Systemic lupus erythematosus: strategies to improve pregnancy outcomes

Figures & data

Table 1 Preconception risk assessment for SLE patients

Contraindications of pregnancy^Citation6

History of severe preeclampsia despite aspirin and heparin use

Heart failure

Restrictive lung disease (FVC <1 L)

Renal insufficiency (Cr >2.8 mg/dL)

Severe pulmonary hypertension (sPAP >50 mmHg)

Suspend pregnancy until stable for 6 months

Active lupus nephritis

Recent SLE flare

High-risk patients

Active lupus nephritis or SLE flare within 6 months

APS

Anti-SS-A or SS-B antibodies

Low-risk patients

No history of severe organ damage

Quiescent disease at conception

Abbreviations: SLE, systemic lupus erythematosus; FVC, forced vital capacity; Cr, creatinine; sPAP, systolic pulmonary artery pressure; APS, antiphospholipid syndrome.

Table 2 Key points in managing the pregnant SLE patients

	Observant	Timing	Monitoring details
Maternal monitoring	Obstetrician	First visit Repeated monthly until 20 weeks Every 2 weeks until 24 weeks Every week until delivery	History taking, physical examination, urine analysis (if dipstick is positive for protein, measure protein–creatinine ratio)
	Rheumatologist	First visit Repeat every month until postpartum	History taking, physical examination, complement, anti ds-DNA antibody, SS-A and SS-B antibodies, cardiolipin antibodies, lupus anticoagulant History taking, physical examination, complement
	Both	First visit Repeat every month until postpartum	CBC, chemistry (including uric acid, liver enzymes, creatinine) Protein–creatinine ratio
Fetal monitoring	Obstetrician	Starting at 16 weeks Starting at 24 weeks Repeated every week until delivery	Echocardiogram BPP, fetal growth, umbilical artery Doppler velocimetry
	Neonatologist	When signs of fetal compromise detected	Consultation for appropriate timing/mode of delivery
	Cardiologist	When signs of CHB or heart failure detected	Consultation for therapy and appropriate timing/mode of delivery

Abbreviations: SLE, systemic lupus erythematosus; CBC, complete blood count; BPP, biophysical profile; CHB, congenital heart block; dsDNA, double stranded DNA.

Table 3 Key points to differentiate preeclampsia from lupus nephritis

	Preeclampsia	Lupus nephritis
Onset	After 20 weeks	Possible onset before 20 weeks
Hypertension	Present	May be present or absent
Urinary sediment	Negative	Positive
Uric acid	>4.9 mg/dL	<4.9 mg/dL^Citation90
Complement	No change	Decrease from baseline during pregnancy (could be within the normal range)
Anti-dsDNA	No change	Increased
Other signs of SLE activity	Absent	Present
Urinary calcium	<195 mg/24 hours	>195 mg/24 hours^Citation91

Abbreviations: dsDNA, double stranded DNA; SLE, systemic lupus erythematosus.

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