Many of my clients with Lyme disease want to get pregnant or were pregnant before their Lyme was discovered. Here is what we discuss regarding
- the odds of transmission,
- antibiotics to prevent transmission during pregnancy,
- expectations for the mother’s Lyme disease during and after pregnancy, and
- treatment or testing decisions for the baby or an older child.
Evidence and Opinion
There is limited science to guide decision-making in these areas. My advice is an informed opinion based on this limited science, observations from my years of practice, and anecdotal evidence (observations) from other Lyme literate medical doctors (LLMDs). In this article I review the science that exist and my observations from my practice.
Transmission Risk and Prevention
There are numerous documented reports of Lyme transmission in pregnancy. However, there is not a single study following large numbers of women to determine the actual Lyme transmission rate. A review was conducted by T Gardner of numerous small studies where the pregnancy outcome was noted (only 263 cases). Her findings were published in Infectious Diseases in the Fetus and Newborn Infant 5th ed 2001. She found 66 infants or fetuses had Lyme. This suggests a 25% transmission rate in pregnancy. However the reality is the transmission rate for all pregnant women could be much higher or lower than this because of the small number of pregnancies actually studied.
Fortunately it appears that transmission is stopped when a pregnant women with Lyme takes antibiotics. In her presentation to the International Lyme and Associated Diseases Society meeting in 2010 Sara Chissell MD notes pediatrician Charles Ray Jones MD followed 160 pregnant women with Lyme in his practice and 5% of children had laboratory evidence of Lyme transmission. Joseph Burascanno MD in his treatment guidelines reports a pregnancy registry was maintained for 11 years beginning in the late 80s by the Lyme Disease Foundation in Connecticut. It showed no transmission of Lyme when pregnant women with the illness took antibiotics during pregnancy.
Based on the above, I advise my female patients with active Lyme that pregnancy is safe with a nearly 0% risk of transmission as long as antibiotics are taken throughout the pregnancy. The oral antibiotics I suggest are amoxicillin, cefuroxime, cefdinir or azithromycin as single agents. If there is risk of bartonella transmission during the pregnancy I suggest azithromycin taken alone or in combination with one of the other three antibiotics. Doses I recommend are amoxicillin 500mg 2 pills 3 times a day, cefuroxime 500mg 1 pill 2 times a day, cefidinir 300mg 2 times a day, and azithromycin 500mg 1 time a day. In my opinion and experience these antibiotics are safe for the developing baby and the mother as well.
But what about a woman who has completed a Lyme disease treatment? This is a tricky subject. In busy Lyme disease practices such as mine, many who complete treatment for chronic Lyme go on to relapse at some point. This suggest most with treated chronic Lyme still harbor the germ. Even when a woman who had Lyme disease is well it is possible the infection could be transmitted during pregnancy. On this subject there is absolutely no science to guide me. And there is limited to non-existent anectdotal evidence as well. So I do not know if there is a risk of transmission in this situation, but there could be. Because of this I do offer preventive antibiotics in these situations after having a thorough discussion about the risk and benefits of treatment. I believe a decision to treat should always be made considering the wishes of the patient who knows the risk of treatment whenever the science is extremely limited about outcomes.
Health of the Mother
In my practice most pregnant woman have improvements in their Lyme disease symptoms during pregnancy. (One of my patients who has had a number of pregnancies notes she wishes she could just stay pregnant.) This may be due to decreased inflammatory reactions by the immune system in the hormonal environment created by pregnancy. However there are no human studies to show this. There are very limited animal studies that show the decreased inflammation response. Note even though inflammation is decreased the Lyme infection may not be under better control.
Unfortunately, most women with Lyme do have worsening of their Lyme symptoms compared to pregnancy after delivery. I believe this could be due to a combination of the Lyme infection and the physical demands of caring for a newborn infant.
Treatment of An Infant or Child Whose Mother Had Lyme Disease During Pregnancy
In the newborn period I base my decision to treat a baby based on whether he or she has Lyme disease or laboratory evidence of the infection without disease. In my opinion and those of other LLMDs any child in the newborn period who has Lyme disease based on symptoms with or with positive testing should be treated. I also recommend treatment for the newborn with positive testing who does not have symptoms for a minimum of 6 months to prevent Lyme disease. There are no human studies to guide my decision-making here. There is anecdotal evidence suggesting newborns with positive testing without symptoms who are treated for 6 months do not develop Lyme disease.
What about children whose mothers discover they had Lyme disease well after the pregnancy? This is a frequent question I am asked. Should I have my child tested for Lyme? I usually do not advocate testing of the healthy child. Even if testing is positive, I would not treat in this situation. I believe the majority of people, children or adult, who have Lyme infection do not develop Lyme disease. Lyme disease is the medical mess that sometimes results from a Lyme infection but does not always occur. Our immune systems do have the ability to get rid of the infection or to keep it under control. There are no animal or human studies that show what percent of the time Lyme disease develops in those with positive testing.
There are no outcome studies to show what happens when antibiotics are given to the healthy child who does not have symptoms of Lyme disease. It is possible using antibiotics in this situation could trigger a more virulent form of the Lyme germ or treatment resistant infection causing Lyme disease to develop down the road. I take an “if it is not broken do not fix it” approach in these situation.
One other point it is possible to have false positive testing too. The ability of a test to truly predict a disease is increased if symptoms of the illness are present.
However, if a child has symptoms of Lyme disease and his or her mother had Lyme disease during the pregnancy than testing should be done. And if it is determined the child has Lyme disease based on symptoms, figuring out first that some other medical condition is not causing his or her symptoms, and the outcomes of Lyme testing, then treatment should be started.
by Marty Ross MD