Expert Perspective on a Clinical Challenge: Lupus and Pregnancy.

Systemic lupus erythematosus (SLE), a multi-organ systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about pre-conception 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 preeclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, fewer than 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 as their offspring are at increased risk for congenital heart block. SLE patients should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of preeclampsia. 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 preeclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist. This article is protected by copyright. All rights reserved.