Case Report: Systemic Lupus Erythematosus and Pregnancy Planning

A 28-year-old female with systemic lupus erythematosus (SLE) with lupus nephritis presented to rheumatology clinic for preconception counseling. Her other clinical manifestations included rash, inflammatory arthritis and serositis. Her medications included mycophenolate mofetil, tacrolimus, hydroxychloroquine and lisinopril. She reported feeling well, and blood work showed normal renal functioning without any markers of disease activity.

Since mycophenolate mofetil and lisinopril are considered teratogenic, the patient was counseled on controlling disease with pregnancy-compatible medications prior to attempts at conception. She was switched to azathioprine and nifedipine.

The patient went on to conceive at a time of very low disease activity. She presented for follow up at 10 weeks gestation. According to American College of Rheumatology guidelines for the management of reproductive health in patients with rheumatic and musculoskeletal diseases, the next step in her care plan was to assess risk for neonatal lupus.

Her bloodwork showed positive anti-Ro/SSA antibodies. Although she had no history of neonatal lupus, she was sent to maternal-fetal medicine for regular echocardiograms. Her bloodwork was negative for antiphospholipid antibodies. She continued follow up with rheumatology during her second and third trimesters and fortunately delivered a healthy baby girl. Given the stability of lupus activity at her postpartum checkup, she was continued on azathioprine, hydroxychloroquine and tacrolimus, which are all safe options for breastfeeding.

Watch below as Emily Littlejohn, DO, MPH, associate staff in the Department of Rheumatologic and Immunologic Diseases, provides details about alternative medications, ongoing monitoring during pregnancy and neonatal risk assessments for this patient and offers insights on general management of pregnancy planning in patients with SLE.

“This case outlines the importance of rheumatology involvement at each stage of the family planning journey,” says Dr. Littlejohn. “There needs to be a clear communication on the safest treatment options and appropriate disease monitoring from preconception counseling through the postpartum period.”