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

• Published in: American journal of obstetrics and gynecology 2023-03, Vol.228 (3), p.B41-B60
• Main Authors: Silver, Robert, Craigo, Sabrina, Porter, Flint, Osmundson, Sarah S., Kuller, Jeffrey A., Norton, Mary E.
• Format: Article
• Language: English
• Subjects: Antibodies, Antiphospholipid; Antiphospholipid Syndrome - complications; Aspirin - therapeutic use; Female; Heparin, Low-Molecular-Weight - therapeutic use; Humans; Hydroxychloroquine - therapeutic use; lupus; Lupus Erythematosus, Systemic - complications; Lupus Erythematosus, Systemic - diagnosis; Lupus Erythematosus, Systemic - drug therapy; nephritis; Nephritis - complications; Nephritis - drug therapy; Perinatology; Pregnancy; Pregnancy Complications - drug therapy; Pregnancy Complications - therapy; Referral and Consultation; systemic lupus erythematosus; thrombocytopenia
• ISSN: 0002-9378; 1097-6868
• DOI: 10.1016/j.ajog.2022.09.001

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, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus 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 systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient’s rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic eve