Management of Systemic Lupus Erythematosus in Pregnancy

Pre-Pregnancy and Early Pregnancy Assessment

The American College of Rheumatology recommends that all women with SLE should continue or initiate hydroxychloroquine during pregnancy, start low-dose aspirin (81-100 mg daily) in the first trimester, undergo antiphospholipid antibody testing early in pregnancy, and receive at least trimester-based disease activity monitoring to optimize maternal and fetal outcomes 1, 2, 3
Essential laboratory testing should include testing once before or early in pregnancy for lupus anticoagulant, anticardiolipin antibodies, and anti-β2GPI antibodies, and testing once for anti-Ro/SSA and anti-La/SSB antibodies to assess risk of neonatal lupus and congenital heart block 1, 2, 3, 4, 5, 6
Baseline assessment should include complete blood count with differential, urinalysis with protein:creatinine ratio, serum creatinine, complement levels, and anti-dsDNA antibody titers 6

The American College of Rheumatology strongly recommends continuing hydroxychloroquine throughout pregnancy if already taking it, and conditionally recommends starting it if not taking it and no contraindication exists 1, 2, 3, 4, 5
Low-dose aspirin should be started at 81-100 mg daily in the first trimester and continued until delivery, as SLE patients are at high risk for preeclampsia and aspirin prophylaxis is recommended by both the American College of Rheumatology and the American College of Obstetricians and Gynecologists 1, 2, 3, 4, 5
Antiphospholipid antibody-positive patients should receive treatment stratification based on APS status, including low-dose aspirin plus prophylactic heparin for obstetric APS and low-dose aspirin plus therapeutic-dose heparin for thrombotic APS 4, 5

Disease activity should be monitored at least once per trimester with clinical history, examination, and laboratory tests, including complete blood count with differential, urinalysis with protein:creatinine ratio, serum C3/C4 complement levels, and anti-dsDNA antibody titers 1, 2, 6
Laboratory monitoring should include CBC with differential, urinalysis with protein:creatinine ratio, serum C3/C4 complement levels, and anti-dsDNA antibody titers, and increase monitoring frequency based on individual disease activity and medication requirements 6, 7

Serial fetal echocardiography should be performed from weeks 16-26 for patients with positive anti-Ro/SSA or anti-La/SSB antibodies, and weekly fetal echocardiography if history of neonatal lupus in prior pregnancy 4
A brief course of dexamethasone may be used if first or second-degree heart block is detected, but dexamethasone should not be used for third-degree heart block and prednisone should not be used for fetal heart block prevention 4
Routine ultrasonographic screening should include first trimester (11-14 weeks), second trimester with Doppler (20-24 weeks), and third trimester monthly surveillance with Doppler of umbilical artery, uterine arteries, ductus venosus, and middle cerebral artery 7