Since most newly diagnosed systemic scleroderma patients are women of child-bearing age, the issue of pregnancy and childbirth is an important topic for many scleroderma patients. Historically, pregnancy in scleroderma patients was considered high risk, and physicians typically recommended that scleroderma patients avoid pregnancy or consider elective abortions if pregnancy occurs.
However, it is now clear that, while still high risk compared to a normal pregnancy, most scleroderma patients can have successful pregnancies if closely monitored and carefully managed.
Fertility and Overall Outcome
Scleroderma appears to have little effect on fertility. There does appear to be an increased frequency of premature deliveries and lower weight infants as compared to the normal population.
Miscarriage risk in scleroderma appears to be associated with the presence of antiphospholipid antibodies (APS). While APS antibodies are associated with several diseases and are sometimes found in healthy patients as well, several studies have looked at the prevalence of APS antibodies and have found these antibodies are present in scleroderma patients at a much higher rate than are found in the general population – up to 57% in some studies but typically in the 30% to 42% range vs. 2% to 4% in the general population (Mubarak et al. 2013). APS antibodies cause blood to flow improperly and can lead to clotting problems, which can be especially problematic during pregnancy. APS antibodies, when present, are a major cause of recurrent miscarriages and pregnancy complications. While the complications of APS syndrome can usually be managed effectively, it is important that patients with scleroderma be tested for APS antibodies so appropriate interventions can be started at the beginning of pregnancy to minimize later complications.
Effects of Scleroderma on Pregnancy
Raynaud’s symptoms usually improve during pregnancy, especially in the later stages when there is increased blood flow to support the developing fetus. While reflux is common in all pregnancies, since reflux disease is common in scleroderma, the severity may be worse than usual during a scleroderma pregnancy.
The greatest danger during a scleroderma pregnancy is the occurrence of renal crisis that can be life-threatening. Any pregnant scleroderma patient must be closely monitored to detect this. Normally, ACE inhibitors (standard treatment for scleroderma renal crisis) would not be recommended during pregnancy because of an increased risk of fetal abnormalities. However, in this case the risk to the mother may require their usage in the event of renal crisis.
Generally, it is recommended that pregnancy be avoided during the early stages of rapidly progressing diffuse scleroderma because of increased risk of renal and cardiac problems that are common even without pregnancy. Once the disease has stabilized after this initial rapid progression, pregnancy risk is lowered. However, in all cases, scleroderma pregnancies should be considered high risk and should involve a multidisciplinary team in the management of the pregnancy.
Effects of Pregnancy on Scleroderma
Following a successful scleroderma pregnancy, Raynaud’s symptoms and reflux symptoms generally return to pre-pregnancy levels. For limited scleroderma patients, there appears to be little or no overall post-partum effect on scleroderma symptoms. However, for diffuse patients, there are a few reports of increased blood pressure causing worsening of kidney disease and increased lung problems. However, given that diffuse scleroderma tends to be progressive at a significantly faster rate than limited scleroderma, it is difficult to determine if this is directly related to the pregnancy or is more a manifestation of normal progression of the disease.