When a person’s own immune system attacks her body thinking that healthy cells are a threat, an autoimmune disease occurs. Such disorders are more common amongst women, especially those of reproductive age, say studies.
In the past, women who had autoimmune disorders were discouraged from having children as this put both the baby’s and mum-to-be’s lives at risk. Luckily, medicine has evolved to such an extent that women dealing with such disorders have great medical support and can still enjoy healthy pregnancies. The most common autoimmune disorders affecting women of childbearing age are:
- Antiphospholipid syndrome (or APS) Blood clots form too easily or excessively.
- Systemic lupus erythematosus (SLE) Affects the skin, joints, kidneys, brain, and other organs.
- Rheumatoid arthritis Causes damage to the hip joints or lower (lumbar) spine.
- Grave’s disease An overactive thyroid gland makes too much thyroid hormone, producing symptoms like rapid weight loss, anxiety, tremors, insomnia, irregular menses, chest pains and heat intolerance.
- Hashimoto’s disease Causes an underproduction of thyroid hormones. Symptoms include, depression, fatigue, muscle aches, unexplained weight gain and prolonged menses.
- Type 1 diabetes mellitus The body is unable to produce insulin as the beta cells in the pancreas are destroyed by the autoimmune disorder. Symptoms include, nausea, blurred vision and unexplained weight loss.
While it’s advisable to get the condition under control (ideally, you should be in remission before trying for a child), none of these conditions should pose a problem to your fertility or pregnancy if the condition is well managed well, assured doctors SmartParents spoke to.
Obstetrician-gynaecologist experts, Dr Chris Chong of Gleneagles Medical Centre and Dr Tony Tan of Raffles Hospital, answer your pressing questions if you have an autoimuune condition and are trying to get pregnant or already pregnant…
In the past, women who had autoimmune disorders were discouraged from having children as this put both the baby’s and mum-to-be’s lives at risk.
What maternal health complications commonly occur with an auto-immune disease?
Complications depend on which area of the woman’s health that is being compromised by the disorder ― while thyroid conditions are generally manageable, joint problems may worsen and hurt more as the pregnancy progresses. Kidney and heart diseases can pose problems throughout the gestational period. Most medications are also relatively safe to take despite limited data for its use in pregnancy. In fact, not taking the medications when the disease flares up could be a much worse scenario.
Dr Chong In the first trimester there’s a risk of miscarriage, vomiting and bleeding. With all the other trimesters, issues can arise with blood pressure, renal damage or failure and the placenta separating from the baby. The medications she takes can also cause side effects like anaemia, water retention and muscles wasting away from steroids.
Dr Tan In the first trimester, look out for miscarriages and the role of the medication in causing teratogenic effects [birth defects] on the baby. The risk of miscarriages may be increased if there is antiphospholipid syndrome [elevated levels of antibodies causing recurrent foetal loss]. Medication should be reviewed to ensure that those with better data in pregnancy are used. She will also have to get regular checks for blood pressure and a urine dipstick test to check for proteinuria [excess protein in the urine] to detect pre-eclampsia. These are common complications of autoimmune disorders.
Can autoimmune disorders pose a health threat to the baby…? Read on!
What about the foetus, how can it’s health be compromised?
Premature birth or with low birthweight are health threats that any ill mother might be at risk of. Patients with lupus and rheumatic diseases harbor dangerous auto-antibodies that could potentially cause stillbirths or heart damage in the foetus. To catch any issues early on, there will be a foetal structural abnormality scan done in the second trimester, plus regular ultrasounds to check on the growth velocity of the foetus.
Dr Chong Because of the medication the mum takes, baby can be born with defects such as a cleft lip or organ damage and poor organ growth. If placenta separation happens, the foetus will also be severely deficient of oxygen supply.
Dr Tan There could potentially be ill effects to the foetus. One way is through the transmission of these autoimmune antibodies from the mother to the baby, which could cause ill effects. For example, some thyroid autoimmune antibodies could excessively stimulate the growth and hormonal production of the thyroid gland of the foetus. Some antibodies may cause congenital heart blockages in the foetus and potential heart failure. Another way is if the mother develops end-organ damage from the diseases (eg high blood pressure, heart failure or kidney failure) or her pregnancy is induced earlier due to complications such as pre-eclampsia or intrauterine growth restriction [baby is not growing at a normal rate inside the womb]. Premature delivery from complications of the diseases could also complicate foetal health.
A pregnant woman with an autoimmune disorder is generally classified as having a high-risk pregnancy.
How does pregnancy care and delivery options differ for patients with an autoimmune disease?
A pregnant woman with an autoimmune disorder is generally classified as having a high-risk pregnancy. These patients need a great amount of close monitoring, which includes regular sonograms and blood-flow evaluations, especially during the home stretch. It is even recommended that the baby is delivered at 38 weeks to avoid further complications.
Dr Chong It’s crucial that they are co-managed with a team that includes the autoimmune diseases specialist. There should also be frequent scans, especially the Doppler scan to assess the umbilical artery pressure [to monitor foetal growth and signs of pre-eclampsia]. Pregnant women should take good care of their health, take supplements like folic acid, get hormonal support and avoid certain foods. For example those with Grave’s disease should avoid food high in iodine. As for delivery options, they can generally opt for a vaginal birth if the condition is well controlled and the foetus is growing well.
Dr Tan Such patients should be seen closely by their rheumatologists, endocrinologists or immunologists and a specialist in high-risk pregnancies. In general, these conditions do not increase the risk of a Caesarean section if there is no complication of pre-eclampsia or intrauterine growth restriction resulting from these disorders.
Can bubba “catch” your disorder? Click to find out.
Anything to keep in mind post-delivery?
Autoimmune diseases can flare-up at any time, so it’s crucial for your doctor to keep a close eye on you and your condition post birth. There might also be issues concerning breastfeeding and the changing or continuation of medical regimens.
Dr Chong The condition can still get worse, so continual monitoring is essential. They are free to breastfeed, unless they are taking cytotoxic [toxic to cells] drugs which could be harmful. In that case, it’s best to consult their doctor first.”
Dr Tan It is important to monitor the disease post-delivery. Sometimes, worsening of the disease may be confused with common post-delivery symptoms like postnatal depression or poor sleep. So, it’s important to continue seeing your physician. As for breastfeeding, it depends on the medications you’re taking, but in general, it’s fine to do so. Do check with both your obstetrician and the physician about the suitability of the medications when breastfeeding.
It is important to monitor the disease post-delivery. Sometimes, worsening of the disease may be confused with common post-delivery symptoms like postnatal depression or poor sleep.
What is the likelihood that a foetus will develop its mother's autoimmune disorder?
Not very likely, but even if it does, very often the mother’s autoimmune antibodies are passed down to the foetus only transiently, say both doctors.
Dr Chong It’s generally very variable, but they [the babies] are at a higher risk compared with the general population.
Dr Tan Conditions like myasthenia gravis and congenital lupus syndrome can be passed down transiently to the foetus. There is, on the other hand, also an increased chance of a genetic predisposition to developing the mother’s condition later on as an adult.
Are there any autoimmune disorders where women should avoid pregnancy altogether?
In general all these conditions can make conceiving difficult, but there’s no need to completely avoid trying for a baby. However, there’s always a chance that some autoimmune diseases may get worse during pregnancy. For example, SLE worsens in one-third of patients during pregnancy and this can lead to renal failure and severe high blood pressure. Since it’s difficult to predict which patients would get it worse, the disease activity is closely monitored during the pregnancy.
Dr Chong Before she [the woman] tries to have a baby, we will do a few assessments. This includes checking to see if the medication she’s taking will have any side effects and can cause abnormalities for the child. If so, we will see if she can be off the medication or opt for a safer drug with minimal or no side effects. We will also have to investigate if the pregnancy can cause the mum’s condition to deteriorate further.
Dr Tan APS can increase the risk of miscarriages, and cause complications like pre-eclampsia and intrauterine growth restriction. Also, if the patient is on drugs like cyclophosphamide or methotrexate for the treatment of the autoimmune diseases, it could also reduce fertility.
Dr Christopher Ching is an obstetrician-gynaecologist who practises at Chris Chong Women & Urogynae Clinic at Gleneagles Medical Centre. Dr Tony Tan is a specialist in obstetrician and gynaecology at the Raffles Women’s Centre at Raffles Hospital.
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