Journal List > J Rheum Dis > v.18(2) > 1063949

Lee and Lee: Management of Pregnancy in Women with Systemic Lupus Erythematosus

Abstract

Systemic lupus erythematosus (SLE) predominantly affects women of childbearing age, and the management of pregnant patients with SLE is challenging because pregnancy can aggravate SLE and vice versa. Furthermore, the drugs used to treat SLE can adversely affect the fetus. Accordin-gly, pregnancy should be planned in advance in women with lupus, and careful planning and treatment are required to care for women with lupus who become pregnant. This article reviews the pre-pregnancy evaluation and management of pregnant women with SLE with the aim of providing general guidelines to physicians regarding the monitoring and treatment of women with SLE that want to become pregnant.

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Table 1.
Pre-pregnancy checklist (Adapted from reference (7))
Age
Any previous pregnancy
Previous pregnancy complications
SLE organ involvement
Degree of irreversible damage
Recent or current SLE activity
Presence of aPL antibodies
Positivity of anti-Ro and/or anti-La antibodies
Current treatment: any forbidden drugs

SLE: Systemic lupus erythematosus, aPL: antiphospholipid

Table 2.
Pregnancy management plan (Adapted from reference (6))
Coordinated care by a medical-obstetric team with experience in autoimmune diseases and high-risk pregnancies
Fully equipped neonatal unit
Full autoantibody profile available before pregnancy
Visits more frequent as pregnancy progresses
Blood pressure and urine dipstick on every visit
Uterine artery Doppler study at 20 weeks in patients with aPL
antibodies, renal disease, hypertension or history of pree-
clampsia. Repeat at 24 weeks if abnormal
Umbilical artery Doppler study from 20 weeks, with frequency
according to medical and obstetric course, in women with aPL
antibodies, renal disease, active disease or previous com-
plicated pregnancy
Fetal echocardiogram from 20th week in women with anti-Ro
and/or anti-La antibodies

aPL: antiphospholipid

Table 3.
Drug constraints during pregnancy and lactation
Drug FDA risk Pregnancy Lactation Comments
NSAIDs B, C Yes Yes Avoid third trimester use
Low dose aspirin B Yes Yes No consensus on when to stop low dose aspirin before delivery
Prednisone B Yes Yes Indicated for maternal use
Dexamethasone C Yes No Not recommended for routine use in pregnancy
Betamethasone C Yes No Not recommended for routine use in pregnancy
Hydroxychloroquine C Yes Yes  
Azathioprine D Yes No When indicated, azathioprine can be used during pregnancy
Methotrexate X No No  
Cyclophosphamide D No No  
Cyclosporin A C Yes Yes? Can be maintained in pregnancy at the lowest effective dose
Tacrolimus C Yes? Yes? May be maintained in pregnancy at the lowest possible dose
Mycophenolate C No No  
Intravenous immunoglobulin C Yes Yes? Breastfeeding probably possible
Anti-TNF B No No  
Bisphosphonate C No No? Insufficient data on breastfeeding

NSAIDs: nonsteroidal antiinflammatory drugs, Anti-TNF: antitumor necrosis factor The United States Food and Drug Administration (FDA) pregnancy risk categories are as follows: A: no risk in controlled clinical studies in humans, B: human data reassuring, and when absent, animal studies show no risk, C: human data lacking, but animals studies indicate risk or have not been done, D: positive evidence of risk, but benefit may outweigh the risk, X: contraindicated during pregnancy

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