“Most women have an uneventful pregnancy if they go to rheumatologists who have experience in autoimmune diseases and pregnancy.”
Systemic autoimmune diseases (rheumatoid arthritis, antiphospholipid syndrome, and systemic lupus erythematosus) and inflammatory arthritis (Sjögren’s syndrome, scleroderma, and polymyositis/dermatomyositis, etc.) are the rheumatic pathologies that usually affect women of childbearing age.
This is a group of diseases characterized by the abnormal production of “autoantibodies” by the immune system, which can cause damage to multiple organs and systems (in the case of systemic diseases) or joints (inflammatory arthritis).
Currently, autoimmune diseases have become better known among the population, but they are still surrounded by myths and incorrect information. One of them is the affectation of maternity, since until a few years ago, pregnancy was not recommended for these patients. But the ability to conceive is the same as that of healthy people , although abortions are more freqHowevert.
Various studies have confirmed that if the disease is well-controlled and has been in remission for a reasonable period, it is more likely that the pregnancy will reach term without major complications. The profile of antiphospholipid antibodies, anti-Ro/anti-La antibodies, pulmonary pressure, and the evaluation of the level of activity are determinants to define the risk of pregnancy.
Follow-up requires a multidisciplinary team, serial analytical controls, and Doppler ultrasound of the maternal-fetal circulation. Treatment will be aimed at adequately controlling these diseases and employing the most effective therapy for the disease with the least risk to the fetus, thus optimizing obstetric outcomes.
Autoimmune and inflammatory diseases are not a contraindication to pregnancy
Neither systemic autoimmune diseases (SAE) nor inflammatory diseases are a contraindication for pregnancy. “Women with rheumatic diseases can have children as a healthy woman does, although it is necessary to plan the pregnancy with the rheumatologist and have a multidisciplinary team that knows how to adequately address the possible complications that may arise”, according to Dr. María José Cuadrado, a rheumatologist at the Clínica Universidad de Navarra, within the framework of the II ‘Course on childbearing age in EAS and chronic inflammatory pathology’ organized by the Spanish Society of Rheumatology, with the collaboration of the biopharmaceutical UCB.
In this sense, Dr. Paloma Vela Casasempere, a rheumatologist at the Alicante General University Hospital and co-coordinator of the course, insists that “pregnancy is possible on most occasions. But it is essential to reach him after an adequate evaluation and programming, take the medication and carry out the controls during the pregnancy strictly, and in case of any doubt, go to the professionals to solve them ”.
Life-threatening situations during pregnancy
Life-threatening situations can be as different as EAS are. “Pulmonary hypertension, which can appear in several of them—progressive systemic sclerosis (P systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS) as the most frequent—is an absolute contraindication for pregnancy.
Maternal mortality is high and fetal losses frequent. If pregnancy occurs, some drugs are contraindicated but others can be used. It is a difficult situation for both the mother and the fetus”, says Dr. Cuadrado.
These situations should always be faced with a multidisciplinary team that has experience. In the opinion of the specialist, “if this equipment is not available, the patient should be referred to a center that does. This is especially important in the case of pulmonary hypertension but also in any patient with serious complications. The obstetrician and the rheumatologist must lead the therapeutic decisions, but always relying on the other specialists who can improve the patient’s care”.
In other rheumatic diseases such as inflammatory arthritis, there may be problems during pregnancy, but generally, they are not life-threatening situations. “It is important that pregnancies are planned, that the medication change is made before pregnancy, and that we make sure that the disease continues to be controlled.
In addition, regarding biological drugs, we now know which ones are safe during pregnancy, when we have to use them, and at what point in the pregnancy we should stop them, if necessary”, says Dr. Cuadrado.
Childbirth and puerperium*
On the other hand, Dr. Nuria Martínez, a gynecologist at the La Paz University Hospital in Madrid, explained that “the majority of patients with EAS have normal deliveries. But it is important to take into account the clinical situation of the pregnant woman, the obstetric conditions (situation of the fetus, cervix…), as well as the drugs that the pregnant woman is taking to assess changes or withdrawal of them to reach the moment of delivery. I give birth in the best conditions”. In general, spontaneous onset of labor is better, but if any complications have occurred in the fetus othe r the mother, induction of labor should be considered. In addition, she -she has added- “it is important to individualize each case with the specific situation of each pregnwoman, as well as the obstetric history”.
Regarding the puerperium, Dr. Andrea Pluma, a rheumatologist at the Vall d’Hebrón University Hospital, has specified that “an important part of the patients with rheumatic conditions will present a reactivation of their disease during the postpartum period. Therefore, it is important to have effective treatments to reduce the activity of the disease and help patients adapt as well as possible to their new family situation. Furthermore, follow-up in these cases must be very close”.
One of the most important peculiarities of this period is the possibility for the patient to opt for breastfeeding, the experts detail. Therefore, it is necessary to choose those drugs that are effective for the patient and at the same time compatible with breastfeeding. “On some occasions, due to the activity of the maternal disease, this will not be possible. But it must be stressed that thanks to advances in research, these cases are becoming fewer and fewer”, according to Dr. Pluma.
*The puerperium is the period from the end of labor to the appearance of the first menstruation. During this time, a multitude of physiological changes are developed simultaneously in the woman to gradually return to the pre-pregnancy state and establish lactation.