Society for Maternal-Fetal Medicine Consult Series #64: Systemic lupus erythematosus in pregnancy

Abstract

Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies (ANA), are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with SLE, and an initial diagnosis of SLE during pregnancy is associated with increased morbidity. Common complications of SLE include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of SLE during pregnancy. The following are the SMFM recommendations: we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with SLE to decrease the occurrence of preeclampsia (GRADE 1B); we recommend that all patients with SLE, other than those with quiescent disease, either continue or initiate HCQ in pregnancy (GRADE 1B); we suggest that for patients with quiescent disease, shared decision making is used to decide whether to initiate HCQ during pregnancy (GRADE 2B); we recommend that prolonged use (>48 hours) of NSAIDs should be avoided during pregnancy (GRADE 1A); we recommend that Cox-2 inhibitors and full dose aspirin should be avoided during pregnancy (GRADE 1B); we recommend discontinuing methotrexate and mycophenolate mofetil/mycophenolic acid at least three months prior to attempting pregnancy (GRADE 1A); we suggest against initiating newer biologic medications with pregnancy unless alternatives with better safety profiles are ineffective (GRADE 2C); we suggest treatment with a combination of prophylactic unfractionated or low molecular weight heparin and low-dose aspirin for patients without a prior thrombotic event who meet obstetric criteria for APS (GRADE 2B); we recommend therapeutic unfractionated or low molecular weight heparin for patients with a history of thrombosis and aPL antibodies (GRADE 1B); we suggest treatment with low-dose aspirin alone in patients with SLE and antiphospholipid antibodies without clinical events meeting criteria for APS (GRADE 2C); we recommend that steroids should not be routinely used for the treatment of fetal heart block due to anti-SSA/SSB antibodies, given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA or anti-SSB antibodies (GRADE 1B); we recommend that patients with SLE undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); we recommend that pregnancy should be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); we recommend antenatal testing and serial growth scans in pregnant patients with SLE due to the increased risk of FGR and stillbirth (GRADE 1B); and we recommend adherence to the Centers for Disease Control and Prevention (CDC) medical eligibility criteria for contraceptive use in patients with SLE (GRADE 1B).