Systemic lupus erythematosus (SLE) mainly affects young women between the ages of 20 and 40 - exactly the period in which the desire to have a child plays a major role for many. A recent study looks at the risks of pregnancy with known SLE for both mother and child and the effects of different treatment regimens - which medications should definitely be continued and which should be changed.
Women with SLE who wish to have children are not uncommon in the daily practice of rheumatologists. Even though most pregnancies are successful despite the disease, they are generally counted as high-risk pregnancies in SLE patients.
As long as there is no severe organ damage and the disease activity has been constantly controlled in the last few months before conception, people with SLE do not need to be advised against pregnancy. The situation is different if one of the following contraindications is present: severe renal failure, heart failure, advanced pulmonary fibrosis and pulmonary hypertension. Similarly, severe thromboembolic events in the medical history count as a risk factor, since in these cases an increased risk of thrombosis during and after pregnancy must be assumed.
Even without the risk factors mentioned, pregnancy in an SLE patient requires an increased level of diagnosis and preparation.
During pregnancy, disease activity must be controlled as best as possible, despite any necessary changes in treatment regimens. It is recommended that conception be planned for as controlled a phase of the disease as possible (at least six months without relapse).
For risk assessment during pregnancy, the current antibody status in the maternal blood can be checked. Elevated antinuclear antibodies (anti-SSA/anti-Ro and anti-SSB/anti-La) are associated with an increased risk of congenital heart block and neonatal lupus. Therefore, regular echocardiographic controls of the foetus should be carried out in affected women. In addition, antiphospholipid antibodies (lupus anticoagulants, anticardiolipin antibodies, anti-beta-2-glycoprotein) serve as biomarkers for the outcome of an SLE pregnancy. Also recommended is regular monitoring of thyroid levels - about 10% of women with SLE have hypothyroidism.
There are also some recommendations regarding drug therapy during and before pregnancy. Hydroxychloroquine should definitely be continued. After discontinuation of the drug, there is a proven increased risk of flare-up of SLE in affected women. In addition, there is no evidence that hydroxychloroquine negatively affects the outcome of pregnancy or increases the risk of maternal or fetal complications. On the contrary, it has been shown to reduce the likelihood of pre-eclampsia.
The drug regimen for SLE patients taking mycophenolate mofetil is more complex. The only two immunosuppressants compatible with pregnancy are azathioprine and tacrolimus. If the patient wishes to have a child, the medication is therefore switched to azathioprine in a two-stage setting - initially with regular monitoring of disease activity over several months. If a relapse occurs, the administration of mycophenolate mofetil should be restarted immediately. Otherwise, tacrolimus can be added in the next step. The positive effect of the active substance on the control of disease activity during pregnancy has already been proven by a number of studies.
Treatment with methotrexate and leflunomide in existing lupus-related arthritis must be discontinued at least six weeks before a planned pregnancy. The same applies to the use of ACE inhibitors and angiotensin receptor blockers as antihypertensives.
SLE is no longer an exclusion criterion for wanting to have children - nevertheless, pregnancies of those affected are associated with some risks. Due to the medication changes, a successful pregnancy requires long-term planning and close cooperation between rheumatologists and gynaecologists - and appropriate counselling.
Reference:
1. Petri M. Pregnancy and Systemic Lupus Erythematosus. Best Pract Res Clin Obstet Gynaecol. April 2020;64:24-30.