Lupus and Pregnancy: An Improving Outlook
In the past, most — if not all — lupus sufferers were warned against getting pregnant. The combination of signs and symptoms, coupled with the bodily strain from the pregnancy, would combine into a high-risk situation for both the mother as well as the baby. Furthermore, the fact that most victims of this condition were — and still are — women of reproductive age only served to compound the impact of this disease on the general populace. Regardless, as medical technology and our understanding of this condition evolve, pregnancy and lupus is no longer the dangerous combination it was a few years back.
The fact is, the idea that lupus is dangerous for pregnant women was never based on hard evidence. Instead, the general consensus was that it was more dangerous for female sufferers since it’s a disease that mostly affected this gender, which suggested that their increased amount of hormones, compared to men, played a vital role in the pathogenesis of the disease. Pregnancy itself is a state in which the number of hormones in the body multiplies exponentially, which made the relapse of the condition in patients which were otherwise in control a very real outcome. Nevertheless, instead of trying to control the condition during pregnancy, most physicians tended to take the safe route and recommended to avoid conceiving a child altogether, suggesting that, perhaps, the risks of lupus in women were over-generalized due to fear. This isn’t to say that this condition should be taken lightly because it shouldn’t. Fortunately, we are now living in an age where controlling lupus is no longer the insurmountable task it used to be and, even conceiving and birthing babies is a very real possibility, thanks to modern medicine.
When it comes to lupus and other disorders of which our understanding is still growing, data and information are key in order to successfully control and live with these conditions. For this reason, the stratification and study of patients depending on the extent and gravity of their condition is paramount to having a successful pregnancy and delivering a perfectly healthy baby. Of course, the knowledge of what actually is the most common cause of miscarriages in lupus sufferers is also a vital piece of the puzzle; a piece which the advances in medicine and intensive research have yielded over the course of several lengthy studies.
What do recent studies have to say about the disease?
As it turns out, the most common cause of issues during pregnancy on women with lupus was not caused by thrombosis, as it was actually believed. Instead, studies suggest that miscarriages and complications during pregnancy for lupus sufferers are actually related more to inflammation; inflammation driven by activation of complement. The study in question, which was initially conducted using groups of mice induced with lupus pregnancies, was then, due to its promising results, funded by the National Institutes of Health to expand its scope to involve over 700 patients — 500 with lupus, and 200 for control purposes. The research spanned over 11 years, and its findings were positively amazing:
There are several risk factors to be considered when stratifying the gravity of any given lupus sufferer. For instance, though its causality has yet to be established, race plays an important role in the outcome of this disease, as non-Hispanic whites had significantly reduced odds of suffering complications with the condition than Hispanic or African-American individuals. Furthermore, patients who consume antihypertensive medication on a regular basis had almost sevenfold the risk of pregnancy complications, despite keeping their blood pressure in check.
Third, and most important, is a risk factor related to the disease itself: the presence of lupus anticoagulants within the body. In short, these substances are immunoglobulins which bind themselves to phospholipids and proteins associated with the cell membrane, resulting in inappropriate clotting, and potential complications during pregnancy. Keep in mind that the study references exclusively lupus anticoagulants as the risk factor, as other antiphospholipid antibodies, anticardiolipin antibodies, and anti—beta-2 glycoprotein I did not pose an independent risk.
What can we learn from these findings?
In the past, lupus was an almost insurmountable condition which severely restricted the activities the affected person could perform. Today, thanks to studies such as this one, we now know more than ever about the disease and its complications, as well as the risk factors which indirectly affect patients who suffer from lupus. While these discoveries may offer little comfort to those who already suffer from advanced stages of the condition, the results can help them to live with it in a healthier manner. On the other hand, patients who are in the exploratory phase, still gauging the extent of the disorder, and that don’t have any of the aforementioned risk factors are the ones with the highest odds of a positive outcome.
As a baseline, patients who don’t have any risk factors (caucasian, not taking antihypertensive medication, and without the presence of lupus anticoagulants) have the same odds of having a healthy pregnancy as a regular non-lupus sufferer; which is about 93 to 94 percent of total pregnancies. Meanwhile, women that suffer from lupus and present some of the risk factors such as being of African-American descent, dependence on antihypertensives, and signs of lupus anticoagulants can have a risk of suffering complications during pregnancy of almost 60%.
As we mentioned above, this stratification is exceedingly important, as not all sufferers of lupus will need to undergo the same amount of treatment and restrict themselves to the same extent that those with multiple risk factors have to. Patients with no risk factors need not subject themselves to monthly sonograms during pregnancy. Furthermore, the psychological impact of not having to constantly worry about the presence of lupus anticoagulants, as well as every possible negative outcome can further help the pregnancy to flow smoothly. On the other hand, patients that present several of the risk factors mentioned above can get properly stratified by their clinician, and receive the appropriate treatment for their condition.
As matters stand today, modern medicine is still no closer to treating high-risk lupus pregnancies than where it was a few years ago. Nevertheless, several preliminary studies suggest that there are medications — such as aspirin — which can help offset some of the most preeminent symptoms of the condition (namely, preeclampsia), and reduce the possibility of fetal mortality. Furthermore, patients who have a history of thrombotic or obstetric antiphospholipid syndrome will likely receive treatment with heparin as it is the anticoagulant of choice because it doesn’t cross the placenta and has no effect on the fetus during its development. However, the fact remains that high-risk lupus pregnancies are still a significant concern among the medical community, and remain a subject of intense research. Now that the risk factors associated with complications are no longer a mystery, patients can be properly treated to improve their odds of having a healthy, happy life.
The next step
The next step would be the development of interventional clinical trials aimed at the prevention of serious complications during pregnancy. Preliminary studies involving the inhibition of tumor necrosis factor alpha on women with high-risk pregnancies are underway, with hopes that the TNF holds the key to preventing preeclampsia, further lowering the chances of fetal mortality. The reasoning behind this is that, during the tests on mice, the inhibition of TNF yielded positive results in the prevention of fetal injury. Moreover, if studies are successful, this treatment could also be used on non-lupus, high-risk patients with high risk of preeclampsia to rescue pregnancies and reduce fetal death.
That being said, the flashes of lupus during pregnancy can be fairly common, often appearing in the first or second trimester, or during the first few months after delivery. The most common symptoms are usually arthritis, rashes, and general fatigue, all of which pose little threat to both the patient and the baby, and can be addressed with a symptomatic treatment.
As matters stand today, the future is looking very bright for those that suffer from lupus, as well as other autoimmune conditions. With advances in medicine, not only are the risks of fetal death reduced by a significant percentage, but the possibility of living a normal, fulfilling life is growing closer with each passing day.
