Society forMaternal-FetalSMFM Consult SeriesMedicineHigh-risk pregnancy expertssmfm.orgSociety for Maternal-Fetal MedicineCheck for updatesConsult Series #64:Systemic lupuserythematosus in pregnancySociety for Maternal-Fetal Medicine (SMFM);Robert Silver,MD;Sabrina Craigo,MD;Flint Porter,MD,MPH;Sarah S.Osmundson,MD;Jeffrey A.Kuller,MD;Mary E.Norton,MD;Publications CommitteeThe American College of Obstetricians and Gynecologists(ACOG)endorses this document.Systemic lupus erythematosus(SLE)is a chronic,multisystem,inflammatory autoimmune disease charac-terized by relapses(commonly called"flares")and remission.Many organs may be involved,and although themanifestations are highly variable,the kidneys,joints,and skin are commonly affected.Immunologic abnor-malities,including the production of antinuclear antibodies,are also characteristic of the disease.Maternalmorbidity and mortality are substantially increased in patients withsystemiclupus erythematosus,andan initialdiagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity.Com-mon complications of systemic lupus erythematosus include nephritis,hematologic complications such asthrombocytopenia,and a variety of neurologic abnommalities.The purpose of this document is to examinepotential pregnancy complications and to provide recommendations on treatment and management of sys-temic lupus erythematosus during pregnancy.The following are the Society for Maternal-Fetal Medicinerecommendations:(1)we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery inpatients with systemic lupus erythematosus to decrease the occurrence of preeclampsia(GRADE 1B);(2)werecommend that all patients with systemic lupus erythematosus,other than those with quiescent disease,either continue or initiatehydroxychloroquine(HCQ)in pregnancy(GRADE 1B);(3)wesuggestthat for all otherpatients withquiescentdisease activity who arenot takingHCQorother medications,itis reasonableto engagein shared decision-making regarding whether to initiate newtherapy with this medication in consultation withthe patient's rheumatologist(GRADE 2B):(4)we recommend that prolonged use(>48 hours)of nonsteroidalantiinflammatory drugs(NSAIDs)generally beavoided during pregnancy(GRADE1A);(5)werecommendthatCOX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B);(6)we recommend dis-continuing methotrexate 1-3months and mycophenolate mofetil/mycophenolic acid at least 6 weeks beforeattempting pregnancy(GRADE1A);(7)we suggest thedecision to initiate,continue,or discontinuebiologics inpregnancy be made incollaboration with a rheumatologist and be individualized to the patient(GRADE2C);(8)we suggest treatmentwith acombinationofprophylactic unfractionated or low-molecular-weight heparin andlow-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for anti-phospholipid syndrome(APS)(GRADE 2B);(9)we recommend therapeutic unfractionated or low-molecu
