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Pregnancy and autoimmune diseases

https://doi.org/10.1016/j.berh.2004.02.012Get rights and content

Abstract

Until about 15 years ago, the general advice to women with autoimmune rheumatic diseases, especially systemic lupus erythematosus, systemic sclerosis and vasculitic syndromes, was to avoid pregnancy as there was a high risk of maternal and fetal morbidity and mortality. However, it is now clear that these risks can be reduced in general by avoiding pregnancy when the diseases are active and continuing appropriate medication to reduce the chances of disease flare during pregnancy. This article will review the evidence for this advice and will also consider other issues that should be discussed with women before they attempt to become pregnant. This will include the influence of pregnancy on the individual autoimmune diseases, as well as the potential impact of the diseases and drug therapy on fertility and pregnancy outcomes. Anti-phospholipid antibody syndrome has emerged as a major cause of fetal loss, pre-eclampsia and premature birth. The clinical and laboratory diagnosis of this condition will not be covered, but the reader is referred to an excellent recent review [Obstet. Gynecol. 101 (2003) 1333]. Much of the data on pregnancy and autoimmune rheumatic diseases come from retrospective analyses, but some prospective studies have been reported over the past 10 years. There have been very few meta-analyses or randomized clinical trials.

Section snippets

Fertility

There is no evidence that the disease SLE or any of the inflammatory arthritides, such as rheumatoid arthritis or spondyloarthropathy, affect fertility. In the past, there was concern that systemic sclerosis and anti-phospholipid antibody syndrome were associated with reduced fertility, but this has not been supported by more recent studies.1., 2. There have been no studies looking at fertility in the vasculitides, which more often affect women after the reproductive period.

The main risk

Systemic lupus erythematosus

The most studied autoimmune disease with respect to pregnancy is SLE. In the past, there was considerable concern that lupus was aggravated by oestrogens, especially in pregnancy. In recent years, there has been increasing interest in the role of prolactin as there is some evidence that prolactin is associated with pregnancy-related and postpartum flares.4 Data over the past 10 years have, however, shown that the risk of lupus flare is not as great as many people used to think and that flares,

Risk of autoimmune diseases being transmitted from mother to fetus

Maternal transmission of IgG antibodies to the fetus usually occurs between weeks 16 and 3242, but an autoimmune condition in the neonate may not be diagnosed until after delivery. The best-recognized condition is neonatal lupus syndrome due to the transmission of anti-Ro and/or anti-La antibodies to the fetus from a mother with lupus, primary Sjögren's syndrome or an undifferentiated connective tissue disease. There have been three reports of neonatal cutaneous vasculitis in infants born to

Effect of autoimmune diseases on fetal outcome

The two main determinants of fetal outcome in patients with autoimmune diseases are the degree of active disease at conception and the presence of anti-phospholipid antibodies. The two main outcomes are fetal loss and premature delivery. The term ‘fetal loss’ includes spontaneous abortions under 10 weeks, miscarriages between 10 and 24 weeks, and stillbirths from 24 weeks onwards.

Use of drugs in pregnancy and breast-feeding

The use of analgesic, anti-rheumatic and immunosuppressive therapy in pregnant patients with rheumatoid arthritis, lupus and vasculitis is summarised in Table 2, Table 3, Table 4. These tables also address the advisability of breast-feeding while taking these drugs.

Summary

Pregnancy in autoimmune conditions requires close co-operation between the physicians and obstetricians caring for the mother and fetus. Most maternal conditions improve in pregnancy if the disease is well controlled at the time of conception, but the disease may appear for the first time in pregnancy. Appropriate drug use to keep autoimmune disease suppressed and to reduce the risk of co-morbid complications, especially hypertension and thrombosis is important. For patients with

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