Navigating Pregnancy with Autoimmune Diseases: Challenges and Progress

Pregnancy is a complex journey, especially for individuals with autoimmune diseases. These conditions pose distinct challenges, balancing disease management with pregnancy health. However, recent advancements offer hope and new strategies to navigate this intricate path.

Autoimmune diseases like systemic lupus erythematosus (SLE) and rheumatoid arthritis present unique challenges during pregnancy. The same immune dysregulation that complicates these diseases also affects pregnancy outcomes, linking inflammation control to improved maternal health.

While some conditions like RA often improve during pregnancy, others such as SLE may flare, making preconception disease control critical. The disruption of immune balance affects both maternal and fetal health, particularly increasing risks of complications such as preeclampsia, pregnancy loss (including miscarriage), and fetal growth restriction. Understanding these links is crucial for tailored management strategies.

Emerging evidence and care models highlight the role of targeted therapies and enhanced interdisciplinary collaboration in managing autoimmune diseases during pregnancy, and these insights are informing updates to care pathways.

For those experiencing heightened symptoms, the use of safe medications is vital. Hydroxychloroquine is generally recommended to continue during pregnancy and breastfeeding, while methotrexate is contraindicated before conception and throughout pregnancy, with a preconception washout period advised.

Because medication adjustments and disease quiescence are often needed before conception, managing pregnancy with these conditions requires thoughtful planning. Early preconception counseling allows for optimization of maternal health and informed decision-making, supporting a comprehensive approach to care.

Care during pregnancy benefits from a team-based approach that connects the dots from preconception counseling to delivery and postpartum support. Building a shared plan—covering flare monitoring, blood pressure surveillance, lab schedules, and delivery planning—helps align patient goals with clinical safety, and ensures that updates to medications or testing are communicated across specialties.

Throughout pregnancy, disease activity should be reassessed at regular intervals. When disease is quiescent, visit cadence may be routine; during active periods or in conditions with higher pregnancy risk (such as SLE with renal involvement), closer monitoring and coordinated adjustments become essential. These decisions build directly on the mechanistic links between inflammation control and maternal-fetal outcomes described earlier.

Postpartum is a pivotal transition. Hormonal shifts, sleep disruption, and medication changes can precipitate flares, so proactive plans for postpartum monitoring, lactation-compatible medications, and contraception are key. Reconnecting the care team during this window supports safe medication titration and early detection of complications such as hypertension or delayed wound healing.

Despite innovations, gaps remain in fully addressing pregnancy challenges for those with autoimmune conditions, underscoring the need for continued research and collaboration across medical specialties. As our understanding grows, so too do the opportunities for improved outcomes, both for pregnant people and their infants.

Key Takeaways:

• Risk-stratify by disease and activity: plan conception when disease is quiescent and tailor monitoring to condition-specific risks.
• Build a coordinated care pathway: routine communication between rheumatology and obstetrics improves safety and supports shared decisions.
• Use medication decision frameworks: prefer agents with established pregnancy and lactation compatibility, and stop teratogens with appropriate washout.
• Time interventions: prioritize preconception counseling for medication adjustments and vaccination review, and adjust plans throughout pregnancy and postpartum.