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Pregnancy and Autoimmune Diseases
Pathology Perspectives

By Ruth Werner

Originally published in Massage Bodywork magazine, December/January 2007. Copyright 2007. Associated Bodywork and Massage Professionals. All rights reserved.

Recently, a bodyworker who specializes in working with pregnant women pointed me in the direction of a largely unexplored topic: the relationship between pregnancy and autoimmune diseases. How does one affect the other, and how can we and our clients make the best possible choices in this context?

As I began to research this topic, I quickly realized there are no simple answers to these questions. Different autoimmune conditions have different implications for women who are pregnant, so no rubber stamping is appropriate here. What follows then is a brief look at autoimmune diseases in general, with specific implications about pregnancy for some of the most common conditions on this list: type 1 diabetes, multiple sclerosis, rheumatoid arthritis, scleroderma, lupus, and Crohn's disease.


Autoimmune Diseases
Autoimmune diseases are situations in which the immune system makes a mistake. Instead of attacking a bacterium, virus, fungus, or other foreign invader, immune system agents (lymphocytes, macrophages, and antibodies) launch an assault against our own tissues. In some cases the confusion can be traced to exposure to certain pathogens that have membrane proteins resembling our own: years later the immune system may be startled to recognize that cells in the lining of the metacarpal-phalangeal joints bear a striking resemblance to Coxsackie virus, for instance, and, with the right genetic prompting, they can mount an attack to quell this dangerous invader--even though there is nothing inherently threatening about healthy synovial membranes. This describes one possible sequence for the development of rheumatoid arthritis, an autoimmune disease that affects more than three million people in the United States.

Autoimmune diseases have a typical pattern of running in cycles of flare and remission. During flares a person might have symptoms limited to one area or tissue type, but many people experience system-wide reactions. This period is usually followed by remission, when symptoms subside. After each flare, however, some function may be permanently lost. The goal with treating these conditions then is to reduce the severity of flares (often with powerful anti-inflammatories and/or immune-suppressing drugs) and to reduce the frequency of flares, which can be accomplished by identifying and avoiding triggers, eating, exercising, sleeping well, and managing stress.

Most autoimmune diseases seem to be related to a combination of genetic predisposition and environmental exposures. They tend to run loosely in families, although they may take different forms among different people. So one person might have rheumatoid arthritis, but her daughter might have multiple sclerosis, and her niece might have lupus. That said, if one family member has an autoimmune disease, the risk of another person in that family developing a problem is only slightly higher than the risk for someone with no family history of this kind of problem.

The pronouns chosen for the scenario above were intentional. Autoimmune diseases affect women roughly three times more often than men. They are the fourth leading cause of disability among women, and the women most at risk are in their childbearing years. This raises questions about the role of fluctuating hormones in the disease process--questions that have yet to be answered for these common, but poorly understood conditions.

The range of autoimmune diseases and the tissues they affect is immense. Some are equally distributed between men and women, and some (notably ankylosing spondylitis) are more common in men. But the large majority of these are much more common in women, and depending on the age group, women with certain conditions may outnumber men by ten to one or more. The box on the right contains a small sampling of known autoimmune diseases organized by the tissues they affect most profoundly. Be aware, however, that several conditions affect multiple tissues: lupus can damage the heart, lungs, and kidneys as well as the joints; scleroderma can damage internal organs as well as the skin; and so on.


Pregnancy and Autoimmune Conditions
Pregnancy adds another complicated layer to the process of many autoimmune diseases. Pregnancy involves radically changing hormone levels, and some conditions that are exacerbated when estrogen levels are high tend to flare during this time. Conversely, pregnancy tends to suppress the immune system, so the mother won't reject the new tissue she is growing. Some autoimmune diseases move into remission during pregnancy, only to rebound with sometimes violent flares when the mother is postpartum.

In the recent past, a woman with a diagnosed autoimmune disease was often counseled not to get pregnant, as the risks to herself and her baby were difficult to manage. Nowadays, with better treatment options and more understanding of how to control the disease process, many women with these conditions can look forward to successful, if somewhat complicated, pregnancies.

What follows is a brief discussion of how a few common autoimmune diseases impact pregnancy, and how pregnancy may likewise influence the course of some conditions.

Type 1 diabetes. This condition involves the destruction of islet cells in the pancreas, leading to a lack of insulin. It is usually diagnosed during childhood. Adult women with type 1 diabetes may have successful pregnancies, but they tend to fare better if their disease is well controlled, with no heart, eye, or kidney problems. Diabetic women must be extremely vigilant about their blood sugar, especially for the first eleven weeks. This is more difficult than it sounds, because blood sugar fluctuates radically with hormonal secretion. Poor blood sugar regulation puts the mother at risk for pregnancy-induced hypertension and eclampsia; it puts the baby at risk for being overly large (requiring a Caesarean section), having Down's syndrome, spina bifida, or other congenital problems.

Most pregnant diabetic women are encouraged to induce labor at thirty-eight weeks, because high blood sugar causes the placenta to mature faster than normal.

Multiple sclerosis. This disease affects myelin in the central nervous system. It has been diagnosed in about three hundred fifty thousand Americans, and young women outnumber young men with the disease by about two to one. Many women find their condition goes into remission while they are pregnant, although they are often hit with a significant flare four to six weeks after delivery. One special caution for pregnant women with multiple sclerosis (MS) is that they may lack the muscular strength to deliver the baby without surgical intervention.

Massage for a woman with MS is fine as long as sensation is present and the therapist avoids rapid and extreme changes in the ambient temperature; people with this condition often don't tolerate extreme hot or cold temperatures well.

Rheumatoid arthritis. This condition targets synovial membranes. The metacarpal-phalangeal joints are especially vulnerable, but toes and ankles may be involved as well. During a flare a person with rheumatoid arthritis (RA) may also have inflammation in the lungs, heart, liver, and blood vessels. However, like MS, RA tends to go into remission during pregnancy.

Scleroderma. Scleroderma is an autoimmune disease that attacks the lining of small blood vessels, causing scar tissue to accumulate close to the skin. Systemic versions of the disease can cause a similar problem in internal organs. A combination of pregnancy and scleroderma isn't common, because this disease is typically diagnosed between age forty and fifty--a time when most women have completed their childbearing. About three hundred thousand people have been diagnosed with scleroderma in the United States.

When a woman with scleroderma does get pregnant, the possible complications are serious. About 18 percent of these pregnancies end in miscarriage; 26 percent end in preterm birth. The joint pain and gastroesophageal reflux disorder associated with scleroderma tend to get worse during pregnancy. On the other hand, episodes of Raynaud's phenomenon (when the hands or feet go through temporary but extreme bouts of vasoconstriction followed by vasodilation) tend to subside. One risk unique to scleroderma is that the uterus and cervix may lose flexibility, requiring a C-section. Many women with scleroderma experience a flare a few weeks after delivery.

Lupus. Systemic lupus erythematosus (SLE) involves an autoimmune attack against a variety of tissues, but it especially focuses on connective tissues. People with SLE are likely to develop severe arthritis, and many are at risk for renal failure as inflammatory chemicals accumulate in the kidneys. One form called discoid lupus only affects the skin, but many people who start with discoid lupus go on to develop the systemic form. About one million people in the United States have been diagnosed with some form of lupus, and depending on the age group, women outnumber men by about nine to one.

Lupus is usually controlled with steroidal hormones. These drugs carry some risks to a developing fetus, but if the doses can be kept low, the risks are considered to be reasonable. Lupus carries a high risk of miscarriage, as it can promote blood clots that may interfere with placenta function. Babies born to women with lupus have congenital heart problems more often than the general population, and they sometimes develop a neonatal form of the disease, but this typically clears up within about six months.

Crohn's disease. Crohn's disease is an autoimmune attack on disconnected patches in the digestive tract. It usually begins at the ileum--the last segment of the small intestine. It involves inflammation, abscesses, fistulae, ulcerations, and the chance of perforations and peritonitis. Some people with Crohn's disease develop large ulcerations on their legs during flares. Many people with Crohn's disease have repeated surgeries to remove sections of the GI tract that have become obstructed with scar tissue or otherwise seriously damaged. Women are usually counseled to wait for a year after abdominal surgery before starting a pregnancy.

Some women with Crohn's disease have problems getting pregnant, but once the process has begun, and as long as the mother doesn't have a flare early in the process, the risk of miscarriage is fairly low. C-sections are common for women with Crohn's disease, especially if they have a history of abscesses or fistulae at the rectum near the vagina. Like most other autoimmune diseases, many women with Crohn's disease experience a flare in the weeks following giving birth.


Massage and the Pregnant Client with an Autoimmune Disease
Pregnancy puts an unusual demand on a woman's ability to adapt to changing environments. Autoimmune diseases, some of which may be more active during this time, place additional stresses on the system. To make things even more challenging, the stress of knowing she is having a high-risk pregnancy can also increase a woman's risk of miscarriage.

Bodywork or massage in these contexts can be a wonderful gift, but the goals of the bodyworker must be realigned away from challenging homeostatic processes to simply supporting them. This can involve adjustments in the frequency or duration of sessions, the positioning of the woman (side-lying is generally considered to be the safest option), and certainly in the depth and intrusiveness of the modalities used. Abdominal work that might be safe for a woman with an uncomplicated pregnancy may be threatening for a woman with a more precarious situation, and outside of gentle stroking it should be avoided.

Massage therapists working with this population should be in communication with the rest of the client's healthcare team, specifically to gather information about circulatory health, the risk of blood clots, and any changes in sensation or other function that may influence choices about the best modalities. In this way the worst risks of prenatal massage can be avoided, while the best benefits (reduced stress, reduced stress-related hormones, improved sleep, less pain and fatigue, the list goes on and on ...) can be enjoyed by mother and baby alike.

Ruth Werner is a writer and educator for massage therapists. She teaches several courses at the Myotherapy College of Utah and is approved by the NCTMB as a provider of continuing education. She wrote A Massage Therapist's Guide to Pathology (Lippincott, Williams Wilkins, 2005), now in its third edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.


Resources
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Does Pregnancy Hold the Key to Autoimmune Diseases? 2006. Society for Women's Health Research. http://health. yahoo.com/topic/pregnancy/afterdelivery/article/
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Evers, Inge M. Risk of Complications of Pregnancy in Women with Type 1 Diabetes: Nationwide Prospective Study in the Netherlands. BMJ 2004;328:915 (17 April), doi:10.1136/ bmj.38043.583160.EE (published April 5, 2004). http://bmj.bmjjournals.com/cgi/content/abstract/328/7445/915 (accessed summer 2006).
Jimenez, Sergio. Scleroderma. 2006. WebMD. www.emedicine.com/ med/topic2076.htm (accessed summer 2006).
Multiple Sclerosis and Pregnancy. 2006. Aetna InteliHealth Inc. www.intelihealth.com/IH/ihtIH/WSIHW000/8320/21154/31523.html?d=dmtContent (accessed summer 2006).
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