Understandably, the best time to attempt pregnancy is when your disease is stable and you are not experiencing a flare, experts say. For most women with lupus, getting pregnant is no more difficult than it is for other women. When infertility is an issue, medications for lupus – rather than lupus itself – are likely to be responsible. The biggest offender is cyclophosphamide (Cytoxan), an immunosuppressive drug given for severe autoimmune disease, including lupus complicated by severe nervous system disease or kidney disease. “If a woman is over 30, she has about a two-thirds chance of infertility if treated with Cytoxan,” says Michelle Petri, MD, professor in the division of rheumatology at Johns Hopkins University in Baltimore and co-director of the Hopkins Lupus Pregnancy Center. The reason is that Cytoxan can cause premature ovarian failure, which renders a woman irreversibly infertile. However, research shows that the hormonal drug leuprolide (Lupron) may help reduce the risk of sterility in women taking Cytoxan.

Although most other drugs don’t have severe effects on fertility, 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 (See “Arthritis Medications in Pregnancy: What’s Safe, What’s Not”) – 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

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, says Dr. Petri.

Some drugs, such as cyclophosphamide, 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. If experience morning sickness with frequent vomiting during the first trimester, let your doctor know, as this may interfere with your body’s absorption of medications you need.

From now until the end of your pregnancy, there’s a possibility that your disease may flare or become more active, although research results have been inconsistent on just how great that possibility is.

Whether pregnancy affects your lupus or not, there is a chance that lupus may affect your pregnancy – particularly if you have antiphospholipid antibodies. These antibodies, which are present in as many as 30 percent of people with lupus and a much smaller percentage of otherwise healthy people, can cause blood clots in the placenta that can lead to miscarriage. In fact, they may be responsible for as many as 10 percent of all miscarriages. “Although antiphospholipid antibodies are usually associated with pregnancy loss in the second or third trimester, there is a subset of women who have very early loss from antiphospholipid antibodies,” says Dr. Petri.

Treating the antibodies with the blood-thinning medication heparin and aspirin can help prevent clots. If you have lupus it’s essential that you be tested for antiphospholipid antibodies. You should also be tested for two other antibodies, anti-Ro and anti-La (also known as SS-A and SS-B), that can cross the placenta and are associated with inflammation in the baby’s heart, leading to a condition called heart block which interferes with the electrical impulses that tell the heart to beat. (More on that in the second trimester.)

Second Trimester

If you have anti-Ro or anti-La antibodies, this is the time the effects on the baby become evident. Beginning around your 15^th 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 lupus 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 (C-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 with lupus 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

In the rare event that your baby developed heart block during the second trimester, he or she will likely be scheduled for delivery sometime during this 12-week period, especially if dexamethasone didn’t arrest the condition. Your doctor will continue to monitor the baby closely, and if there are signs that the heart is in trouble, he’ll deliver the baby immediately. “You can’t treat the baby for heart failure inside the mother – at least not yet,” says Dr. Lockshin. In some instances, women with lupus experience premature rupture of membranes. In other words, their water breaks before their baby is due. In those cases, labor may occur spontaneously or the doctor may induce labor or perform a C-section, because once the amniotic fluid leaks there is a risk of infection, says Dr. Petri.

Preeclampsia and placental insufficiency continue to be risks in the third trimester. 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

About 25 percent of women with lupus deliver healthy babies prematurely, often by C-section. 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.

If you took corticosteroids for more than two or three weeks during pregnancy, your doctor will likely give you stress doses of corticosteroids during delivery and monitor your baby after delivering to make sure she is producing adequate corticosteroids on her own.

Post-Partum

If your baby came prematurely, he or she may have to spend some time in the neonatal intensive care unit. If your baby was born with heart block, he may need to have a mechanical pacemaker implanted. Fortunately, most babies do well, says Dr. Petri and, except in the case of heart block, a mothers’ lupus probably won’t have a lasting effect on an unborn child.

A more common and much less serious problem for babies of mothers with lupus is a skin rash. “It could be anything, but often it is often spots all over [the baby] or just on the face,” says Dr. Lockshin. For a physician who is not familiar with the problem it may appear to be something more serious and for a woman who doesn’t know to expect it, it can be terrifying. “I make sure my lupus patients know about this in advance. And I tell them if their baby is born with a rash to call me first before they listen to what anyone else thinks it is.” Fortunately, the rash resolves on its own with time without any permanent effects.

If you plan to breast feed be sure to discuss medications with your doctor. Certain medications may also interfere with breast feeding – either because they suppress milk production or pass through the breast milk and are unsafe for the baby.