Overview

Twenty-five years ago, women with lupus were counseled not to become pregnant because of the risk of a flare of the disease and an increased risk of miscarriage. Research and careful treatment have made it possible for more and more women with lupus to have successful pregnancies. Although a lupus pregnancy is still considered high risk, most women with lupus are able to carry their babies safely to term. Experts disagree on the exact numbers, but approximately 10 percent of lupus pregnancies end in miscarriage. Pregnancy counseling and planning before pregnancy are important. Optimally, a woman should have no signs or symptoms of lupus before she becomes pregnant.

Researchers have identified two closely related lupus autoantibodies, anticardiolipin antibody and lupus anticoagulant, that are associated with risk of miscarriage. One-third to onehalf of women with lupus have these autoantibodies, which can be detected by blood tests. Identifying women with the autoantibodies early in the pregnancy may help physicians take steps to reduce the risk of miscarriage. Pregnant women who test positive for these autoantibodies and who have had previous miscarriages are generally treated with baby aspirin and heparin throughout their pregnancy. While it used to be said that flares, if they occurred, were more frequent postpartum, they can in fact occur during any trimester as well. Some women may experience a mild to moderate flare during or after their pregnancy; others may not. Pregnant women with lupus, especially those taking corticosteroids, are also likely to develop pregnancy-induced hypertension, diabetes, hyperglycemia, and kidney complications. About 25 percent of babies of women with lupus are born prematurely, but do not suffer from birth defects. If a patient has not been on glucocorticoids during pregnancy, there is no reason to initiate these medications to prevent a postpartum flare.

In rare cases, babies may be born with a condition called neonatal lupus. This condition causes the fetus or neonate to develop problems in the heart, skin, liver, and/or blood. Neonatal lupus is not the same as SLE. It is associated with maternal antibodies called anti- Ro(SSA) and anti-La(SSB). Neonatal lupus can be identified in utero between 18 and 24 weeks. The most common manifestations are heart block (heart beats abnormally slowly) or a rash, most often seen around the eyes.

Potential Lupus Complications During Pregnancy Lupus flare morning stiffness and swollen joints fever development or worsening of a rash Miscarriage cramping vaginal bleeding (spotting to heavy bleeding) Pregnancy-induced hypertension blood pressure 140/90 and over during the second half of pregnancy generalized edema proteinuria Pre-eclampsia blood pressure 140/90 and over during the second half of pregnancy proteinuria epigastric pain hyperreflexia edema, including face and hands headache Eclampsia all of the symptoms of pre eclampsia seizures Neonatal lupus transient rash transient blood count abnormalities heartblock

Potential Problems

1. lupus flare

2. increased risk of spontaneous abortion or stillbirth

3. pregnancy-induced hypertension

4. increased risk of prematurity

5. neonatal lupus

Nursing Interventions

Objective: Educate the woman regarding birth control options and risks of pregnancy.

1. Encourage patient to plan pregnancy during remission and only after consulting with her doctor.

2. Discuss birth control options:

• Barrier methods (diaphragm or condom with spermicidal foam) are the safest.
• Intrauterine devices (IUD) should be considered for people with lupus on a caseby- case basis. Women on immunosuppressive drugs in particular may be at increased risk of infections from IUDs. Women with thrombocytopenia may have an increased risk of bleeding.
• Oral contraceptives may be appropriate if there are no APLs.