What are the follow-up guidelines for Systemic Lupus Erythematosus (SLE) during pregnancy?

From the Guidelines

Systemic Lupus Erythematosus (SLE) follow-up guidelines during pregnancy are crucial for preventing adverse maternal and fetal outcomes. The American College of Rheumatology recommends testing for LAC, aCL, and anti-βGPI antibodies once before or early in pregnancy, and against repeating these tests during pregnancy 1.

Key Recommendations

• Hydroxychloroquine (HCQ) use: All women with SLE should take HCQ during pregnancy if possible, as it has been shown to have maternal and pregnancy benefits and low risk for mother and fetus 1.
• Low-dose aspirin: Women with SLE should be treated with low-dose aspirin (81 or 100 mg daily) beginning in the first trimester to prevent or delay the onset of gestational hypertensive disease 1.
• Disease activity monitoring: SLE disease activity should be monitored with clinical history, examination, and laboratory tests at least once per trimester, including complete blood cell count, differential cell count, urinalysis results, and urinary protein:creatinine ratio, or anti-DNA, C3, or C4 levels 1.
• Fetal surveillance: Pregnant women with SLE and/or antiphospholipid syndrome should undergo supplementary fetal surveillance with Doppler ultrasonography and biometric parameters, particularly in the third trimester to screen for placental insufficiency and small for gestational age fetuses 1.
• Preconception counseling and risk stratification: Assessment of risk factors for adverse maternal and fetal outcomes is crucial for preconception counseling and implementing appropriate preventive strategies and patient-tailored monitoring plan before and during pregnancy 1.

Medications to Avoid

• Mycophenolic acid, cyclophosphamide, leflunomide, and methotrexate should be avoided due to known or possible teratogenicity 1.

Additional Considerations

• Calcium, vitamin D, and folic acid supplementation should be offered to patients with SLE and/or antiphospholipid syndrome, with particular consideration to those with low circulating levels of 25-OH vitamin D in the first trimester of gestation and receiving glucocorticoids and/or heparin for their detrimental effects on bone mass 1.
• HPV vaccination can be considered in women with SLE and/or antiphospholipid syndrome and stable/inactive disease 1. These guidelines aim to reduce the risk of adverse maternal and fetal outcomes in women with SLE during pregnancy.

From the Research

Follow-up Guidelines for Systemic Lupus Erythematosus (SLE) during Pregnancy

• Preconception risk assessment and counseling are essential to identify factors that may lead to poor pregnancy outcomes 2, 3
• Women with SLE should be followed according to a protocol that includes regular reviews and early recognition of flares and complications 4, 2
• Disease activity should be monitored using scales such as the Systemic Lupus Erythematosus Disease Activity Index and Systemic Lupus Erythematosus Pregnancy Disease Activity Index 4
• Effective immunosuppressive therapy can decrease clinical and laboratory activity of SLE, but unfavorable perinatal outcomes can still occur even when lupus activity is under control 4
• Pregnancy complications such as preterm premature rupture of membranes, preeclampsia, and preterm labor are common in women with SLE 4, 2, 3
• Fetal outcomes such as neonatal lupus, preterm birth, and fetal growth restriction are also common in women with SLE 2, 3, 5

Management of SLE during Pregnancy

• A multidisciplinary approach involving obstetricians, rheumatologists, and other specialists is essential for effective management of SLE during pregnancy 2, 3, 5
• Women with SLE should be closely monitored for lupus flares, worsening renal impairment, and other complications 2, 3, 5
• Antirheumatic medications should be used cautiously during pregnancy, and the latest guidance on their use and safety should be followed 2, 3
• Postnatal care should include ongoing management of SLE and monitoring for potential complications 2, 3

Recommendations for Pregnancy Follow-up in Women with SLE

• Regular assessments of disease activity and fetal well-being are essential 4, 2, 3, 5
• Women with SLE should be educated on the signs and symptoms of lupus flares and complications, and how to seek medical attention if necessary 2, 3
• A coordinated care approach involving obstetricians, rheumatologists, and other specialists can help improve pregnancy outcomes in women with SLE 2, 3, 5