miscarriage rate in women with lupus has dropped considerably.

The miscarriage risk is attributed to the health problems lupus can cause, including high blood pressure, kidney problems, and antiphospholipid antibodies/lupus anticoagulant that attacks the proteins involved in blood clotting. Blood clotting irregularities can interfere with the proper development and function of the placenta.

Testing positive for the lupus anticoagulant in the first trimester of pregnancy is a risk factor for miscarriage.

Between 1960 and 2000, the miscarriage rate for women with lupus fell from 40% to 17%, according to research. More recent studies have reported rates between 10% and 25%, which is fairly in line with the overall risk of miscarriage in a confirmed pregnancy (10% to 20%).

Some research has historically found an elevated miscarriage risk in women with RA, but newer studies have found the rate to be the same as in the general population. Among those who do miscarry, most go on to have successful subsequent pregnancies.

Research hasn't been done on the risks to women with both of these conditions.

Medication Use

Some, but not all, drugs used to treat RA and lupus are considered appropriate for pregnant and nursing women.

If you're planning to become pregnant, your healthcare provider may advise you to wait until your medications have been adjusted and you've achieved low disease activity or remission to start trying. You may need a "washout" period or procedure after discontinuing a drug for it to be safe to conceive.

Of course, pregnancy sometimes comes as a surprise. If you have these conditions and suddenly find yourself expecting, talk to your rheumatologist right away, ask whether you need to change medications, and get in to see an obstetrician as soon as possible.

Pregnant women with lupus or RA may need an adjustment in their medications during gestation and again after giving birth. Drugs considered off limits may become safe options again, some even if you're nursing.

Discuss with your rheumatologist and obstetrician before stopping your current lupus or RA medications.

Drug Safety During/After Pregnancy

DRUG/CLASS PREGNANCY BREASTFEEDING
Actemra (tocilizumab) Caution Caution
Arava (leflunomide) Not safe Not safe
Azulfidine (sulfasalazine) Preferred Preferred
Glucocorticoids Caution Caution
Imuran (azathioprine) Preferred Caution
Kineret (anakinra) Not safe Caution
Methotrexate Not safe Not safe
NSAIDs Caution Caution
Orencia (abatacept) Not safe Caution
Plaquenil (hydroxychloroquine) Preferred Preferred
Rituxan (rituximab) Caution Preferred
Tylenol (acetaminophen) Preferred Preferred
Xeljanz (tofacitinib) Not safe Not safe
This information is given for general purposes only. Follow your healthcare provider's instructions regarding all medications while pregnant or breastfeeding.

What is most appropriate for you is personal, and you should have an open conversation with your healthcare providers about what is being recommended and the pros/cons in your case.

A 2021 study may provide some treatment guidance. Researchers found that Plaquenil plus low doses of aspirin, heparin, and corticosteroids appeared safe for mother and baby and effective at treating lupus, RA, and other autoimmune diseases during pregnancy.

Currently, research and opinions are mixed regarding anti-TNF agents during pregnancy, but some research points to encouraging data regarding this newer class of drugs. Your healthcare provider may recommend staying on a TNF-blocker early in pregnancy and then weaning off later.

Some lupus and RA drugs may interact negatively with the vaccines given to newborns. If you're on any of these drugs, it may mean your baby has to wait to be vaccinated.

Some additional drugs and drug classes that are generally considered safe while breastfeeding include:

Postpartum Flares

Regardless of how light or severe your symptoms are during pregnancy, you may have a flare in the disease shortly after giving birth.

Sometimes this can strike right away, and other times it can be delayed by as much as three months in lupus and as much as six months in RA. Flare symptoms are generally identical to those that occur independent of pregnancy.

In lupus, reasons for a postpartum flare aren't well understood but some research suggests it may be due to elevated levels of the hormones prolactin. Most postpartum lupus flares are mild to moderate.

In RA, this is believed to happen because the immune-system changes that relieved symptoms during pregnancy go back to their pre-pregnancy state.

The flare risk for women with lupus is estimated at between 35% and 70%, while for those with RA it's up to 50%.

Certain risk factors may make a postpartum flare more likely.

  • Lupus: Active disease in the six months before conception
  • RA: Positive anti-CCP antibody and RF tests; stopping anti-TNF therapy too early
  • Both: Higher disease activity in the second and third trimesters

Let your healthcare provider know if you're having a postpartum flare so they can help you manage it. Management involves the same medications as for any other flare, but you may need to avoid certain drugs if you're breastfeeding.

A Word From Verywell

Careful planning before conception can help you have a successful pregnancy and avoid possible complications that put your health and your baby's health at risk. Talk to your healthcare provider about preconception counseling before you begin trying to get pregnant—it can make a big difference in lowering risks and improving outcomes.

Using birth control until your disease activity has been stable and minimal for six months before conception, selecting the safest medications, and working with your healthcare provider to minimize your risks are all important factors.

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