System Lupus Erythematosus and Pregnancy
"Royal diseases result from royal eating habits, for instance lupus ..., which rarely takes up residence in those who lead frugal lives and work hard." A late medieval sermon.
From the above quotation, it is clear that misunderstandings about lupus have persisted through the ages. When I was a young faculty member at the Johns Hopkins Hospital, fifteen years ago, the prevailing advice given to young women with a diagnosis of lupus was to never become pregnant. In 1987, a young rheumatologist from the University of California, San Francisco, Dr. Michelle Petri, joined the faculty at Johns Hopkins. Our mutual interest in medically complicated pregnancies led to the establishment of the Johns Hopkins Lupus Pregnancy Center. I focus on that time in 1987 as the time when more enlightened attitudes about lupus pregnancy began to prevail.
Pregnancy, while a normal physiologic event, is not without risk. When complicated by a disease such as lupus, these risks can increase several-fold. Nevertheless, with improvement in high-risk obstetrical care, fetal testing and ultrasound, and neonatal intensive care, it is possible for many women with lupus to safely undertake pregnancy and to anticipate a favorable outcome. The most important questions generally asked by women with lupus who are considering having a child are:
1. How will my pregnancy affect my lupus?
2. How will lupus affect my pregnancy?
3. How will my pregnancy be managed?
 First and foremost, pregnancy will not affect lupus in most patients. It is important to remember however that some patients, on the order of approximately 10%, may have worsening kidney function as a direct result of pregnancy. Also, it appears that lupus flares (sudden increases in disease activity) are more common during pregnancy and post
partum.
How lupus affects pregnancy is another matter. There are several important criteria to consider before counseling a woman about pregnancy in the setting of lupus. Good prognostic features are listed in the table, Factors Favoring Successful Pregnancy in Lupus. While the majority of women in this category will go on to have uneventful pregnancies, complications, even life threatening complications, may still occur. Examples of such complications include high blood pressure, stroke, preeclampsia, diabetes, and pre-term delivery, among others. It is imperative that the decision to proceed with pregnancy in the setting of lupus be a decision arrived by the couple in conjunction with their perinatologist (high risk obstetrician) and rheumatologist.
Pregnancy management is frequently quite routine until the beginning of the third trimester. At that point, weekly assessment of the mother and fetus is necessary in order to assure that maternal and fetal well-being are maintained. Rarely, specific effects of lupus on the fetus can be diagnosed. These effects can result in the need for a cardiac pacemaker in the newborn child and other manifestations of transient lupus. It does not appear however that lupus is genetically transmitted in the traditional sense, that is to say, it is not considered to be a hereditary disorder.
Great strides have been made in the management of lupus pregnancy. A team approach including skilled providers in a tertiary center with skilled rheumatology, anesthesiology, and neonatal back-up supporting high-risk obstetrical services offers the best chance for a successful outcome.
Contributed by John T. Repke, MD, Past-Chair, UNMC Department of Ob/Gyn
Date last updated: January 14, 2004
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