Scleroderma and Pregnancy
Get the information you need to plan for pregnancy.
If you have recently been diagnosed with scleroderma and would like to start a family, the experts’ best advice is to wait. “No woman with scleroderma should attempt to get pregnant within three years of diagnosis, because disease complications [including hypertension and kidney damage] are likely to show up within the first three years of the disease and could complicate a pregnancy,” says Virginia Steen, MD, professor of medicine at Georgetown University Medical Center in Washington, D.C. “If you get through these critical early years of the disease without complications, it’s probably safe to have a baby,” she says.
First, however, it is important to speak with your doctor about your medications.
Aside from cyclophosphamide (Cytoxan), which can cause ovarian failure, most drugs used for scleroderma don’t have severe effects on fertility; however, some can affect an unborn child from the very earliest days of pregnancy. Because the effects of certain drugs can remain in the body for a period of time after you stop taking them, ideally, you should work with your doctor to taper off harmful medications – and perhaps switch to less risky medications – for at least a few months before you try conceive.
Before you get pregnant is also the best time to speak to your doctor about prenatal vitamins and supplements of folic acid, which can help reduce the risk of certain birth defects. Your doctor may also recommend a calcium and vitamin D supplement, but will probably advise that you avoid any over-the-counter herbal remedies.
First Trimester with Scleroderma
Drugs continue to be a concern in the first trimester and throughout pregnancy. If you didn’t discuss medications with your doctor before you got pregnant, now is the time.
Some drugs, such as Cytoxan, can cause birth defects. Others, such as methotrexate, can cause miscarriages. If you’re taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, your doctor may let you continue to using them – at least for a while. The greatest risk of these drugs comes later in pregnancy, when they may interfere with labor, affect amniotic fluid production or cause excessive bleeding during delivery. If you need medications to keep your disease under control, your doctor may put you on a corticosteroid, such as prednisone, that reduces arthritis inflammation but crosses through the placenta only minimally.
There is some evidence that scleroderma may become more active during pregnancy, but this is debated. Dr. Steen has found the disease generally does not get worse during pregnancy, provided the woman has waited past the first three years of diagnosis to become pregnant – the most critical period in the development of complications, whether a woman is pregnant or not. On the other hand, scleroderma can affect later stages of pregnancy.
Second Trimester with Scleroderma
If you have scleroderma and worry that your stiff skin won’t accommodate your expanding belly, that’s one worry you can put aside. Dr. Steen, who says she has never seen a woman whose skin interfered with or was damaged by pregnancy.
Likewise, concerns about Raynauds’s phenomenon – a common complication of scleroderma and some other arthritis-related diseases in which the blood vessels to the extremities go into spasms in response to cold temperatures or stress – can be laid to rest. Raynaud’s often eases as your blood flow increases in pregnancy. Heartburn, on the other hand, will probably get worse during pregnancy.
If you have anti-Ro or anti-La antibodies, this is the time the effects on the baby become evident. These antibodies, also known as SS-A and SS-B, can cross the placenta and are associated with inflammation in the baby’s heart, leading to a condition called heart block which interferes with electrical impulses that tell the heart to beat. Beginning around your 15th week of pregnancy, your doctor will monitor the fetus by fetal echocardiogram either monthly or weekly, depending on your antibody levels (called titers) and medical history. Echocardiogram is a procedure that uses ultrasound waves to view the action of the heart as it beats. If heart block is detected, your doctor will probably prescribe dexamethasone, a corticosteroid medication that crosses the placenta to help minimize the inflammation. Your doctor will continue to treat and monitor you throughout your pregnancy, because heart block may necessitate early delivery of the baby. If your baby hasn’t developed heart block by week 25, it’s not going to happen, says Michael Lockshin, MD, professor of medicine and Ob/Gyn at Weill Cornell Medical College and director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York.
Late in the second trimester, women with scleroderma are also at risk of toxemia (also called preeclampsia) – high blood pressure that develops during pregnancy and is accompanied by excessive fluid retention and protein in the urine. While toxemia is a risk late in pregnancy for any woman, women with antiphospholipid antibodies tend to get toxemia earlier.
Recent research has also shown that women with preeclampsia are likely to have a mutation in at least one of three genes associated with a rare disorder called hemolytic uremic syndrome, which triggers a potentially fatal, out-of-control immune response. This finding suggests that doctors may one day be able to screen women for risk of preeclampsia and that an experimental drug for hemolytic uremic syndrome could potentially be useful in the treatment of preeclampsia.
In the meantime, treatment for preeclampsia is primarily bed rest. The problem doesn’t resolve until the baby is born, so your doctor may have to deliver the baby by Cesarean-section as soon as it is mature enough to survive outside the womb, as late as possible and not before the 25th week of pregnancy.
Another problem that can occur in scleroderma is placental insufficiency, a condition in which blood flow through the placenta isn’t sufficient to supply the necessary nutrients to the baby. The reason may be thickening or blockage of the blood vessels in the placenta and the result may be a low-birth weight baby.
Third Trimester with Scleroderma
During the final months of pregnancy preeclampsia and placental insufficiency continue to be risks for women with scleroderma. If you have preeclampsia, you’ll continue to stay on bed rest – possibly in the hospital – for the rest of your pregnancy. Placental insufficiency may lead to premature labor and delivery. Either of these conditions may necessitate an early delivery.
Labor and Delivery with Scleroderma
Although women with scleroderma may be concerned that a lack of tissue “stretchability” may present a problem during delivery, Dr. Steen says that is very rarely the case. In the event that a woman with scleroderma does have to have to a have a C-section, both doctors and patients have worried about how the incision will heal. Dr. Steen, however, has found no increased healing problems among those patients.
Infection is a possibility after any delivery. If you are taking medications that suppress your immune system, however, infection is more likely. Most infections can be cleared up fairly easily and quickly with available antibiotics.