Expert Perspective on a Clinical Challenge: Lupus and Pregnancy

Arthritis & RheumatologyVolume 76, Issue 3 p. 321-331 Expert Perspectives on Clinical Challenges Expert Perspective on a Clinical Challenge: Lupus and Pregnancy Laura Tarter, Corresponding Author Laura Tarter [email protected] orcid.org/0009-0001-7820-0091 Brigham and Women's Hospital, Boston, Massachusetts Address correspondence via email to Laura Tarter, MD, at [email protected].Search for more papers by this authorBonnie L. Bermas, Bonnie L. Bermas orcid.org/0000-0002-1007-4084 University of Texas Southwestern Medical Center, Dallas, TexasSearch for more papers by this author Laura Tarter, Corresponding Author Laura Tarter [email protected] orcid.org/0009-0001-7820-0091 Brigham and Women's Hospital, Boston, Massachusetts Address correspondence via email to Laura Tarter, MD, at [email protected].Search for more papers by this authorBonnie L. Bermas, Bonnie L. Bermas orcid.org/0000-0002-1007-4084 University of Texas Southwestern Medical Center, Dallas, TexasSearch for more papers by this author First published: 17 November 2023 https://doi.org/10.1002/art.42756 Author disclosures are available at https://onlinelibrary.wiley.com/doi/10.1002/art.42756. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Abstract Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist. 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