Pregnancy With Autoimmune Disease: What New Research Reveals About Managing Rheumatoid Arthritis and Lupus

Women with autoimmune diseases like rheumatoid arthritis and lupus can have successful pregnancies, but it requires careful coordination between their rheumatology and obstetric care teams. Recent research shows that pregnancy triggers profound immune changes in the body that can either improve or worsen autoimmune disease activity, depending on the specific condition. The key is timing conception during periods of disease stability, continuing safe medications, and monitoring closely throughout all three trimesters.

How Does Pregnancy Change the Immune System?

During a normal pregnancy, the body undergoes a remarkable immune transformation to protect the developing fetus. This isn't simply a weakening of immunity—it's a sophisticated reprogramming. The immune system shifts toward what researchers call "Th2-skewed cytokine signaling," meaning it produces different types of immune chemicals that promote tolerance rather than inflammation. Additionally, the body expands regulatory T cells, which are specialized immune cells that calm down overactive immune responses. At the maternal-fetal interface (where the mother's tissue meets the placenta), the trophoblast—the outer layer of the placenta—actively sends immunomodulating signals that help the mother's body accept the fetus as "self" rather than a foreign invader.

These adaptations are powerful enough to influence autoimmune disease activity. However, the effect isn't uniform across all conditions. Some women experience improvement in their symptoms, while others face flares—periods of increased disease activity—during pregnancy.

Which Autoimmune Conditions Improve or Worsen During Pregnancy?

The three most common rheumatologic conditions affecting pregnancy are rheumatoid arthritis (RA), systemic lupus erythematosus (SLE, commonly called lupus), and spondyloarthritis (SpA). Each responds differently to pregnancy's immune changes.

Rheumatoid arthritis shows the most favorable pattern. Research demonstrates that a significant portion of women with RA experience improvement in their joint pain and swelling during pregnancy, a phenomenon driven by those immune tolerance mechanisms. However, this improvement isn't guaranteed for everyone, and disease activity can fluctuate throughout the nine months. Some women maintain stable disease, while others may experience flares, particularly if they discontinue their medications.

Lupus presents a more complex picture. While some women see improvement, others experience worsening of their condition during pregnancy. Lupus can affect pregnancy outcomes more directly than RA—particularly in women with lupus nephritis (kidney involvement) or antiphospholipid antibodies (immune proteins that increase clotting risk). The good news: research spanning 40 years shows that pregnancy loss rates in lupus patients have decreased significantly over time, suggesting that modern management strategies are working.

Spondyloarthritis, which includes conditions like ankylosing spondylitis, can also flare during pregnancy in some patients, though the pattern varies individually.

What's the Strategic Approach to Planning Pregnancy With Autoimmune Disease?

Doctors now follow a three-part framework for managing pregnancy in women with autoimmune conditions:

• Preconception Counseling: Women should work with their rheumatologist before becoming pregnant to achieve sustained disease remission or low disease activity. This timing dramatically reduces the risk of flares during pregnancy and improves outcomes for both mother and baby.
• Medication Continuity: Many disease-modifying therapies are safe to continue during pregnancy and lactation. The 2024 European League Against Rheumatism (EULAR) updates provide clear guidance on which drug classes are acceptable, allowing women to maintain disease control without compromising fetal safety.
• Trimester-Specific Monitoring: Close follow-up appointments throughout pregnancy—adjusted for each trimester—help catch disease flares early and adjust treatment as needed to protect both mother and baby.

The framework emphasizes what researchers call "harmonizing maternal health with fetal well-being." In other words, the goal isn't to eliminate all medications for the sake of pregnancy; it's to maintain the mother's health in a way that also supports a healthy pregnancy.

What Specific Risks Should Pregnant Women With Lupus Know About?

Lupus poses particular challenges during pregnancy because the disease can directly affect pregnancy outcomes. Women with lupus have historically faced higher rates of pregnancy loss, premature delivery, and low birth weight babies. However, several factors predict better outcomes. Women who achieve complete remission of lupus nephritis before pregnancy have significantly better outcomes than those with active kidney disease. Similarly, controlling antiphospholipid antibody levels—measured through blood tests during pregnancy—reduces the risk of blood clots and pregnancy complications.

Early identification of risk factors matters enormously. Research has identified specific predictors of poor outcomes in lupus pregnancies, allowing doctors to intensify monitoring and treatment for high-risk patients from the start.

How Does Disease Activity During Pregnancy Affect the Baby?

In rheumatoid arthritis, maternal disease activity during pregnancy correlates with birth weight. Studies show that women with higher disease activity during pregnancy are more likely to deliver babies with lower birth weight compared to women who maintain low disease activity. This association underscores why achieving disease control before conception and maintaining it throughout pregnancy matters for fetal development.

The relationship between maternal autoimmune disease and fetal outcomes highlights the importance of the interdisciplinary approach. Rheumatologists, obstetricians, and maternal-fetal medicine specialists must coordinate care to balance the mother's need for disease control with fetal safety.

For women with autoimmune conditions considering pregnancy, the message is encouraging: modern medicine has made significant strides in enabling safe, healthy pregnancies. The key is planning ahead, maintaining open communication with your healthcare team, and understanding that your specific condition will require a tailored approach. With proper management, most women with rheumatoid arthritis, lupus, and spondyloarthritis can have successful pregnancies and healthy babies.