Overview of management of pregnant people with systemic lupus erythematosus

Timeline	All patients with SLE	Modifications for patients with APS
Throughout pregnancy	Perform clinical evaluation and laboratory testing^* for disease activity at least once per trimester Monitor blood pressure Review medication adherence Continue hydroxychloroquine unless it is contraindicated^¶ Coordinate care across the patient's medical team, including maternal-fetal medicine
First trimester	Start aspirin 81 to 162 mg/day at 12 to 16 weeks of gestation for pre-eclampsia prophylaxis If medication change is needed due to unplanned pregnancy or lupus flare, obtain an early ultrasound for viability and dating, ideally in the first trimester	Start aspirin 81 to 162 mg/day once intrauterine pregnancy is confirmed for both preeclampsia prophylaxis and prophylaxis against early pregnancy loss; and Adjust anticoagulation as needed once intrauterine pregnancy is confirmed based on the subtype of APS^Δ
Second trimester	Obtain an ultrasound prior to 20 weeks gestation for anatomic survey and assessment of fetal growth and amniotic fluid volume
Third trimester	Obtain an ultrasound evaluation for fetal growth; subsequent frequency of surveillance for fetal growth is typically every 4 weeks but sooner if clinical suspicion for fetal growth restriction (eg, uterine size less than dates, development of preeclampsia or worsening SLE) At 32 to 36 weeks of gestation, begin fetal testing (ie, nonstress tests and/or biophysical profile) once or twice weekly^◊ May stop aspirin after 36 weeks of gestation^§	Starting at 32 weeks of gestation, begin fetal testing (ie, nonstress tests and/or biophysical profile) once or twice weekly^◊ In patients with a history of thrombosis related to APS (eg, stroke, myocardial infarction), consider continuing aspirin past 36 weeks
Postpartum	Perform clinical evaluation and laboratory testing for disease activity approximately 4 to 6 weeks postpartum^* Monitor blood pressure^¥ If patient is breastfeeding, ensure medications are compatible^‡	In patients with vascular APS, oral anticoagulation can be resumed postpartum in place of therapeutically-dosed LMWH^†; certain agents (eg, warfarin) are compatible with breastfeeding In patients with obstetrical APS, prophylactically dosed LMWH can be discontinued at 6 to 12 weeks postpartum

To be used with UpToDate content on pregnancy in patients with SLE.

APS: antiphospholipid syndrome; CRP: C-reactive protein; dsDNA: double-stranded deoxyribonucleic acid; ESR: erythrocyte sedimentation rate; LMWH: low-molecular weight heparin; SLE: systemic lupus erythematosus.

* Laboratory testing includes the following: kidney function (creatinine, urinalysis with urine sediment, spot urine protein/creatinine ratio), complete blood count with differential, liver function tests, ESR, CRP, anti-dsDNA antibody, and complement (C50, or C3 and C4). Physiologic changes during pregnancy may include mild anemia, mild thrombocytopenia, elevated ESR, proteinuria (<300 mg/24 hours), and elevated C50, C3, and C4.

¶ Refer to UpToDate content on antimalarials in rheumatic disease and safety of rheumatic disease medication use during pregnancy.

Δ The dose of LMWH will be individualized and determined by APS subtype. Prophylactic dosing (usually enoxaparin 1 mg/kg once daily) is favored for obstetric APS, while therapeutic dosing (eg, enoxaparin 1 mg/kg twice daily) is favored for those on lifelong anticoagulation. For more information on dosing, refer to UpToDate content on the management of APS during pregnancy.

◊ Testing is initiated before 32 weeks when the pregnancy is complicated by multiple high-risk conditions or when a condition with a high risk of fetal demise before 32 weeks is present (eg, severe growth restriction). In such cases, testing is individualized and initiated at the gestational age at which delivery for perinatal benefit would be considered if test results are abnormal.

§ Aspirin may be continued for longer in patients who have SLE and APS with certain arterial thrombotic complications.

¥ Blood pressure should be followed closely after discharge since blood pressure peaks 3 to 6 days postpartum when most patients are at home. Home blood pressure monitoring may be useful.

‡ Refer to UpToDate content on safety of rheumatic disease medication use during pregnancy and lactation.

† LMWH is sometimes continued during the postpartum period because of difficulty adjusting oral anticoagulation in the setting of weight and plasma volume fluctuations.

Adapted from: Tarter L, Bermas BL. Expert perspective on a clinical challenge: Lupus and pregnancy. Arthritis Rheum 2024; 76:321.

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Overview of management of pregnant people with systemic lupus erythematosus