Can a woman with lupus have a baby

The Risks of Pregnancy for Women With Lupus

Lupus is a disease that most commonly affects women during their childbearing years. In the past, women with lupus were advised not to get pregnant because it was thought to be too dangerous for both mother and baby. Although pregnancy with lupus is still considered high risk, most women with lupus who want to have children will be able to have safe, successful pregnancies.

How Does Lupus Affect Pregnancy?

Lupus doesn’t affect a woman’s ability to get pregnant, but it does increase the risk of some pregnancy complications. “Although most pregnancies go well, there is an increased risk of miscarriage and premature birth. Women with lupus are at risk for renal complications including renal failure if pregnancy occurs during a phase of active renal disease,” notes Ignacio Sanz, MD, a rheumatologist at the University of Rochester Medical Center in Rochester, N.Y., and chair of the research committee for the Lupus Foundation of America. Here’s what you need to know about the risks of pregnancy in different stages:

  • First Trimester. Miscarriage during the first trimester is sometimes associated with active lupus symptoms. About 10 percent of pregnancies in women with lupus end in miscarriage, while nearly 15 percent of all pregnancies in the United States result in miscarriage.
  • Second Trimester. Pregnancy complications in the second trimester may be due to a lupus antibody known as the antiphospholipid antibody. These antibodies are present in the blood of about 36 percent of women with lupus and are associated with the formation of blood clots that can cause miscarriage.
  • Late-term complications. Pre-term birth occurs in about 25 percent of lupus pregnancies. Women with lupus are also more likely to develop high blood pressure and retain body fluid during pregnancy, a condition called preeclampsia, which can cause the placenta to rupture.

Maternal Risks of a Lupus Pregnancy

“The main concern for women with lupus has always been that pregnancy will cause their lupus to flare up. We have learned that although many women do have a flare , they are not as severe as we once feared,” says Dr. Sanz. “However, this sense of safety only applies to pregnancies that occur when lupus has been well controlled for several months.”

Flares occur in about 18 percent of pregnant women with lupus. They are likely due to increased estrogen production that takes place in the body during pregnancy, stimulating the immune system to react. Flares are more common in women who have kidney involvement with their lupus before or during the pregnancy.

Fetal Risks of Lupus

There are certain risks to the baby if the mother has lupus during her pregnancy. These include:

  • Small baby. Babies of mothers with lupus have a higher risk for a condition called intrauterine growth retardation (IUGR), meaning that the baby remains much smaller than is normal. IUGR occurs in about 15 percent of lupus pregnancies. IUGR may be more likely if the mother has preeclampsia, antiphospholipid antibody, or was treated with steroids during pregnancy.
  • Neonatal lupus. In rare cases, the baby can be born with lupus antibodies that cross the placenta. In 95 percent of these cases, the antibody is a type called anti-Ro. Even when the mother has anti-Ro antibody, neonatal lupus occurs in only about one percent of cases. Most of the symptoms of neonatal lupus are mild and go away in a few months, but there is one serious complication called congenital heart block. In these cases the baby does not have a normal heart rhythm and may need a pacemaker.

Managing Lupus During Pregnancy

“If we need to treat lupus during pregnancy we can still use many of the same drugs we used before pregnancy,” says Sanz. Prednisone, Plaquenil (hydroxychloroquine), and the immunosuppressive drug Imuran (azathioprine) can all be used if needed to control lupus during pregnancy.

In women who have tested positive for antiphospholipid antibody, especially if they have a previous history of pregnancy complications, a combination of aspirin and the blood thinner heparin can be given to prevent blood clotting that can cause a second trimester miscarriage.

How to Prepare for a Lupus Pregnancy

If you want to become pregnant with lupus, you should talk to your doctor first. “We advise women not to get pregnant if they have active lupus. This is especially important if the activity involves the kidneys or central nervous system. We would like to see their lupus in good control for about six months before they become pregnant,” advises Sanz.

Once you get the okay to get pregnant, you should be tested for antiphospholipid and anti-Ro antibodies. The doctor who treats your lupus can recommend an obstetrician who has experience with high risk pregnancies. It is wise to be monitored by your treatment team once a month. Monitoring should include blood work and urine testing to detect any increase in lupus activity as early as possible.

In women who are at risk of transferring anti-Ro lupus antibodies to the baby or of having premature births, regular fetal heart monitoring and ultrasound exams of the fetus and the placenta should be done.

With proper timing and careful management, most women with lupus can have safe and successful pregnancies. Although a lupus pregnancy is still considered high risk, doctors know how to monitor for complications and how to treat complications when they develop. The days of counseling women with lupus not to get pregnant have passed.

by Michelle Petri, M.D., M.P.H

Because lupus is a disease that strikes predominantly young women in the reproductive years, pregnancy is both a practical and a research issue. For most women with lupus, a successful pregnancy is possible. This is an immense change from the 1970’s, when most women with lupus were counseled not to become pregnant. Studies of the immune system in pregnancy are of interest for what they have taught us about the effect of hormones on lupus flares.

Risk of Miscarriage

First, the risks of pregnancy in lupus patients are real and involve both the mother and the fetus. About ten percent of pregnancies currently end in miscarriage. The first trimester losses appear either to have no known cause or to associate with signs of active lupus. Later losses occur primarily due to the antiphospholipid antibody syndrome, inspite of treatment with heparin and aspirin. All women with lupus, even if they do not have a previous history of miscarriage, should be screened for antiphospholipid antibodies, both the lupus anticoagulant (the RVVT and sensitive PTT are the best screening battery) and anticardiolipin antibody.

The classification criteria for the antiphospholipid antibody syndrome were revised last year. There are now two major criteria–vascular thrombosis and pregnancy morbidity. A woman who has had a past venous or arterial thrombosis should be therapeutically anticoagulated during the next pregnancy. A woman who has pregnancy morbidity–one or more late losses, three or more first trimester losses, or severe pre-eclampsia or placental insufficiency–should be treated with prophylactic doses of heparin and a baby aspirin during the next pregnancy. Several clinical trials have indicated that the combination of heparin and aspirin is likely preferable to aspirin alone, although some women do have successful pregnancies on aspirin alone. These pregnancies should be considered high risk, with appropriate fetal monitoring, including ultrasounds to monitor growth and placental development, and biophysical profiles, usually from the 26th week onwards. Many of these babies can be rescued by early C-section when there are signs of severe placental insufficiency. There is no consensus on whether treatment is indicated for the woman with lupus who has antiphospholipid antibodies in her first pregnancy. Many authorities in the field would use a baby aspirin in this situation.

Risk of Preterm Birth and Intrauterine Growth Retardation

An equal, if not more important risk is the risk of preterm birth. Preterm birth in lupus is usually not due to antiphospholipid antibodies, but due to pre-eclampsia and premature rupture of membranes. Risk factors for preterm birth in general include active lupus, high dose prednisone, and renal disease. Maternal hypertension in the second trimester is a good predictor. Overzealous treatment of maternal blood pressure could reduce placental blood flow, and is not recommended. We have not found any risk factors that predict premature rupture of membranes. In addition to being preterm, the baby is also at risk for intrauterine growth retardation (IUGR). We have not found a clinical variable that is predictive of IUGR. In fact, lupus activity, prednisone, and antiphospholipid antibodies are not predictive of IUGR. The best predictor using ultrasound monitoring is an abdominal circumference below the 10th percentile and an estimated fetal weight below the 50th percentile.

Maternal Risks

The most important maternal risk, that of a lupus flare, is actually the most controversial. In prospective studies at both Hopkins and in London, the risk of flare is greater in a pregnant than a non-pregnant woman. However, other centers have not confirmed this. There may be differences in patient selection that account for the different findings. We have found that the hormone prolactin, which rises during pregnancy, is associated with lupus activity during pregnancy. Likely other hormonal influences, especially estrogen, changes in cytokines are involved as well, although these have not been studied. We have found that the type of organ system involvement is different in pregnant vs. non-pregnant patients. In pregnancy we have found an excess of renal and hematologic flares, and fewer arthritis flares.

Some of the risk to the mother is not directly due to lupus. In a case-control study we found that women with lupus were more likely to have multiple complications of pregnancy, including diabetes, urinary tract infections, and pre-eclampsia. For this reason, referral to a high-risk obstetrician is always appropriate. Women on prednisone were more likely to have hypertension and diabetes, as would be expected. The physician caring for a woman with lupus who wishes to become pregnant must review her medications. Prednisone is largely metabolized by the placenta, and is unlikely to cause any fetal malformations, but will increase the risk of diabetes and hypertension in the mother. Some immunosuppressives, such as imuran (azathioprine) have been continued during lupus pregnancy when necessary to control maternal lupus. Cyclophosphamide should never be used during pregnancy because of the high risk of important birth defects. Because of potential teratogenicity, Coumadin should be switched to heparin as soon as the woman knows she is pregnant. ACE-inhibitors, because of effects on fetal kidney development, should be stopped as soon as the woman knows she is pregnant. NSAIDs are usually allowed during the first trimester only, because of potential adverse effects on the fetal ductus arteriosus. Plaquenil (hydroxychloroquine) has a good safety record in lupus pregnancy, and is usually continued if needed to control maternal lupus.

Management and Monitoring

Lupus pregnancy should be timed to coincide with a period of good disease control if at all possible. It does not make sense to taper medication simply because a woman desires pregnancy, because of the likelihood of inducing a flare if medications are reduced too low. General screening tests should include the antiphospholipid antibodies, and also anti-Ro and anti-La. A woman who is positive for these antibodies is at increased risk of congenital heart block in the baby, and monitoring of the fetal cardiac conduction system by 4-chamber fetal cardiac echo should be instituted. We generally monitor the mother monthly during pregnancy and obviously more often if disease activity warrants it. Laboratory monitoring done monthly includes the complete blood count, creatinine, liver function tests, urinalysis, and a 24 hour urine for creatinine clearance and total protein. It is controversial whether serologic tests are helpful during pregnancy. In normal pregnancy the C3 and C4 should rise.

Summary

We are lucky to have a long-term collaboration between our high-risk obstetricians and the Lupus Center at Hopkins that has allowed not only for superb clinical care of the mothers and babies, but also for the prospective database that has led to the studies summarized above. For nearly all mothers, a happy outcome is possible, but we must not forget that we have had one maternal death in our 150 pregnancies and that 7% of the pregnancies are characterized by a severe maternal complication. This is our impetus to continue our research into lupus and its interactions with pregnancy.

Selected Reference

Petri M. Systemic lupus erythematosus and pregnancy. Rheum Dis Clin North America 20:87117, 1994.

Fine LG, Barnett EV, Danovitch GM, et al. Systemic lupus erythematosus in pregnancy. Ann Intern Med 94:667-677, 1981.

Cowchock FS, Reece EA, Balaban D, et al. Repeated fetal losses associated with antiphospholipid antibodies: A collaborative randomized trial comparing prednisone with low dose heparin treatment. Am J Obstet Gynecon 166:1318-23, 1992.

March’s Topic of the Month – Lupus and Pregnancy

During Pregnancy
NHS Choices have an excellent checklist to help you stay organised through your pregnancy. You can print the list to keep track of things you need to do, such as book antenatal classes, tell your work you’re pregnant and think about where you’d like to have your baby. It also includes a number of helpful hyperlinks for additional information – Your Pregnancy To-Do List

Common health problems during pregnancy
Your body has a great deal to do during pregnancy. Sometimes the changes taking place can cause irritation or discomfort, and sometimes you may be concerned. You may experience a number of problems that are unrelated to your lupus and are rarely a need for alarm, but it is important to mention anything that is worrying you to your maternity team.

Some common health problems in pregnancy include;

  • Constipation
  • Cramp
  • Feeling faint
  • Feeling hot
  • Incontinence
  • Frequent urination
  • Skin & hair changes
  • Varicose veins


You can read more about these and other common health problems in pregnancy HERE.

Some common changes due to pregnancy can be mistaken for a lupus flare. All pregnant women can develop knee swelling (effusions) or carpal tunnel syndrome during pregnancy, but if there is a lupus flare your doctor should detect synovitis (inflammation of the joint lining). Pregnant women can develop redness (erythema) of palms and face, which is important to differentiate from a lupus rash.

Lupus flares during pregnancy

Lydia and baby James

The risk of flares during and after pregnancy due to hormonal changes is estimated to be approximately 50%, but most of these will be mild to moderate, affecting skin and joints predominantly rather than kidneys. The risk does vary according to patients’ background; a higher risk of flares is seen in women who have had a flare within six months prior to conception, previously very active disease, and if SLE therapy has been stopped.

It is important to promptly identify and treat flares during pregnancy as they can cause complications to both mother and baby. Complications include a possible increase in pre-eclampsia in mothers and a threefold increase in prematurity (birth before 37 weeks) and IUGR (poor growth of the baby) resulting in stillbirth.

It is important not to mistake active lupus nephritis (kidney disease) for pre-eclampsia. For doctors to diagnose lupus nephritis it is essential that the urine is examined for cells and/or casts. If cells are present, infection of the urine must be excluded. In patients with lupus nephritis proteinuria will normally rise before blood pressure whereas in pre-eclampsia the opposite is true. To assist with diagnosing a renal flare, there will often be other features of active disease in the patient and a change in the blood test results; rising anti-double stranded DNA antibodies and/or low complement. Pre-eclampsia will be more likely if associated with the features of HELLP syndrome (Haemolysis Elevated Liver enzymes Low Platelets).

Virginia and baby Delilah

If new symptoms are due to a lupus flare then it should be treated with steroids and immunosuppression, but if due to pre-eclampsia then steroids may make the blood pressure worse. The ultimate treatment for pre-eclampsia is delivery of the foetus, but anti-hypertensives (treatment for high blood pressure) may be used in the first instance.

One interesting phenomenon that can occur during pregnancy is that some women will actually have decreased lupus activity. This may be related to the fact that the foetus and placenta actually produce steroids such as cortisone and progesterone during pregnancy. These steroids can enter the mother’s bloodstream and help to decrease lupus activity, especially during the second and third trimesters.

“My blood counts and lupus were the best they had been during my pregnancy and I felt the healthiest I had been; no joint pain.”

Thrombosis (blood clots)
All pregnant women are at risk of thrombosis, but especially those with lupus and/or antiphospholipid antibodies. Patients with confirmed antiphospholipid syndrome are likely to require treatment with both aspirin and subcutaneous heparin throughout pregnancy. Patients with recurrent miscarriages in the first trimester may be treated with aspirin. Aspirin may also be commonly used in women with SLE who do not have antiphospholipid antibodies to prevent thrombosis and pre-eclampsia.

Effects of lupus on the baby
Intrauterine growth restriction (IUGR): This refers to poor growth of a baby while in the mother’s womb during pregnancy. The risk of IUGR is increased in women with lupus when compared to the general population, especially in those who have antiphospholipid antibodies, active lupus at conception and high blood pressure during pregnancy. IUGR increases the risk of premature delivery.

Dalila with baby Benjamin

Premature delivery: This is more common in women with lupus and is defined as delivery before 37 weeks. It occurs in 40-50% of SLE pregnancies. The risk of premature delivery increases if the mother has active lupus, kidney involvement, hypertension, pre-eclampsia and high dose steroids (20mg or more of prednisolone). The delivery may be spontaneous or more often induced, due to concerns regarding foetal growth (IUGR), reduced liquor (amniotic fluid around the foetus), foetal distress or rupture of membranes. Once the baby is mature enough to be delivered and survive in a neonatal ward, it is often advised to have an induced birth or caesarean to deliver the baby before it dies in utero, if there are concerns. There are numerous consequences of premature delivery for the foetus. The most serious are breathing problems; mothers will normally be given a course of special corticosteroids (eg. dexamethasone, which can cross the placenta), to promote foetal lung development. Other possible complications include infection, liver problems (jaundice), feeding difficulties, developmental delays or neonatal death (within 4 weeks of birth).

“Both of my sons were born with neonatal lupus. One nearly died. I had many complications throughout each pregnancy, particularly with oligohydramnios (low fluid), which is common in lupus. My second son was born at 37wks due to oligohydramnios. The only fluid he had in the womb was one tiny 2cm pocket under his chin. When he came out the cord was wrapped around his neck twice and he never cried. He was blue and put on oxygen and sent to intensive care. There they told me to say goodbye, as his platelets were dangerously low. After 2 weeks in intensive care he got to go home. He is now almost 12 years old.”

Foetal loss: Foetal loss includes spontaneous abortion before 10 weeks, miscarriages between 10 to 19 weeks and still births from 20 weeks onwards. There is an increased rate of foetal loss and miscarriages in lupus patients. The risk is higher in those with a previous history of foetal loss (especially before 10 weeks), antiphospholipid syndrome, active lupus before or during pregnancy, kidney disease and pre-eclampsia.

Congenital heart block: In approximately 1% of cases anti-Ro and anti-La antibodies can cross the placenta and cause congenital heart block. If these antibodies are present they can only cross the placenta after about 16 weeks and therefore weekly foetal heart monitoring will be undertaken by a midwife/doctor from this point. A few babies will die in utero due to a congenital heart block and the related cardiac complications. The majority who are born do well. However, approximately 30% will require a pacemaker during the first month of life, 30% in the first year, and the remainder will require a pacemaker by the age of 10 to 12 years.

“I was under very close supervision from 16 weeks – weekly heart monitoring for baby, and then 4 weekly for me, due to having anti-Ro/La antibodies in addition to my lupus. It was a tough pregnancy and has continued to be difficult. My baby is now 9 months old. I was closely supported by my obstetrician and rheumatology throughout at a large hospital and this really helped. It was difficult, but I have no regrets; it is the best thing ever being a mummy!!”

Delivery

Rachael with Oliver and Leila

In people with SLE a vaginal delivery should be possible, with pregnancy planning and joint care. A caesarean is normally reserved for emergencies, women who have previously had a caesarean and do not want the trial of vaginal delivery, and women with severe hip disease. However, to reduce the risk of still birth in women with active lupus and/or antiphospholipid syndrome, induction is usually planned at 38-39 weeks.

“I have SLE, antiphospholipid syndrome and lupus nephritis. I thought I couldn’t have a baby but thanks to the LIPS (lupus in pregnancy service) clinic at St Mary’s in Manchester I had my baby in October 2017 by emergency section weighing 4lbs 6oz at 34 weeks. I was monitored every few weeks. It was tough but he’s absolutely fine.”

After Delivery
“I have suffered with SLE since I was 16. I gave birth to a healthy baby boy at 30 years old in 2007 with no complications and my pregnancy went well. I was very blessed despite being a lupus patient. My lupus remained in remission until he was 7 and then I encountered a bad flare where I was hospitalised a few times, but that was 3 years ago and now I am in remission again.”

Breast feeding
Breast feeding has multiple benefits and can reduce the risk of certain health complication for the baby such as;
-Infection
– Atopic dermatitis (eczema)
– Asthma
– Obesity
– Type 1 and 2 diabetes
– Childhood leukaemia
– Sudden infant death syndrome
It can also reduce the risk of health complications for the mother, including;
– Type 2 diabetes
– Breast cancer
– Ovarian cancer
– Postnatal depression

It is safe to breastfeed whilst taking prednisolone, hydroxychloroquine and heparin or warfarin. It is also increasingly accepted that it is safe to breastfeed whilst taking azathioprine as there are only low levels of the active form of the drug in breast milk. For information about the safety of more drugs for breastfeeding, .

You can get lots of great information and advice about breastfeeding from The Breastfeeding Network.

Lupus flares
There is a risk of flares in the postpartum period, even if the disease has been stable before and during pregnancy. It is important to seek medical attention if you experience symptoms of a lupus flare, so your drugs can be appropriately managed.

Blood clots
All women will have an increased risk of blood clots after pregnancy; this risk is further increased in women with lupus (with or without antiphospholipid antibodies). It is essential to keep as active as possible and remain on any recommended blood thinning medication (heparin or warfarin). If you experience any symptoms of a blood clot such as a painful swollen calf or breathlessness with chest pain, you must seek urgent medical attention.

Advice from mums with lupus

Kayleigh with Noah and Effie

“If help is offered to you – take it!”

“Don’t feel you need to be perfect and do everything. Rest and enjoy sitting having cuddles doing nothing. If people offer help, take it. It’s exhausting anyway but much harder with lupus.”

“My advice is don’t get so caught up in taking care of your little one that you ignore signs your body is giving you that something isn’t right. Speak to your doctor straight away. When you are at your best then your care for your child is also at its best! Ask for help from the ones around you and rest as much as you can. It helps to explain to your loved ones how your lupus affects you; giving them understanding of your symptoms can really help.”

“My little one is now 18 months old and full of energy, here are little tips I have learnt along the way. These are things that have helped/worked for me:
1) Try to set up a baby changing area/station both upstairs and downstairs. Make sure it is at a height that is comfortable for you and safe for a baby/wriggling toddler!
2) You can buy car seats that come on a 360 degree ISOFIX base. I have the Joie Spin 360 and it’s amazing; I can turn the seat to face the car door to get my son in and out the car and then turn it so it’s rearward facing. It puts less stress on backs/joints.
3) Car seats/baby carriers are heavy enough without babies in. There is a knack to carrying them more comfortably (take a look at this video).
4) Try and do online food shopping. Food shopping is the last thing on your mind when you are sleep deprived and have a cute little one to cuddle.
5) The saying, “rest when the baby is resting” is near enough impossible until they are a bit older and you make the most of their naps. I have learnt that this means make the most of help offered and don’t be afraid to tell people what would help!
6) If you are going to be inundated with visitors, just put mugs, tea and coffee etc. on the side – let them help and wash their mugs themselves and thank them for being so helpful!
7) Be aware of your triggers for flares and share these with family and close friends. Sometimes you are so wrapped up in your little one that you forget about yourself, but they can notice first.
8) Don’t forget to book your check-up with your GP or rheumatologist if your medication was stopped or changed, as you may need to have this reviewed. Your hormones are going to go crazy and if you’re like me, this can cause a flare.
9) Enjoy your baby, be aware of your body and be open with family.
10) Don’t feel you have to go to every baby club, toddler group and activity in your local area! Find the ones that suit you, your fatigue levels (e.g. are you feeling less achy/fatigued in morning or afternoon) and the baby’s routine!
Finally, congratulations! Being a parent is so much fun (sleep deprivation and tantrums aside)! Lupus is part of our lives but you have a huge distraction that will put a big smile on your face every day.”

“I’ve written a few blog posts on my experiences when I had my daughter two years ago. I hope they’re useful; ‘Great Expectations’, ‘The Greatest Act’.”

Will my child develop lupus?
Neonatal lupus syndrome
In mothers who are positive for anti-Ro and/or anti-La antibodies the baby may develop neonatal lupus syndrome. This syndrome may present as a transient rash, heart block (as described previously), liver abnormalities or low platelets.

The rash is rarely evident at the time of birth; in most babies it requires exposure to ultraviolet light before it occurs. This may occur soon after birth or weeks or months later (on average first becoming apparent six weeks after birth). The rash causes circular-shaped red areas, especially on the face (particularly around the eyes) and scalp. The most important part of treatment is protecting the baby from light and using sunscreen. The rash usually does not scar the skin significantly, but it may leave mild discolouration.

The anti-Ro and anti-La antibodies disappear from the baby’s system within six to eight months. Having neonatal lupus syndrome does not appear to increase a child’s risk of developing SLE later in life.

SLE
There are many genes involved in the development of lupus (only half of which are likely to be inherited from one parent with lupus), and because environmental triggers have to occur during the life of the individual to make the disease appear, it is not common for the children of people with lupus to also have the disease. Most studies have shown that about 1 in 20 people with lupus will have a close relative (mother, aunt, sister, brother; less often father or uncle) with lupus.

Further Reading
LUPUS: A Guide to Pregnancy
Further information about pregnancy in lupus can be found in our booklet, ‘LUPUS: A Guide to Pregnancy’. You can read and download the booklet HERE. If you require a physical copy, contact us to request one, free of charge.

NHS Choices – Your Pregnancy and Baby Guide
Keeping well in pregnancy
Healthy pregnancy diet

Baby Centre
Information covering everything through conception, pregnancy and baby health.

Tommy’s
Tommy’s fund research into miscarriage, stillbirth and premature birth, and provide pregnancy health information to parents.

Premature Babies
The information on this website is for intended parents, friends and families who have given birth to a premature baby and in need of knowledge to support their loved ones.

***Please note that this article is written for informational purposes only and should not be a substitute for professional medical advice or treatment. Do not delay seeking or disregard medical advice based on information here. Always seek the advice of your local family physician or other qualified health professional before starting any new treatment or making any changes to existing treatment. It is also advisable to consult a medical professional before making any changes to diet or starting complementary remedies, which may interact with other medications.***

Thank you so much to everyone who submitted their tips and experiences for this month’s topic. We’re sorry if we weren’t able to use your comment in the article this time.

Miscarriage: What you need to know

Miscarriage can happen for a range of reasons.

Placental problems: If the placenta develops abnormally, blood supply from the mother to the baby is interrupted.

Chromosome problems: Sometimes, a fetus can receive the wrong number of chromosomes, causing abnormal development of the fetus. Miscarriages that occur during the first trimester are mainly related to chromosomal abnormalities in the baby.

Womb structure abnormalities: Abnormally shaped wombs and the development of fibroids (non-cancerous growths) in the womb can put a developing fetus at risk.

Polycystic ovary syndrome (PCOS): This occurs when the ovaries are too big, causing a hormonal imbalance.

Weakened cervix: The cervix is the neck of the womb. When the muscles of the cervix are weak, they can open up too early during pregnancy, resulting in miscarriage.

Lifestyle factors: Habits such as smoking, drinking alcohol, or using illegal drugs can lead to miscarriage.

Underlying health conditions

Share on PinterestPre-existing kidney conditions can increase the risk of miscarriage.

Underlying health conditions among pregnant woman that are associated with miscarriage include:

  • high blood pressure
  • coeliac disease
  • diabetes
  • kidney disease
  • lupus
  • thyroid gland problems
  • HIV
  • malaria
  • rubella
  • chlamydia
  • syphilis
  • gonorrhea

Being overweight or underweight

Obesity is known to increase the risk of first and subsequent miscarriages.

Women with a low body mass index before they become pregnant are also at a heightened risk of miscarriage. Research published in the International Journal of Obstetrics and Gynaecology reported that underweight women were 72 percent more likely to suffer a miscarriage during their first 3 months of pregnancy, compared with women whose weight was healthy.

Be aware of current medications

It is crucial to check with a doctor which medications are safe to take during pregnancy. Medicines that should be avoided (if possible) while pregnant include:

  • retinoids
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • methotrexate
  • misoprostol
  • antidepressants

Limit caffeine

A meta-analysis published in the European Journal of Epidemiology combined data from 60 studies and concluded:

“Greater caffeine intake is associated with an increase in spontaneous abortion, stillbirth, low birth weight, and SGA, but not preterm delivery.”

The World Health Organization (WHO) advises that women who consume more than 300 milligrams (mg) of caffeine per day should reduce their intake.

Miscarriage myths

There are many misconceptions regarding miscarriage. Many people believe that having sex and/or exercising can result in miscarriage, but there is no evidence to suggest this. However, some types of exercise would not be suitable for a woman who is 8 months pregnant. If you are pregnant, ask your doctor which exercises are appropriate.

In many cases, a miscarriage has no apparent cause.

What Causes Miscarriage to Happen?

The first question that many couples ask after experiencing miscarriage is simple: Why? A miscarriage can be an incredibly devastating event with long-lasting emotional repercussions. But one of the most difficult aspects of a pregnancy loss is the complete lack of knowledge surrounding the reasons it happened.

In many cases, particularly with early miscarriages, it can be hard to determine exactly what went wrong. But as the experts see it, it’s amazing how often pregnancy actually goes right. “When you think about a pregnancy, and you think about the beginnings of a human being forming and all the things that have to go perfectly, it really and truly is a miracle when it happens,” says Elizabeth Nowacki, D.O., an OBGYN at St. Vincent Fishers Hospital in Indiana. “You have two sets of genetic material coming together that have to divide, and sometimes things go wrong. The simplest way to think about it is that (miscarriage) is sort of nature’s way of making sure that a human being is compatible with life.”

  • RELATED: Signs of Miscarriage: When Should I Worry?

While many couples who suffer a miscarriage blame themselves, the truth is that they’ve probably done nothing to cause it. Here’s everything you need to know about the reasons for pregnancy loss, with tips for reducing your risk.

Why Do Miscarriages Happen?

According to the American Pregnancy Association (APA), the most common cause of miscarriage is a genetic abnormality in the embryo. But several other factors can also be the culprit, including thyroid disorders, diabetes, immunological disorders, drug abuse, and more.

Chromosomal Abnormalities

Up to 70 percent of first trimester miscarriages and 20 percent of second trimester miscarriages occur because of a glitch in the fetus’s genes, according to the March of Dimes. During fertilization, the sperm and egg each bring 23 chromosomes together to create perfectly matched pairs. This is a complex process, and a minor glitch can result in a genetic or chromosomal abnormality.

  • RELATED: What Is A Genetic Disorder and How Does It Occur?

While some chromosomal abnormalities are compatible with life (such as trisomy 21, the most common type of Down syndrome), other chromosomal disorders are simply not. “Genetically, (development) just stops,” in these cases, explains Dr. Nowacki.

Miscarriages caused by chromosomal abnormalities happen more often in women older than 35. “This is because all the eggs that a woman will ever have are present from birth, and the eggs age with her,” says Stephanie Zobel, M.D., an OBGYN with Winnie Palmer Hospital. “Paternal age may also similarly play a role. The frequency of miscarriage in women below age 20 is around 12 to 15 percent and doubles as the woman approaches age 40. There is nothing that can be done to prevent miscarriage due to a chromosomal abnormality and once a miscarriage has begun there is nothing one can do to stop it.”

  • RELATED: Will Thyroid Disease Affect My Baby?

Thyroid Disorders

Whether it be hypothyroidism (too low) or hyperthyroidism (too high), thyroid disorders can lead to problems with infertility or cause recurrent miscarriages. The Malpani Infertility Clinic’s website explains that in cases where a woman’s thyroid function is low, her body will try to compensate by producing hormones that can actually suppress ovulation. Conversely, a thyroid that is producing too many hormones can interfere with estrogen’s ability to do its job, and it may make the uterus unfavorable for implantation or lead to abnormal uterine bleeding.

Diabetes

“Women with diabetes need to work with their primary care physician or endocrinologist to optimize their sugar control,” Dr. Zobel says. “Uncontrolled insulin-dependent diabetes in the first trimester can lead to increased miscarriage rates and also a markedly increased risk of major birth defects.”

  • RELATED: The 13 Different Types of Miscarriages You Can Have

Physical Complications

A less common cause of miscarriage can be physical problems with the mother, reports Dr. Nowacki, adding that this usually occurs in the second or third trimester. Here are some examples:

  • Uterine fibroids can interfere with implantation or blood supply to the fetus.
  • Some women are born with a septum, an uncommon uterine defect linked to miscarriage.
  • Women may develop bands of scar tissue in the uterus from surgery or second-term abortions; this scar tissue can keep an egg from implanting properly and may hamper blood flow to the placenta.

A doctor can determine uterine defects through specialized X-rays before pregnancy. Most cases can be treated, which may reduce the risk of miscarriage.

Blood Clotting Disorders

Like physical abnormalities, miscarriages from blood clotting disorders (such as Factor V Leiden), are more rare, but they do occur. “I work a lot of people up on blood clotting disorders,” explains Dr. Nowacki, “But they’re just not as common as the other reasons.”

  • RELATED: What Are Your Chances of Miscarriage?

Hormonal Imbalances

Sometimes a woman’s body doesn’t produce enough of the hormone progesterone, which is necessary to help the uterine lining to support the fetus and help the placenta take hold. “Because this is not very common, we usually wouldn’t test for it unless a woman’s had multiple miscarriages,” says Jonathan Schaffir, M.D., an assistant professor of obstetrics and gynecology at Ohio State University College of Medicine. Medication may improve the odds of a successful subsequent pregnancy.

Using Drugs, Alcohol or Tobacco During Pregnancy

Some lifestyle habits—such as drug abuse, alcohol use during pregnancy, and smoking— have been found to cause early miscarriage and pregnancy loss in later trimesters. Optimizing your health leading up to your pregnancy could help reduce your risk of miscarriage.

  • RELATED: What Happens After a Miscarriage?

Immunological Disorders and Chronic Illness

The American College of Obstetricians and Gynecologists thinks that certain autoimmune disorders play a role in miscarriage, especially with recurrent miscarriages. Although the exact role of immunologic factors in miscarriage is “complicated,” according to Dr. Nowacki, she explains that the simplest way to understand it is that “the body just doesn’t accept the pregnancy.”

Some research has found that certain antibodies present could be among the most common causes of recurrent miscarriages. “Lupus is an autoimmune disease that can result in an increased miscarriage rate, often due to anti-phospholipid antibodies that these women often carry,” Dr. Zobel says. “Up to 5 percent of women can also carry these antibodies. Any woman who has had a recurrent miscarriage—greater than three spontaneous miscarriages—unexplained fetal death after 10 weeks, or a preterm birth before 34 weeks is recommended to be tested for anti-phospholipid syndrome. You cannot control whether you have these antibodies. However, if they are present there are treatments available to reduce the risk of miscarriage and pregnancy loss.”

Other chronic illnesses that may be linked to recurrent miscarriages include heart disease, kidney disease, and liver disease. If you have a chronic illness, find an obstetrician experienced in caring for women with your condition.

  • RELATED: Your Guide to Pregnancy After Miscarriage

Miscarriage Risk Factors

Other factors that may increase your risk of miscarriage include:

  • Listeria, a bacteria that may be present in undercooked meats, raw eggs, and unpasteurized dairy products
  • Maternal trauma, such as a car accident
  • Certain medication
  • Advanced maternal age (over 35)
  • Infections such as Lyme disease or Fifth disease
  • Air pollution (A February 2019 study published in Fertility and Sterility found that increased short-term exposure to nitrogen dioxide correlated with a higher risk of miscarriage).
  • High fever (above 102 degrees) during early pregnancy (A high core body temperature is most damaging to the embryo before 6 weeks)

How Do I Decrease My Risk of Miscarriage?

In many cases, miscarriage can’t be prevented, especially when the cause is chromosomal abnormalities that aren’t compatible with life. Even so, doctors advise optimizing your health before you conceive to give your pregnancy the best fighting chance.

“Generally, I advise that women considering pregnancy see their OBGYN to review chronic conditions and medications, begin prenatal vitamins 2 to 3 months prior to trying to conceive, ensure that all their vaccines are up-to-date, review their diet, and ensure they limit or eliminate alcohol and caffeine in their diets,” recommends Dr. Zobel. “Those who use recreational drugs are advised to quit.”

Keep in mind, though, that even if you followed all of that advice, you may not be able to prevent miscarriage from happening to you.

  • RELATED: How to Prevent Miscarriage
  • By Andrea Dashiell and Chaunie Marie Brusie, RN, BSN

In This Section

  • Miscarriage
  • How do I know if I’m having a miscarriage?

What is a miscarriage?

Miscarriage is when an embryo or fetus dies before the 20th week of pregnancy. Miscarriage usually happens early in your pregnancy — 8 out of 10 miscarriages happen in the first 3 months.

Lots of people experience this kind of pregnancy loss. In fact, 10-20% of pregnancies end in miscarriage. But even though miscarriage is common, it can be emotionally difficult. Feelings of grief and loss are normal after losing a pregnancy.

The medical term for miscarriage is “spontaneous abortion.”

What are the causes of miscarriages?

It can be difficult to know exactly why a miscarriage happened, but it’s almost never caused by something the pregnant person did. Normal activities like sex, exercise, working, and taking most medicines do NOT cause a miscarriage. Minor injuries, like falling, don’t generally cause a miscarriage either.

Some things that are known to cause miscarriages include:

  • When the fertilized egg has an abnormal number of chromosomes (genes). This happens at random, so you can’t prevent it or cause it to happen.

  • Certain illnesses, like severe diabetes, can increase your chances of having a miscarriage.

  • A very serious infection or a major injury may cause miscarriage.

  • Late miscarriages — after 3 months — may be caused by abnormalities in the uterus.

  • If you’ve had more than 2 miscarriages in a row, you’re more likely to have a miscarriage.

What are the different types of miscarriages?

There are several types of miscarriages:

  • Threatened miscarriage — You have vaginal bleeding and may have mild cramps, but your cervix stays closed. Half of the time, the bleeding stops and your pregnancy goes on normally. The other half of threatened miscarriages become inevitable miscarriages, and end in pregnancy loss.

  • Inevitable miscarriage — You have increasing bleeding, and your cervix opens. If this happens, there’s no chance for your pregnancy to continue.

  • Incomplete miscarriage — Some of the pregnancy tissue comes out of your uterus, and some stays inside. You may need follow-up treatment to remove the remaining tissue.

  • Complete miscarriage — All the pregnancy tissue comes out of your uterus. You usually don’t need any extra treatment.

  • Missed miscarriage — You have no cramps or bleeding. But ultrasound shows an embryo without a heartbeat or an empty pregnancy sac without an embryo. Usually the tissue passes on its own, but you may need treatment.

Treatments for miscarriage include medicines or procedures that are very similar to those used for abortion. During aspiration, a nurse or doctor puts a thin plastic tube in your uterus and removes the pregnancy tissue with gentle suction.

Miscarriages can be dangerous if they’re not treated. Call your doctor right away if you have any signs or symptoms of miscarriage.

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Lupus and Pregnancy

Having lupus doesn’t mean you can’t have a baby. In fact, many women with this disease give birth to healthy children. The key to a successful pregnancy is knowing how lupus affects the body and keeping the disease under control.

Pregnancy and lupus

Lupus is a type of autoimmune disease. Such diseases cause the immune system to attack the body. Lupus can result in widespread damage to your joints, tendons, and organs. It most often affects the heart, lungs, kidneys, and brain.

Symptoms of lupus may be mild to severe. They also often come and go. These flares can cause fever, rashes, inflammation of the joints, hair loss, and mouth ulcers. The disease can also lead to more serious symptoms. These include kidney disease, nerve problems, and weight loss.

Pregnancy may or may not increase the symptoms of, or change the course of, lupus. Flares may occur at any time in pregnancy or after you have the baby. But they are usually mild. During a flare, your body is more vulnerable to damage from the disease. Plus lupus can make other health problems more likely to happen during pregnancy.

Complications from lupus

Lupus can affect pregnancy at any stage. But flares most often occur in the first trimester. Pregnant women with lupus, especially those having a flare, are at higher risk for complications. These include:

  • Miscarriage

  • Preterm delivery, especially with a lupus flare

  • Early breaking of the amniotic sac (premature rupture of membranes)

  • High blood pressure during pregnancy (preeclampsia)

  • Poor growth of the fetus (intrauterine growth restriction)

  • Stillbirth

  • Infection

  • Low platelets

  • Transfusion

  • Blood clot formation

  • Unplanned cesarean section

Pregnancy loss may be linked to how severe your lupus was when your baby was conceived. Or it might happen if lupus begins during pregnancy. Women with high levels of antiphospholipid antibodies may be at higher risk, too. These antibodies cause abnormal blood clotting. Researchers also think that kidney disease with lupus may play a role in miscarriage.

A rare, temporary condition called neonatal lupus may affect babies of mothers with lupus. This condition can cause a congenital heart block. That’s when the heart beats slower than normal. Neonatal lupus can also cause blood abnormalities and skin rashes on a baby’s face, scalp, chest, and upper back. All of these symptoms usually go away in the first year. A child with neonatal lupus is not usually at risk for lupus as an adult.

Steps to a healthy pregnancy

If you are planning on becoming pregnant, it’s best to see your healthcare provider 3 to 6 months beforehand. Women who have had no flares in the 6 months before conception tend to have the best chance of a good pregnancy outcome. Having your lupus under control can help prevent many health problems.

Because you may have a higher risk for pregnancy loss with lupus, you may need more frequent prenatal visits. Your medicines may also need to be changed. Some lupus medicines, such as methotrexate, may cause birth defects or other problems during pregnancy. Talk with your healthcare provider for the best guidance. Also tell your healthcare provider if you have a history of the following:

  • High blood pressure

  • Kidney disease

  • Blood clots

  • Preeclampsia

  • High levels of antiphospholipid antibodies

During your pregnancy, you may need tests to make sure everything is OK. Blood and urine tests can watch for specific antibodies that help track the severity of lupus. They can also monitor the condition of your liver and kidneys. You may also need tests that check on the health of your baby.

Here are some additional steps you can take to help ensure a healthy pregnancy:

  • See your healthcare provider regularly, at least once every trimester. You may need more frequent visits if you have a flare.

  • Follow your healthcare provider’s instructions about diet and exercise.

  • Take your medicines as directed.

  • Avoid alcohol, tobacco, and drugs.

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