Table 3.

Pregnancy Management

Timeline	Monitoring	Action Plan
Prenatal counseling	● Blood pressure check ● SLE clinical assessments ● Routine labs* with addition of anti-Ro/SSA, anti-La/SSB, antiphospholipid antibodies, lupus anticoagulant	● If pregnancy is not desired, discuss effective birth control options ● For those desiring pregnancy:  o Switch to pregnancy compatible medications  o Ensure low disease activity or remission at least 6 months  o Discontinue NSAIDS in those having difficulties conceiving  o Start on or continue with HCQ if not contraindicated
First Trimester	● Blood pressure check ● SLE clinical assessment ● Labs* ● Fetal ultrasound to ensure intrauterine pregnancy and establish gestational age	● Start Aspirin 81 mg/day ● Be vigilant for disease flares ● Review medication adherence ● Patients with OB-APS should start prophylactic heparin ● Patients with thrombotic APS should start full dose heparin ● for active SLE disease, increase or add pregnancy compatible DMARD
Second Trimester	● Blood pressure check ● SLE clinical assessment ● Labs* with assessment for gestational diabetes and genetic screening (if applicable) ● Fetal ECHO starting at week 16 through week 25 for mothers with +anti-Ro/SSA or +anti-La/SSB ● Ultrasound to evaluate fetal anatomy and to assess fetal growth, placental insufficiency	● Be vigilant for disease flares ● Review medication adherence ● In fetuses with evidence for 1st or 2nd degree heart block, start oral dexamethasone 4 mg daily for several weeks then assess response ● For fetuses with 3rd degree heart block without cardiac inflammation, avoid dexamethasone ● Avoid NSAIDS at 20 weeks and beyond.
Third Trimester	● Blood pressure check ● SLE clinical assessment ● Labs* ● Ultrasound regularly to evaluate fetal growth, adequacy of amniotic fluid, placental insufficiency	● Be vigilant for disease flares ● Review medication adherence ● Review preparations for labor and delivery
Post-partum and Lactation	● Blood pressure check ● SLE clinical assessment ● Labs*	● Be vigilant for disease flares ● Switch to lactation compatible medications if breastfeeding is desired ● For prednisone ≥20 mg/day, avoid breastfeeding 4 hours after dosing

Notes: *Labs to be included: complete blood count (CBC), comprehensive metabolic profile (CMP), urinalysis and morning urine protein to creatinine ratio (UPCR), anti-double stranded DNA (dsDNA) antibodies, complement levels (CH50, or C3 and C4), serum uric acid.

Abbreviations: SLE, systemic lupus erythematosus; HCQ, hydroxychloroquine; NSAIDS, nonsteroidal anti-inflammatory drugs; OB-APS, obstetric antiphospholipid syndrome; DMARD, disease modifying antirheumatic drug; ECHO, echocardiogram.