Version July 2025
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OVERVIEW —
Systemic lupus erythematosus (also called lupus or SLE) is a chronic inflammatory disease that can affect various organs of the body.
Females with SLE do not appear to have problems with fertility (getting pregnant), with the exception of those who have had prior treatment with a medication called cyclophosphamide. However, pregnant individuals with SLE are at higher risk for complications during pregnancy, such as preeclampsia and premature delivery. Additionally, some people with SLE have certain proteins in their blood (called "antiphospholipid antibodies"); the presence of these antibodies increases the risk of miscarriage or stillbirth.
The outcomes for pregnancy in individuals with SLE are best if the disease activity is under good control on medications that are safe to take during pregnancy. In particular, kidney disease should be in remission. Working closely with a rheumatologist and obstetrician before and during pregnancy can help reduce the risk of complications and increase the chances of having a healthy pregnancy and delivery.
This topic review discusses the preparation for and care of SLE during pregnancy. A general discussion of SLE is available separately. (See "Patient education: Systemic lupus erythematosus (Beyond the Basics)".)
RISKS OF PREGNANCY —
Pregnant individuals with systemic lupus erythematosus (SLE) sometimes experience flares during pregnancy. Other pregnancy complications that occur more commonly in pregnant individuals with SLE include high blood pressure, preeclampsia, preterm labor, miscarriage, emergency cesarean section, excessive bleeding after delivery, or blood clots in the leg or lung. Infants born to females with SLE have a higher risk of being born prematurely and having a low birth weight.
Maternal risks
●Risk of SLE flare – Whereas previously many patients with SLE were told to avoid pregnancy, SLE treatment has become more successful over time, making pregnancy an option for most people with this disorder. Flares of SLE symptoms affect 7 to 33 percent of pregnant individuals whose disease has been in remission for at least six months prior to pregnancy. This flare rate is comparable to the flare rate of individuals with SLE who are not pregnant. By contrast, the flare rate is higher (more than 60 percent) for pregnant individuals with active SLE at the time of conception.
●Preeclampsia – Preeclampsia is the medical term for a pregnancy complication that is characterized by high blood pressure and organ damage in a pregnant individual after 20 weeks of pregnancy. It is also called "toxemia." (See "Patient education: Preeclampsia (Beyond the Basics)".)
Preeclampsia occurs in about 15 to 30 percent of pregnant people with SLE. It may occur more frequently among those whose SLE is active during pregnancy, or in those with kidney disease, antiphospholipid antibodies, diabetes mellitus, or prior episodes of preeclampsia. Given the increased risk of preeclampsia with SLE, we advise most pregnant patients with SLE to take a daily low-dose aspirin starting the second trimester of pregnancy, as this may reduce the risk of preeclampsia.
The only cure for preeclampsia is to deliver the baby. In pregnant individuals who are less than 37 weeks pregnant when preeclampsia develops, delivery can sometimes be delayed if there are no severe features of the disease (eg, very high blood pressure, kidney problems, or symptoms like severe headache, vision problems, abdominal pain, or shortness of breath).
For patients with SLE who are less than 34 weeks pregnant, doctors sometimes delay delivery for a day or two in order to give treatment with dexamethasone, which is given as injections in two doses 24 hours apart. Dexamethasone speeds up lung development and significantly reduces the infant's risk of lung complications related to prematurity. However, in some cases (ie, if the health of the pregnant individual or baby is at risk), delivery cannot be delayed to give this medication. (See "Patient education: Preterm labor (Beyond the Basics)".)
Fetal and infant risks
●Fetal loss – Fetal loss is diagnosed when a fetus dies after 10 weeks of pregnancy. The risk of fetal loss is increased in pregnant people with high blood pressure, active SLE, or lupus nephritis (kidney disease) and in those with certain laboratory abnormalities such as low complement levels, elevated levels of anti-double-stranded DNA (anti-dsDNA) antibodies, antiphospholipid antibodies, and/or a low platelet count.
Pregnant patients with SLE should be tested for the presence of antiphospholipid antibodies, as higher-than-normal levels of these antibodies may increase the risk of fetal loss (see "Patient education: Antiphospholipid syndrome (Beyond the Basics)"). Daily low-dose aspirin is given to pregnant people with SLE who test positive for antiphospholipid antibodies. Some patients (eg, who have had pregnancy losses in the past or are known to have blood clotting issues) require treatment with heparin in addition to aspirin.
●Preterm delivery – People with SLE have an increased risk of preterm delivery (when the baby is born before 37 weeks of pregnancy). (See "Patient education: Preterm labor (Beyond the Basics)".)
The risk of preterm delivery is increased in those who have more severe SLE, require higher doses of glucocorticoids (steroids) during pregnancy, take certain immunosuppressive medications such as azathioprine and cyclosporine, or have other pregnancy complications. Careful management of SLE during pregnancy can help to decrease the risk of preterm delivery.
●Low birthweight infant – Having SLE can increase the risk of a low birthweight baby, especially if the pregnant person requires glucocorticoids; has kidney complications, high blood pressure, antiphospholipid antibodies, or preeclampsia; or experiences prelabor "rupture of membranes" (when the water breaks before contractions have begun).
●Neonatal lupus – Neonatal lupus is an autoimmune disease that occurs in about 10 percent of babies born to mothers with certain antibodies called "anti-Ro/SSA" and/or "anti-La/SSB" antibodies. If a pregnant person gives birth to a baby with neonatal lupus, the risk of having another baby with neonatal lupus in a subsequent pregnancy is about 17 percent.
Neonatal lupus is caused by passage of the anti-Ro/SSA and/or anti-La/SSB antibodies from the pregnant person’s bloodstream across the placenta to the developing baby after about the 20th week of pregnancy. Many pregnant individuals who give birth to a baby with neonatal lupus have anti-Ro/SSA or anti-La/SSB antibodies but do not have a diagnosis of SLE or another autoimmune disease at the time of their pregnancy.
Signs of neonatal lupus include a red, raised rash on the scalp and around the eyes. The rash almost always resolves by six to eight months of age because the antibodies are no longer present in the infant's bloodstream; most of these infants do not develop SLE in later years. Infants can also develop elevations in their liver enzymes that also resolve within a few months of birth.
The most serious complication of neonatal lupus is complete heart block, which occurs in approximately 2 percent of newborns whose mothers have anti-Ro/SSA or anti-La/SSB antibodies. Heart block occurs when there is partial or complete blockage of electrical flow in the fetus's heart, causing an abnormally slow heart rate.
Recommendations from professional societies vary regarding the utility of regular ultrasounds to monitor the fetus's heart during pregnancies exposed to anti-Ro/SSA or anti-La/SSB antibodies. Traditionally, ultrasounds were generally obtained at regular intervals from around the 16th through the 26th weeks of pregnancy. The goal is to detect fetal heart block at an early stage so that the fetus can be monitored frequently to assure that the heart is functioning well and to be able to prepare the fetus for a pacemaker if it is needed when born. There is no proven treatment for fetal heart block prior to birth, although some preliminary studies suggest that patients with these antibodies who take hydroxychloroquine during pregnancy have a lower risk of these complications.
If the fetus starts to develop signs of heart block, treatment with dexamethasone, a type of glucocorticoid, is often started; however, this treatment is not proven to be effective.
●Developmental problems – SLE does not increase the risk of having a child with congenital anomalies. It is uncertain whether learning disabilities are more frequent in children of mothers with SLE, as studies have yielded conflicting results.
Pregnant people with kidney disease — People with SLE who have organ damage before pregnancy may have a higher risk of pregnancy complications; this is because pregnancy increases the workload on organs throughout the body. This is particularly true for those with kidney disease.
●Lupus nephritis – People with active lupus nephritis (kidney disease caused by SLE) at the time of pregnancy have an increased risk of fetal loss and worsening of kidney function during pregnancy. Those with preexisting high blood pressure, protein in the urine, or high levels of blood urea nitrogen and/or creatinine (as determined by blood tests) are at the highest risk for these complications.
●Kidney transplantation – Pregnant individuals with SLE who have received a kidney transplant have a slightly higher risk of miscarriage compared with those without SLE who have had a kidney transplant, although most go on to have a successful delivery. Of these patients, one-half to two-thirds have a preterm delivery or a low birthweight baby, and there is an increased risk of developing high blood pressure or gestational diabetes during pregnancy or of requiring a cesarean delivery ("c-section").
CARE BEFORE PREGNANCY —
People with systemic lupus erythematosus (SLE) who wish to get pregnant should talk with their rheumatologist and a high-risk obstetrical provider before they start trying. Getting the right care before and during pregnancy can help reduce the risk of complications.
Am I ready for pregnancy? — It is common for people with long-term medical problems to be worried about the effects of pregnancy and parenting on their health. It is also important to consider the changes that a newborn may bring, including interrupted sleep, fatigue, and, for many individuals, additional stress. Close communication with an obstetric and rheumatology care provider and support from family and friends can help to ease the challenges of being pregnant and of raising a child.
General recommendations — These recommendations apply to all individuals who are considering pregnancy, not just those with SLE.
●All individuals should ensure that they get sufficient dietary folate by taking a nutritional supplement called folic acid at a daily dose of at least 400 mcg (the amount in most multivitamins) (table 1). Folic acid should be started before trying to conceive and should be continued until at least the end of the first trimester in order to reduce the risk of neural tube defects in the fetus.
●People should stop smoking and consuming alcohol or any recreational drugs (eg, marijuana) before trying to become pregnant.
●Caffeine intake should be limited to less than 200 to 300 mg per day while trying to become pregnant and during pregnancy. The table lists the caffeine content of several common beverages (table 2).
●Blood testing for rubella (German measles), varicella (chicken pox), human immunodeficiency virus (HIV), hepatitis B, and inherited genes (eg, cystic fibrosis) may be recommended.
Additional considerations for females with SLE
●Females with lupus nephritis (kidney disease related to SLE) are encouraged to delay pregnancy until their disease has been inactive for at least six months.
●We encourage females with SLE who are interested in becoming pregnant to meet with their rheumatologist and a maternal fetal medicine specialist for a baseline evaluation and preconception counseling. This visit will include checking preconception laboratory tests, which can help providers explain potential risks of pregnancy related to SLE.
●We advise patients to review their prescription and nonprescription medications with their rheumatologist and obstetrical care provider. Some medications are safe during pregnancy, while others are not. In some cases, an alternate medication can be substituted for an unsafe drug. (See 'Medications during pregnancy' below.)
Specific considerations for medications used to treat SLE include the following:
•We advise patients to take hydroxychloroquine regularly during pregnancy, as its use is associated with better pregnancy outcomes.
•By contrast, certain medications used to treat SLE are not safe during pregnancy and should be stopped before conception (see 'Drugs to avoid' below). In particular:
-Cyclophosphamide and thalidomide – Females who take cyclophosphamide or thalidomide should stop these medications for at least three months before trying to get pregnant.
-Methotrexate – Females who take methotrexate should wait at least one full menstrual cycle, and ideally three cycles, after stopping this medication before trying to conceive.
-Mycophenolate mofetil – Females who take mycophenolate mofetil should stop this medication four to six months prior to conception.
-Leflunomide – Females who are taking leflunomide or who have taken it in the previous 24 months and who are interested in becoming pregnant should have undetectable leflunomide blood levels or do a cholestyramine washout until blood levels are undetectable.
Considerations for males with SLE — Certain treatments for SLE may affect fertility in males, including the following:
●Cyclophosphamide or thalidomide – Males who take cyclophosphamide or thalidomide should stop these medications for at least three months before trying to get a partner pregnant. This three-month period is necessary to allow for the development of sperm that have not been exposed to these medications. In addition, males who anticipate starting treatment with cyclophosphamide should be referred for sperm cryopreservation.
●Sulfasalazine – Males who take sulfasalazine who are having trouble conceiving should stop this medication and obtain a semen analysis.
CARE DURING PREGNANCY —
During pregnancy, individuals with systemic lupus erythematosus (SLE) need regular monitoring of their disease, even if it has been stable, and many will need treatment of active disease. Care of pregnant individuals with SLE is usually shared during pregnancy between a rheumatologist and a high-risk obstetrician.
Monitoring SLE disease activity — Pregnant individuals with SLE often have a flare of symptoms during pregnancy or shortly after delivery. It is sometimes difficult to distinguish between the common discomforts of pregnancy and the symptoms of SLE. Normal pregnancy discomforts that are similar to those of SLE include the following:
●Fatigue
●Swelling of the hands, feet, or ankles
●Joint pain, especially in the low back
●Shortness of breath
●Numbness or pain in one or both hands (caused by carpal tunnel syndrome of pregnancy)
●Skin changes (eg, darkening of facial skin)
As soon as pregnancy is confirmed, most clinicians recommend that people with SLE have a complete physical examination, including measurement of blood pressure and blood testing. The blood tests are important to measure kidney function and, if not done during a preconception visit, to check for antiphospholipid, anti-Ro/SSA, and/or anti-La/SSB antibodies. (See 'Fetal and infant risks' above.)
During the pregnancy, blood and urine testing are checked regularly to monitor the activity of SLE; the frequency of testing depends upon the individual patient. This testing usually includes measurement of kidney function (glomerular filtration rate, urine protein/urine creatinine ratio), complement levels (CH50 or C3 and C4), and anti-dsDNA antibodies. When interpreting the laboratory results, it is important to remember that the results of some tests are expected to change during pregnancy, including inflammatory markers and complement levels.
Materal-fetal monitoring
●The first visit – If medication change is needed due to an unplanned pregnancy or SLE flare, patients may obtain an early ultrasound for viability of the fetus and dating, ideally in the first trimester.
●At subsequent visits – Most pregnant individuals with SLE will be seen every two to four weeks until 28 weeks of pregnancy. After 28 weeks, the frequency of visits typically increases.
After 10 to 12 weeks of pregnancy, the fetus's heart rate will be measured. In addition, ana ultrasound is usually recommended in the second trimester before the 20th week of pregnancy to ensure that the fetus is growing and developing normally. Regular ultrasounds may be recommended through the remainder of the pregnancy to monitor the fetus's growth.
●After 28 weeks of pregnancy – After 28 weeks of pregnancy, most people will be seen every one or two weeks. At these visits, the person's blood pressure will be monitored and sometimes their urine will be checked for protein. Fetal monitoring may include a biophysical profile and nonstress testing:
•Biophysical profile – A biophysical profile score is calculated to assess the fetus's health. It consists of five components, including nonstress testing and ultrasound measurement of four fetal parameters: fetal body movements, breathing movements, fetal tone (flexion and extension of an arm, leg, or the spine), and measurement of the amniotic fluid levels. Each component is scored individually, with two points given for a normal result and zero points given for an abnormal result. The maximum possible score is 10.
The level of amniotic fluid (liquid in the uterus) is an important variable in the BPP because a low volume (called oligohydramnios) may increase the risk of umbilical cord compression and may be a sign of changes in the blood flow between the fetus and pregnant individual. Amniotic fluid levels can become reduced within a short time period, even a few days.
•Nonstress testing – Nonstress testing is done by monitoring the baby's heart rate with a small device that is placed on the pregnant person’s abdomen. The device uses sound waves (ultrasound) to measure the baby's heart rate over time, usually for 20 to 30 minutes.
The test is considered reassuring (called "reactive") if two or more fetal heart rate increases are seen within a 20-minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes.
●Delivery – Most pregnant individuals with SLE are able to have an uncomplicated vaginal delivery. However, we advise people with SLE to deliver in a hospital with a neonatal intensive care unit (NICU) since there are increased risks of various complications including having premature rupture of the membranes, a small infant, and preeclampsia.
If a cesarean section delivery is required, individuals who have required glucocorticoids to control SLE during pregnancy may need an increased dose of glucocorticoids. This is called a "stress dose" and helps the body respond normally to the physical stresses of childbirth.
Medications during pregnancy — Medications that are typically used to treat SLE may be divided into three categories: those that should be avoided during pregnancy, those that may have a small risk of harm to the fetus, and those that are probably safe.
Drugs to avoid — Medications that should be avoided during pregnancy because of the risk of congenital anomalies (problems a baby can be born with) include mycophenolate mofetil, cyclophosphamide, methotrexate, and leflunomide. If you take one of these medications and get pregnant, talk to your doctor immediately. (See 'Additional considerations for females with SLE' above.)
Drugs with a small risk of harm — Nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, and glucocorticoids (eg, prednisone) have a small risk of causing fetal harm; their use may be acceptable if necessary to control SLE during pregnancy.
●NSAIDs – NSAIDs, such as ibuprofen (Advil, Motrin) and naproxen (Aleve), cross the placenta and can potentially cause harm to the fetus after 20 weeks of pregnancy. Females who have trouble becoming pregnant may consider avoiding NSAIDs while trying to become pregnant if disease control is not affected. NSAIDs can be continued until week 20 of pregnancy.
A safe alternative to NSAIDs for treatment of pain during pregnancy is acetaminophen (Tylenol), which may be taken at a dose of two 325 mg tablets or capsules every four to six hours as needed. No more than 3000 mg of acetaminophen should be taken per day.
●Aspirin – Low-dose aspirin (less than 160 mg/day) is often given to patients with SLE to reduce the risk of developing preeclampsia. It has also been used safely along with anticoagulation for the treatment of pregnant patients with antiphospholipid syndrome. However, increased rates of stillbirth have been reported with aspirin doses greater than 325 mg/day. Patients should speak with their obstetric or rheumatology care provider about the potential benefit of low-dose aspirin in preventing preeclampsia.
●Glucocorticoids (eg, prednisone) – If SLE flares during pregnancy, most experts recommend starting prednisone (a glucocorticoid, or steroid) at the lowest dose possible. While prednisone crosses the placenta, it appears in only small amounts in the infant's blood.
Glucocorticoids may increase the risk of premature rupture of membranes (breaking the water early) and of growth restriction (having a lower-birthweight infant). These drugs can also increase the risk of pregnancy-induced diabetes and high blood pressure in pregnant people. Despite these risks, glucocorticoids may be required to manage the disease, since uncontrolled SLE disease activity can also be harmful to the pregnant individual and fetus (see 'Risks of pregnancy' above). This decision is best made with an experienced rheumatologist and/or obstetrical care provider.
Drugs with unclear risk
●Biologic medications – There are limited data about the safety of biologic agents in pregnancy. Biologic agents including rituximab and belimumab may be used up until conception. If there are no safe alternative therapies, continued use during pregnancy may be preferable to a flare of SLE.
Drugs that are safe during pregnancy
●Hydroxychloroquine – Normal doses of hydroxychloroquine and related antimalarial drugs do not increase the risk of miscarriage or congenital anomalies. Pregnant individuals with SLE should be encouraged to continue their antimalarial drugs as therapy may decrease the risk of flares, help manage the antiphospholipid syndrome, and possibly decrease the risk of neonatal lupus. These medications are also safe to use while breastfeeding.
●Other immunosuppressive medications – Azathioprine, cyclosporine, and tacrolimus are considered compatible during pregnancy. There are reassuring data in individuals who have received organ transplants to suggest that these medications do not increase the risk of fetal anomalies. Rarely, azathioprine is associated with intrahepatic cholestasis of pregnancy and should be discontinued if this condition occurs.
●Certain anticoagulant medications – People with SLE with high levels of antiphospholipid antibodies who have had a prior pregnancy loss or preeclampsia may require treatment with an anticoagulant or "blood thinning" medication (eg, a low dose of aspirin and/or heparin) during pregnancy, depending upon their individual situation. This treatment helps to reduce the risk of blood clots and miscarriage.
CONSIDERATIONS AFTER DELIVERY —
Some people will experience a flare of systemic lupus erythematosus (SLE) after delivery. Individuals who have had active disease in early pregnancy and those with significant organ damage are at greater risk of disease flares. Thus, regular visits for SLE monitoring are recommended postpartum.
Breastfeeding — Breastfeeding has many benefits for both mother and baby. There is no increased risk of neonatal lupus related to breastfeeding.
Many medications appear to be safe to use while breastfeeding, including antimalarials (eg, hydroxychloroquine), warfarin, and heparin. Azathioprine, cyclosporine, and tacrolimus do enter the breast milk but are present in very low concentrations and breastfeeding mothers may still use them safely. Other medications may need to be avoided or modified while breastfeeding:
●Cyclophosphamide, mycophenolate mofetil, leflunomide, thalidomide, and methotrexate should not be taken while breastfeeding.
●Glucocorticoids (eg, prednisone) can be taken. In doses above 20 mg/day of prednisone or its equivalent, we advise patients to discard breast milk for the first four hours after taking this medication.
The quality of information regarding medication safety in breastfeeding varies. A reliable source of information is LactMed, which is available from the National Library of Medicine.
Several topic reviews about breastfeeding are available separately:
●(See "Patient education: Deciding to breastfeed (Beyond the Basics)".)
●(See "Patient education: Common breastfeeding problems (Beyond the Basics)".)
●(See "Patient education: Pumping breast milk (Beyond the Basics)".)
●(See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)".)
Birth control — Within a few weeks after delivering an infant, it is important to start thinking about birth control. A number of birth control options are available for females with SLE; these should be discussed with a gynecologist and rheumatologist.
WHERE TO GET MORE INFORMATION —
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Lupus and pregnancy (The Basics)
Patient education: Lupus (The Basics)
Patient education: Lupus and kidney disease (The Basics)
Patient education: How to plan and prepare for a healthy pregnancy (The Basics)
Patient education: Prenatal care (The Basics)
Patient education: Nutrition before and during pregnancy (The Basics)
Patient education: Activity during pregnancy (The Basics)
Patient education: Preeclampsia (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Systemic lupus erythematosus (Beyond the Basics)
Patient education: Antiphospholipid syndrome (Beyond the Basics)
Patient education: Avoiding infections in pregnancy (Beyond the Basics)
Patient education: Preterm labor (Beyond the Basics)
Patient education: Preeclampsia (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Birth control; which method is right for me? (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Pregnancy in women with systemic lupus erythematosus
Systemic lupus erythematosus in adults: Clinical manifestations and diagnosis
Systemic lupus erythematosus in adults: Overview of the management and prognosis
Antiphospholipid syndrome: Diagnosis
Antiphospholipid syndrome: Management
Neonatal lupus: Epidemiology, pathogenesis, clinical manifestations, and diagnosis
Prenatal care: Patient education, health promotion, and safety of commonly used drugs
The following organizations also provide reliable health information.
●National Library of Medicine
(www.medlineplus.gov/healthtopics.html)
●National Institute of Arthritis and Musculoskeletal and Skin Disease
●American College of Rheumatology
●Lupus Foundation of America
ACKNOWLEDGMENT —
The editorial staff at UpToDate would like to acknowledge Peter Schur, MD, who contributed to an earlier version of this topic review.
