About Pregnancy and autoimmune disorders
Autoimmune disorders such as autoimmune thyroid disease (Hashimoto and Graves’ disease), celiac disease, type 1 diabetes, inflammatory bowel disease, and psoriasis have been on the rise in the last 20 years. Autoimmune disorders are conditions in which an ongoing, self-directed immune response results in clinical manifestations.
In the past, women with autoimmune diseases were frequently counseled against conceiving. Today, more and more women with a range of autoimmune conditions are enjoying healthy pregnancies. However, they are still considered high-risk pregnancies.
Autoimmune disorders are 5 times more common among women, and incidence tends to peak during reproductive years. Thus, these disorders commonly occur in pregnant women.
A healthy, normally-functioning immune system is designed to fight off harmful invaders, like bacteria or viruses. An autoimmune disorder or autoimmune disease is a condition in which the body’s immune system attacks your own healthy cells. There are many ways that pregnancy and autoimmune disorders can interact. In some cases, pregnancy may have a profound effect on the symptoms of autoimmune diseases, such as in the case of Rheumatoid arthritis and multiple sclerosis.
- Pregnancy may trigger an autoimmune disorder.
- An existing autoimmune disorder can interfere with pregnancy, causing harm to the fetus.
- The antibodies that the mother produces can enter the fetus’s system, affecting its growth.
Antibodies and antigens join to form a floating immune complex, which circulates in maternal blood and can clog the filter of the placenta, causing it to become partially blocked. If the amount and number of nutrients crossing the fetal membrane decreases, the baby will be smaller. These moms have to be watched—especially in the late second and entire third trimester—for early placental dysfunction. Trouble starts when a woman develops placental vasculitis, an inflammation of the capillaries. WBCs come in and try to clean up the problem, but they heal by scarring. This often leads to cell death within the placenta and decreases placental function. Women with vasculitis are at increased risk of preterm delivery and small-for-gestational-age infants.
It is recommended that women with autoimmune diseases achieve remission, meaning their symptoms disappear or substantially improve, for at least six months before pregnancy. Women whose autoimmune conditions are in remission typically have a reduced risk of pregnancy complications and symptom flare-ups.
Your health care provider can adjust your medications and monitor your symptoms to help you achieve this goal.
Lupus and Pregnancy
It’s very difficult to predict what effect lupus (systemic lupus erythematosus) will have on a pregnancy. There have been cases where lupus worsens with pregnancy and other cases where the condition becomes less severe. Some women will develop lupus for the first time while pregnant.
The systemic lupus erythematosus (SLE) may first appear during pregnancy. Women who have had an unexplained 2nd-trimester stillbirth, a fetus with growth restriction, preterm delivery, or recurrent spontaneous abortions are often later diagnosed with SLE.
Although there is a lot of variabilities, one thing we do know is that lupus flare-ups are more likely to occur immediately after giving birth.
Many lupus patients have a history of miscarriages, intrauterine growth restriction (IUGR), and preterm birth. As a result of their lupus, many women have also sustained kidney damage, which can increase the risk for the fetus. If you have lupus, it might be best to wait to get pregnant until:
- Your disorder has been inactive for 6 months or more.
- Your disorder is under control with the help of medication
- Your blood pressure and kidney function are both normal.
If you get pregnant, you run the risk of lupus antibodies crossing the placenta and affecting your baby. The fetus may develop complications such as:
- Slow heart rate
- Low platelet count
- Low white blood cell count
Generally, the maternal antibodies slowly disappear, and the baby’s symptoms will clear up after birth. You can continue taking hydroxychloroquine during pregnancy, and if you experience a flare-up, you can take a low dosage of prednisone, methylprednisolone, or an immunosuppressant under the instruction and care of your health care provider.
Significant preexisting renal or cardiac complications increase the risk of maternal morbidity and mortality. Diffuse nephritis, hypertension, or the presence of circulating antiphospholipid antibodies increases the high risk of perinatal mortality. Neonates may have anemia, thrombocytopenia, or leukopenia.
SLE may be viewed as a prototypical autoimmune rheumatic disease, a high-risk condition and frequently resulting in pregnancy loss.
Antiphospholipid Antibody Syndrome (APS)
This disorder causes excessive clotting of the blood. It increases the mother’s risk of developing hypertension (high blood pressure) and preeclampsia and increases the baby’s risk of IUGR, miscarriage, and stillbirth.
A pregnant patient with antiphospholipid syndrome can typically be treated with low-dose aspirin and anticoagulants throughout the pregnancy, until about six weeks after childbirth. This can decrease the amount of clotting as well as the risk of complications.
APS is an autoimmune disorder that predisposes patients to thrombosis and, during pregnancy, increases risk of:
- Fetal demise
- Pregnancy-induced hypertension
- Intrauterine Growth Restriction
APS is caused by autoantibodies to certain phospholipid-binding proteins that would otherwise protect against excessive coagulation activation.
Rheumatoid Arthritis and Pregnancy
Some women may develop rheumatoid arthritis during pregnancy, or in the weeks following delivery. Rheumatoid arthritis will not affect the fetus, but it can cause pain, stiffness, weakness, fatigue, and swelling for the mother. If the lower spine or hip joints have been affected, this can make delivery more challenging.
If you already have rheumatoid arthritis, your symptoms may become less severe during pregnancy, only to return to their previous severity after birth.
Flare-ups can be treated during pregnancy with prednisone, a corticosteroid.
Immune Thrombocytopenia (ITP)
Immune thrombocytopenia (ITP), mediated by maternal antiplatelet IgG, tends to worsen during pregnancy and increases the risk of maternal morbidity.
ITP is a tricky condition to treat pregnant women. ITP causes the body to release antibodies that decrease the number of platelets in the blood. Platelets are the component of blood that enables clotting. When they are in low supply, both the mother and child may suffer from excessive bleeding.
A doctor may prescribe prednisone to increase the mother’s platelet count, but this is only effective in the long term for about half of the patients. Prednisone also increases the risk of some fetal complications.
To reduce the risk of hemorrhage during vaginal birth, your doctor can administer a high dose of immune globulin through an IV right before delivery. This can help control the bleeding. IV immune globulin increases platelet count significantly but briefly so that labor can be induced in women with low platelet counts. Platelet transfusions are indicated only when
- Cesarean delivery is required and maternal platelet counts are < 50,000/microL.
- Vaginal delivery is expected and maternal platelet counts are < 10,000/microL.
Although antiplatelet IgG can cross the placenta, it only very rarely causes fetal or neonatal thrombocytopenia. Maternal antiplatelet antibody levels (measured by direct or indirect assay) cannot predict fetal involvement. Risk of neonatal intracranial hemorrhage due to maternal ITP is not affected by the mode of delivery nor by birth trauma. Accordingly, the current accepted practice is vaginal delivery, without routinely determining the fetal platelet count, and cesarean delivery only for obstetric indications.
Myasthenia gravis, which causes weakness in the muscles, thankfully does not come with many risks of complications during pregnancy. However, treating the disorder may require higher doses of prescription drugs, or adding a new prescription to the treatment regimen, like corticosteroids or immunosuppressants.
Some drugs that are a regular part of prenatal care, like oxytocin and magnesium, can aggravate the symptoms of myasthenia gravis. Be sure to let your doctor know your medical history before starting these drugs. In very rare cases, pregnant women with myasthenia gravis have difficulty breathing and require assisted ventilation.
In about one out of every five cases, the mother’s antibodies cross through the placenta and cause the disorder in the baby. Fortunately, this is usually a temporary condition, since the baby’s body will flush the mother’s antibodies out once it’s outside the womb. The baby’s body does not naturally produce those antibodies.
Scleroderma and Pregnancy
Scleroderma occurs when the immune system, which normally fights infection, instead attacks the body, causing the skin and blood vessels to thicken and tighten, and scars to form on the kidneys and lungs. Localized scleroderma affects the skin, and the systemic type affects the organs and connective tissue, the fibers that bind and support the body’s cells, organs, and tissues. Systemic scleroderma can damage ligaments, nerves, muscles, and tendons and may cause hypertension, or high blood pressure.
Women with systemic forms of scleroderma, which affect many parts of the body, require additional monitoring during pregnancy. They are at risk of developing preeclampsia, which refers to pregnancy-induced high blood pressure and protein leakage in the kidneys, preterm labor, and other kidney problems. Localized scleroderma rarely affects pregnancy.
Sjogren’s Syndrome and Pregnancy
In Sjogren’s syndrome, the body’s white blood cells, which fight infection, attack the glands that produce moisture, such as those in the eyes and mouth. Diagnosed most often in women, the condition can cause dry and burning eyes, dry mouth, difficulty swallowing, swollen neck glands, and even vaginal dryness. It can also affect the blood vessels, central nervous system, gastrointestinal system, kidneys, liver, lungs, and pancreas.
Primary Sjogren’s syndrome occurs on its own and is not triggered by another condition. Secondary Sjogren’s syndrome develops in a person who has another autoimmune condition, usually rheumatoid arthritis or lupus.
Some pregnant women with Sjogren’s syndrome have a higher risk of miscarriage. Women with Sjogren’s syndrome who have anti-Ro (SS-A) or anti-La (SS-B) autoantibodies—substances in the blood that mistakenly attack the body’s own tissues—are at a higher risk of having a baby born with congenital heart block, a potentially life-threatening condition in which the baby’s heart becomes scarred and beats more slowly.
Autoimmune Disorder Medications and Pregnancy
There is some uncertainty about immunosuppressant drugs, but by and large, it is probably better for a woman to continue such medication and not risk increase disease activity and a flare than to discontinue it. One of the worst scenarios occurs when a woman finds out she’s pregnant and stops her medications cold, only to have the disease explode.
Medications for autoimmune conditions may be given in lower doses or replaced with safer ones. For instance, corticosteroids—potent anti-inflammatory medications—are prescribed at the lowest possible dose during pregnancy to decrease a woman’s risk of developing pregnancy complications. Steroids should not be given on a chronic basis in high doses before 16 weeks’ gestation because they can cause congenital anomalies.
If you are concerned about pregnancy and any autoimmune disorders, or have questions about them, please discuss them with your doctor
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