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Lupus and Pregnancy

Sunday, October 31, 2004

by Michael D. Lockshin, M.D. in http://www.hamline.edu/~wnk/lupus/articles/Pregnancy_in_Lupus.html

Since lupus primarily affects young women, pregnancy often becomes a crucial question. Years ago, all medical texts said that lupus patients could not have children, and if they became pregnant, they should have therapeutic abortions. Clearly, these early conclusions are wrong. Currently, 50 percent of all lupus pregnancies are completely normal, and 25 percent deliver normal babies prematurely. Fetal loss, due to spontaneous abortion (miscarriage), or death of the baby accounts for the remaining 25 percent. While not all of the problems of pregnancy with lupus have been solved, pregnancies are possible, and normal children are the rule.
While it is certainly possible for lupus patients to have children, pregnancy may not be easy. It is important to note that although many lupus pregnancies will be completely normal, all lupus pregnancies should be considered "high risk." "High risk" is a term commonly used by obstetricians to indicate that solvable problems may occur and must be anticipated. Pregnant lupus patients should be managed by obstetricians who are thoroughly familiar with high risk pregnancies and work in close concert with the woman's primary physician. Delivery should be planned at a hospital that has access to a unit specializing in the care of premature newborns. SLE mothers should not attempt home delivery, or be overly committed to "natural" childbirth, since treatable complications during delivery are frequent. However, under close observation, the risk to the mother's health is lessened, and healthy babies can be born.

Will Pregnancy Flare My Lupus?
Although older medical texts suggest that SLE flares are common in pregnancy, recent studies indicate that flares are uncommon and are usually easily treated. In fact, 6-15 percent of lupus patients will actually experience an improvement in lupus symptoms during pregnancy. Flares most often occur during the first or second trimester, or during the two months immediately after delivery. Most of the flares tend to be mild. The most common symptoms of these flares are arthritis, rashes and fatigue. Approximately 33 percent of lupus patients will have a decrease in platelet count during pregnancy, and about 20 percent will have an increase in or new occurrence of protein in the urine.
Women who conceive after 5-6 months of remission are less likely to experience a lupus flare than those who get pregnant while their lupus is active. Lupus nephritis before conception also increases the chance of experiencing a lupus flare during pregnancy.

It is important to distinguish the symptoms of a lupus flare from the normal body changes that occur during pregnancy. For example, because the ligaments that hold the joints together normally soften in pregnancy, fluid may accumulate in the joints, especially in the knees, and cause swelling. Although this may suggest an increase in inflammation due to lupus, it may simply be the swelling that occurs during a normal pregnancy. Similarly, lupus rashes may appear to worsen during pregnancy, but this is usually due to an increased blood flow to the skin that is common in pregnancy (the 'blush' of a pregnant woman). Many women also experience new hair growth during pregnancy, followed by a dramatic loss of hair after delivery. Although hair loss is certainly a symptom of active SLE, this again is most likely a result of the changes that occur during a normal pregnancy.

When is the Best Time to Get Pregnant?
The answer is simple: when you are at your healthiest. Women in remission have much less trouble than do women with active disease. Their babies do much better, and everyone worries less.
Good health rules are essential: eat well, take medications as prescribed, visit your doctor(s) regularly, don't smoke, don't drink, and certainly don't use 'recreational' drugs.

Why are Frequent Doctor Visits so Important in a Lupus Pregnancy?
Frequent doctor visits are important in any high risk pregnancy because many conditions which may occur can be prevented, or treated more easily, if found early.
About 20 percent of lupus patients will have a sudden increase in blood pressure, protein in the urine, or both during pregnancy. This is called toxemia of pregnancy (or pre-eclampsia, or pregnancy-induced hypertension). It is a serious condition, and will require immediate treatment and usually immediate delivery. Toxemia is more common in older women, in black women, in women with twins, in women with kidney disease, in women with high blood pressure, and in women who smoke. Serum complement and blood platelet count may be abnormal in these cases. Since complement levels and blood platelet counts are also abnormal during SLE flares, it may be difficult for the doctor to be certain that a flare is not causing these symptoms. If toxemia is promptly treated the woman should be in no danger, but there is a high risk that the baby will die if it is not rapidly delivered. If toxemia is ignored, both the woman and her baby are in danger.

As pregnancy progresses it is often wise for the doctor to check the baby's growth with sonograms (which are harmless). The doctor should also regularly check the baby's heart beat. Abnormalities in either the baby's growth or heart beat may be the first signs of trouble that can be treated.

Can I Take Medications During Pregnancy?
It is always unwise to take unnecessary medications during pregnancy. However, necessary medications should not be discontinued. Most medications commonly taken by SLE patients are safe to use during pregnancy. Prednisone, Prednisolone, and probably methylprednisolone (Medrol) do not get through the placenta and are safe for the baby. Specifically, dexamethasone (Decadrol, Hexadrol) and betamethasone (Celestone) do reach the baby and are used ONLY when it is necessary to treat the baby as well. For example, these medications might be used to help the baby's lungs mature more rapidly if the baby will be premature. Aspirin is safe; it is often used to protect against a complication known as toxemia of pregnancy. Preliminary reports suggest that azathioprine (Imuran) and hydroxychloroquine (Plaquenil) do not harm babies, but the final word is not yet in on these. Cyclophosphamide (Cytoxan) is definitely harmful if taken during the first three months of pregnancy.
What About 'Prophylactic' (Preventative) Treatment with Prednisone?
A few doctors feel that all pregnant women with lupus should take small doses of Prednisone to prevent early abortion. However, there are no confirmed data that this is necessary. Similarly, some physicians feel steroids should be given or increased after the baby is born to prevent 'post partum flare.' Again, there is no evidence that this is necessary in most cases either. For patients recently on steroids, however, 'stress' steroid is usually given during labor to supplement what the mother can't make herself.
What are Anti-Phospholipid Antibodies and Why are they Important?
About 33 percent of lupus patients have antibodies that interfere with the function of the placenta. These antibodies are called antiphospholidid antibodies, the lupus anticoagulant or anti-cardiolipin antibodies. These antibodies may cause blood clots, including blood clots in the placenta, that prevent the placenta from growing and functioning normally. This usually occurs during the second trimester. Since the placenta is the passageway for nourishment from the mother to the baby, the baby's growth slows. The baby can be delivered at this time and will be normal if it is big enough.
Treatment for lupus patients who have these antibodies is still being tested. Aspirin, Prednisone, Heparin, and plasmapheresis have all been suggested as possible therapies. However, even with the use of such medications, these antibodies may still lead to miscarriage.

Will My Baby Be Normal?
Prematurity is the greatest danger to the baby. About 50 percent of lupus pregnancies end before 9 months, usually because of the complications previously discusssed. Babies born after 30 weeks or over 3 pounds usually do well. Premature babies may have difficulty breathing, may develop jaundice, and may become anemic. In modern neonatal units, these problems can be easily treated. Babies weighing more than 3 pounds at birth grow normally. Even babies as small as 1 pound, 4 ounces have survived and have been healthy in every way; but the outcome is uncertain for babies of this size. There are no congenital abnormalities that occur only to babies of lupus patients (except as described below), and no unusual frequency of mental retardation.

Will My Baby Have Lupus?
About 33 percent of lupus patients have an antibody known as anti-Ro or anti-SSA antibody. About 10 percent of women with Anti-Ro antibodies, or about 3 percent of all lupus women, will have a baby with a syndrome known as neonatal lupus. Neonatal lupus is not SLE. Neonatal lupus consists of a transient rash, transient blood count abnormalities, and a special type of heart beat abnormality. If the heart beat abnormality occurs, which is very rare, it is treatable; but it is permanent. Neonatal lupus is the only type of congenital abnormality found in children of mothers with lupus. For babies with neonatal lupus who do not have the heart problem, there is no trace of the disease by 3-6 months of age, and it does not recur. Even babies with the heart beat abnormality problem grow normally. If a mother has had one child with neonatal lupus, there is about a 25 percent chance of having another child with the same problem.
Will I Have to Have a Caesarian Section?
Very premature babies, babies showing signs of stress, babies of mothers with low platelets, and babies of mothers who are very ill are almost always delivered by Caesarian section. This is often both the safest and fastest method of delivery in these cases. Usually the decision about type of delivery is not made in advance because the specific circumstances at the time of delivery are the determining factors.
Can I Breast-Feed?
Although breast feeding is possible for lupus patients, breast milk may not come if the baby is born very prematurely because very premature babies are not strong enough to suckle, and thus, cannot draw the milk. However, milk can be pumped from the breast to feed a premature baby if the baby is not strong enough to suckle and the mother wishes to do this. Plaquenil and the cytotoxic drugs (Cytoxan, Imuran) are passed through the milk to the baby. Some medications, such as Prednisone, may prevent milk from being produced. If you are taking any medication it is best not to breast feed; but if your doctor approves, you may.

Who Will Care for the Baby?
Prospective parents often do not ask what will happen after the baby is born if the mother is ill and unable to care for the child. Since it is likely that a lupus patient will have future periods of illness, it is wise to think of this possibility in advance and to have plans for alternate child-care (spouse, grandparent, etc.) if needed.

Blogged on 7:56 PM

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Tentang Lupus

.:FAQ:.

Apakah lupus itu ?
Lupus merupakan penyakit kronis (jangka panjang) sistem imunisasi, yang sampai kini belum diketahui penyebabnya. Ciri paling utama adalah ditemukannya tingkat aktivasi sistem imun yang luar biasa (hiperaktif) dan menyerang jaringan tubuh normal yang ada. Penyerangan ini menyebabkan peradangan. Saking beragamnya jaringan yang diserang, lupus seringkali mengecoh pengamatan dengan keahliannya meniru penyakit lain.

Autoimmunne ? Apa itu ?
'Auto' berarti 'sendiri', jadi autoimmune maksudnya sistem imun yang melawan tubuhnya sendiri. Ketimbang melawan dan membunuh jaringan jelek lain, seperti virus, ia malah melawan jaringan yang baik.

Peradangan atau Iflamasi
Merupakan proses protektif yang dilakukan tubuh bila jaringan terluka. Radang membantu menghancurkan jaringan asing atau organisma (virus, bakteria) dan mencegah luka lebih jauh. Tanda-tanda peradangan biasanya adalah: kemerah-merahan, panas, sakit, atau bengkak.

Antibodi?
Antibodi adalah protein yang diproduksi oleh sel darah putih (B lymphocytes). Fungsi normalnya adalah mengikat bakteri dan membuat sel darah putih mudah untuk menangkap dan menghancurkannya. Bila sistem imun tidak bekerja dengan baik, maka antibodies terbentuk (auto-antibody). Kadang infeksi dapat menyebabkan diproduksinya auto-antibodies dan hal ini merupakan salah satu penyebab lupus. Antibodi tersebut akan berputar di dalam darah, tapi beberapa sel tubuh memiliki dinding yang dapat membiarkan antibodi ini masuk. Hal ini dapat menyerang DNA dalam inti sel. Itulah sebabnya beberapa organ dapat diserang, sementara organ yang lain tidak.

Lupus itu ada bermacam-macam lho..
Discoid lupus (atau dikenal sebagai Cutaneous lupus, merupakan lupus yang menyerang kulit.
Systemic lupus: merupakan jenis lupus yang paling "repot" karena menyerang beragam sistem tubuh, termasuk kulit, darah, sendi, paru-paru, ginjal, jantung, otak dan sistem saraf.
Drug-induced lupus biasanya muncul ketika seseorang meminum obat tertentu. Tapi gejalanya bisa hilang setelah obat tersebut dihentikan pemakaianannya.

Bagaimana gejala systemic lupus?
Gejalanya dapat berupa -Arthritis (bengkak dan sakit di persendian), sakit pada otot dan lemah, capek, sensitif terhadap sinar matahari, rambut rontok, bercak merah di wajah berbentuk kupu-kupu (melintang di hidung dan pipi), demam, anaemia, sakit kepala, keguguran berulang, dan seterusnya.

Gejala discoid lupus?
Beragam bercak kulit, photosensitivity, & kadang-kadang sariawan atau mimisan.

Apa beda discoid lupus dibanding systemic lupus?
Discoid Lupus menyerang kulit, sementara systemic lupus menyerang hampir semua sistem organ tubuh, termasuk kulit.

Dapatkah discoid lupus berubah jadi systemic lupus?
Kira-kira 10% penderita discoid lupus berkembang menjadi systemic lupus. Namun hal ini tidak bisa diprediksi, apalagi dicegah.

Apa beda drug-induced lupus & systemic lupus?
Seorang penderita Systemic lupus umumnya tidak menjadi drug-induced lupus, namun sebaliknya bisa terjadi. Gejala drug-induced lupus umumnya tidak termasuk sistem yang berhubungan dengan ginjal ataupun sistem saraf pusat.

Obat apa yang paling sering diasosiasikan dengan drug-induced lupus?
Obat berikut terbukti memiliki asosiasi dengan drug-induced lupus: Procainamide (digunakan untuk heart rhythm abnormalities), Hydralazine (digunakan untuk tekanan darah tinggi), Isoniazid (digunakan untuk tuberculosis), Quinidine (digunakan untuk heart rhythm abnormalities), Phenytoin (digunakan untuk seizures seperti epilepsi, kejang). Beberapa obat pernah dilaporkan menjadi pemicu, namun tidak disertai dengan bukti yang kuat.

Apakah pemakaian obat ini harus dicegah oleh penderita lupus?
Hampir semua obat yang disebutkan diatas aman bagi penderita lupus, namun jika ada pilihan lain, sebaiknya jangan dipakai.

Kapan gejala muncul ?
Pada penderita Drug-induced lupus, waktu yang dibutuhkan untuk menunjukkan gejala lupus bisa beberapa bulan hingga tahunan selama pemakaian obat secara rutin. Namun gejala itu juga bisa segera hilang setelah menghentikan konsumsi obat dimaksud. Variasi hilangnya sangat tinggi, dari harian hingga tahunan. Namun begitu, ANA masih positif selama beberapa tahun.

Apa penyebab lupus
Sampai kini penyebab pasti tidak diketahui. Namun gabungan antara faktor genetik dan lingkungan yang mendukung (stress, misalnya) bisa dijadikan penyebab tercetusnya lupus.

Apakah lupus bersifat heriditas ?
Tidak ada angka pasti yang bisa menunjukkan bahwa lupus bisa diturunkan, namun begitu diperkirakan orang yang memiliki keluarga berpenyakit lupus memiliki kemungkinan terkena lupus sebesar 5-12% lebih besar ketimbang orang normal.

Siapa saja yang bisa terkena lupus ?
Bisa wanita maupun pria, namun pada wanita kasus ini cenderung lebih besar. Sampai sekarang tidak diketahui mengapa lupus dapat menyerang ras tertentu lebih besar ketimbang ras lainnya. Sebagai contoh, pada ras Caucasians kira-kira 1 dari 1000 orang dapat terkena lupus, sementara pada African-Americans 1:250 dan latino (hispanik) 1:500.

Apa yang memicu munculnya lupus ?
Ada beberapa penyebab yang memungkinkan munculnya lupus, termasuk cahaya ultraviolet, pemakaian obat dan antibiotic tertentu, infeksi atau virus, hormones & stress.

Apakah ada obat yang harus dihindari ?
Tidak ada obat tertentu yang wajib dihindari, namun karena pasien lupus umumnya alergi, maka perlu diperhatikan pemberian oral contraceptives, sulfa antibiotics & penicillin.

Apakah ada tes khusus buat SLE ?
Tidak ada. Pasien harus menjalani beragam tes sebelum jatuh pada kesimpulan ia mengidap lupus.

Mengapa SLE sulit didiagnosa ?
Ada beragam penyebab: penyakit ini merupakan multi sistem, yang meniru penyakit-penyakit lain dan menyebar ke beragam organ. Kemampuan kamuflase ini sering kali melecehkan deteksi paramedic atas kondisi pasien dan “menuduhnya” sebagai penyakit yang lain.
SLE juga merupakan penyakit unik yang memiliki diagnosa beragam pada tiap-tiap pasien. Untuk itu disusun 11 kriteria yang dapat menggiring seseorang agar dapat dikatakan positif lupus. Jika 4 dari gejala telah ditunjukkan, umumnya pasien langsung melakukan tes lab khusus untuk mengetahui tingkat dan jenis lupusnya.
SLE lamban berkembang. Gejala yang ditunjukkan juga sering berubah-ubah. Hal ini menyulitkan diagnosa yang tepat dan membutuhkan rangkaian tes yang panjang, mulai dari mengumpulkan sejarah penyakit seseorang, tes lab dan gejala saat ini.

Dokter apa yang harus menangani pasien lupus ?
Tidak ada patokan resmi disini. Setiap dokter spesialis atau gabungan dokter spesialis (rheumatologist, dermatologist, nephrologist, immunologist) merupakan tim yang sempurna.

Apakah gejala pasien lupus sama ?
Tidak. Bahkan seorang pasien lupus dapat menunjukkan gejala yang berbeda dari hari ke hari. Hal ini karena lupus dapat menyerang organ-organ tubuh yang berbeda.

Apakah lupus dapat menginfeksi atau menular ?
Tidak sama sekali.

Apakah ada penyembuhan untuk lupus ?
Saat ini tidak ada obat yang dapat menyembuhkan lupus. Dokter hanya memberi perawatan pada peradangan atau organ-organ yang diserang sambil memberi obat-obatan yang mampu mengontrol lupus, seperti 4 kelompok obat berikut: Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antimalarials, & cytotoxic drugs (chemotherapy).

Apa itu flare ?
Flare merupakan perubahan mendadak suatu aktivitas penyakit, contohnya perkembangan gejala baru. Pasien yang tiba-tiba lemas dan mengalami nyeri otot dan sendi t

Blogged on 7:50 PM

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