Considerations for people with SLE planning pregnancy

Andreoli, 2017Australian Rheumatology Association (ARA), 2011Russell, 2022

Pregnancy can induce a flare of SLE in up to two-thirds of peopleAustralian Rheumatology Association, 2022, 2022. The strongest predictor of flare is disease activity in the 6 months preceding conception. Successful pregnancy can be achieved by people who have SLE, but ideally pregnancy should be a planned event. The best chance of pregnancy success depends on the person conceiving when disease activity is low or in remission, and on having normal kidney function.

Prepregnancy counselling and a team-based approach, addressing individual needs, is ideal. The team should include the general practitioner, rheumatologist, fertility specialist (if applicable), obstetrician (preferably one with an interest in SLE), and other physicians, depending on the person’s disease features (eg cardiologist, haematologist, nephrologist).

Disease activity in SLE can be assessed by measuring:

  • inflammatory markers—erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration
  • kidney function—serum creatinine concentration, urinalysis
  • autoimmune antibodies—anti-double-stranded DNA (dsDNA)
  • complement proteins (C3, C4).

Some of the disease-modifying antirheumatic drugs (DMARDs) used for the treatment of SLE can potentially:

  • have adverse effects on female and male fertility
  • increase the rates of miscarriage
  • be teratogenic to the fetus.

The Australian Rheumatological Association (ARA) recommend all people with SLE should stay on hydroxychloroquine (no more than 400 mg daily) during pregnancy. If systemic corticosteroids are required for disease control the dose should be minimised to less than 20 mg daily and be used in combination with a corticosteroid-sparing immunomodulatory drug. DMARDs that may be used through pregnancy include azathioprine, ciclosporin, tacrolimus, tumour necrosis factor (TNF) inhibitors, and biologic (b)DMARDs for severe diseaseRussell, 2022. For specific advice on immunomodulatory drugs, refer to ARA’s Prescriber’s Information on Medications for Autoimmune Rheumatic Diseases (AIRD) in Pregnancy. Antiphospholipid syndrome associated with SLE can cause recurrent early miscarriages, mid-trimester fetal loss and late-pregnancy complications (eg severe pre-eclampsia). Prepregnancy assessment, counselling and treatment with low-dose aspirin and low molecular weight (LMW) heparin are very important. See Management for obstetric antiphospholipid syndrome for more detail.

People with SLE and positive anti-Ro antibodies require special monitoring during pregnancy because of a risk to their fetus of developing congenital heart block. This is important when planning a pregnancy as fetal echocardiography is required at 18 to 20 weeks’ gestation.