What is the management of Systemic Lupus Erythematosus (SLE) in pregnancy?

From the Guidelines

Pregnancy in women with Systemic Lupus Erythematosus (SLE) should ideally be planned during periods of disease remission for at least 6 months before conception, and hydroxychloroquine (200-400 mg daily) should be continued throughout pregnancy to reduce flare risk and improve outcomes, as recommended by the most recent guidelines 1. The management of SLE during pregnancy involves careful planning, monitoring, and medication management to minimize risks to both the mother and the baby.

Key Considerations

• Medications that are safe during pregnancy include hydroxychloroquine, low-dose aspirin, prednisone, azathioprine, and tacrolimus, as supported by recent studies 1.
• Medications that must be discontinued before conception include mycophenolate mofetil, cyclophosphamide, and methotrexate due to their teratogenic effects.
• Regular monitoring should include monthly visits with rheumatology and high-risk obstetrics, laboratory monitoring of complete blood count, renal and liver function, urinalysis, complement levels, and anti-dsDNA antibodies.
• Ultrasound monitoring should be performed every 4-6 weeks starting at 20 weeks to assess fetal growth.
• Women with anti-Ro/SSA or anti-La/SSB antibodies need fetal echocardiograms between 16-28 weeks to monitor for congenital heart block.

Medication Management

• Hydroxychloroquine should be continued throughout pregnancy if possible, as it reduces flare risk and improves outcomes 1.
• Low-dose aspirin (81 mg daily) is recommended starting in the first trimester to reduce preeclampsia risk, as supported by the American College of Obstetricians and Gynecologists and US Preventive Services Task Force 1.
• For mild to moderate flares, prednisone (5-15 mg daily) can be used, keeping doses as low as possible to minimize complications.
• Azathioprine (1-2 mg/kg/day) is considered safe if immunosuppression is needed.
• For severe disease, intravenous immunoglobulin or tacrolimus may be considered.

Monitoring and Follow-up

• Regular monitoring should include monthly visits with rheumatology and high-risk obstetrics.
• Laboratory monitoring should include complete blood count, renal and liver function, urinalysis, complement levels, and anti-dsDNA antibodies.
• Ultrasound monitoring should be performed every 4-6 weeks starting at 20 weeks to assess fetal growth.
• Women with anti-Ro/SSA or anti-La/SSB antibodies need fetal echocardiograms between 16-28 weeks to monitor for congenital heart block.
• Postpartum, patients should be monitored closely for 6-12 weeks as this is a high-risk period for disease flares.

From the FDA Drug Label

Systemic Lupus Erythematosus: Pregnant women with systemic lupus erythematosus, especially those with increased disease activity, are at increased risk of adverse pregnancy outcomes, including spontaneous abortion, fetal death, preeclampsia, preterm birth, and intrauterine growth restriction Passage of maternal auto-antibodies across the placenta may result in neonatal illness, including neonatal lupus and congenital heart block. Data from published epidemiologic and clinical studies have not established an association with hydroxychloroquine sulfate use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes

The management of Systemic Lupus Erythematosus (SLE) in pregnancy involves considering the risks of untreated or increased disease activity from SLE, which can lead to adverse pregnancy outcomes.

• Key considerations include:
  • Disease activity: Increased disease activity is associated with a higher risk of adverse pregnancy outcomes.
  • Medication use: Hydroxychloroquine sulfate use during pregnancy has not been established to have an association with major birth defects, miscarriage, or adverse maternal or fetal outcomes.
  • Monitoring: Pregnant women with SLE should be closely monitored for signs of increased disease activity and adverse pregnancy outcomes. Based on the available data, hydroxychloroquine sulfate can be used in pregnant women with SLE, but the benefits and risks should be carefully considered, and patients should be encouraged to register with the pregnancy exposure registry 2.

From the Research

Management of Systemic Lupus Erythematosus (SLE) in Pregnancy

The management of SLE in pregnancy involves a multidisciplinary approach, including preconception counseling, medication optimization, and close surveillance 3, 4, 5, 6, 7.

• Preconception Counseling: Preconception counseling is essential to discuss the risks and benefits of pregnancy, as well as to optimize disease control and medication regimens 3, 5, 6.
• Medication Optimization: Medications such as hydroxychloroquine (HCQ) are recommended to be continued during pregnancy, as they appear to be protective against flares, neonatal congenital heart block, and preterm birth 4, 6, 7.
• Close Surveillance: Close surveillance is necessary to monitor for disease flares, preeclampsia, preterm birth, fetal growth restriction, neonatal lupus erythematosus (NLE), and congenital heart block 3, 4, 5, 6, 7.

Medication Use in Pregnancy

The use of medications during pregnancy in women with SLE is crucial to control disease activity and prevent complications.

• Hydroxychloroquine (HCQ): HCQ is recommended to be continued during pregnancy, unless contraindicated 4, 6, 7.
• Low-Dose Aspirin: Low-dose aspirin is recommended to be started at 12 weeks of gestation to decrease the risk of preeclampsia 6.
• Immunosuppressives: Immunosuppressives such as azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered 4.
• Glucocorticoids: Glucocorticoid use in pregnancy should be limited to the lowest effective dose 4.
• Teratogenic Medications: Medications such as mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy 4, 6.

Pregnancy Complications

Women with SLE are at increased risk of pregnancy complications, including:

• Disease Flares: Women with SLE are at risk of disease flares during pregnancy, which can increase the risk of complications 3, 4, 5, 6, 7.
• Preeclampsia: Women with SLE are at increased risk of preeclampsia, which can increase the risk of complications 3, 4, 5, 6, 7.
• Preterm Birth: Women with SLE are at increased risk of preterm birth, which can increase the risk of complications 3, 4, 5, 6, 7.
• Fetal Growth Restriction: Women with SLE are at increased risk of fetal growth restriction, which can increase the risk of complications 3, 4, 5, 6, 7.
• Neonatal Lupus Erythematosus (NLE): Women with SLE are at increased risk of NLE, which can increase the risk of complications 3, 4, 5, 6, 7.
• Congenital Heart Block: Women with SLE are at increased risk of congenital heart block, which can increase the risk of complications 3, 4, 5, 6, 7.