For clinicians

Systemic lupus erythematosus (SLE)

lupus, SLE

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Bottom lineBottom line: outcomes are best when conception occurs during at least 6 months of quiescent or low disease activity on pregnancy-compatible medications. Continue hydroxychloroquine; offer low-dose aspirin for pre-eclampsia prophylaxis; test anti-Ro/La and antiphospholipid antibodies; co-manage with maternal-fetal medicine. With planning and control, fewer than 10% flare.

By domain

Will pregnancy affect my lupus? ●●●○moderate evidencestrong

Tarter & Bermas 2023 (verified primary text): flares may complicate up to half of SLE pregnancies, mainly in women with active disease at conception. In one study of over 300 patients with mild-to-moderate disease at conception, fewer than 10% had mild flares and 3% had severe flares. Flares typically involve previously affected organ systems.^[3]

Will lupus affect the pregnancy? ●●●○moderate evidencestrong

Increased risk of pre-eclampsia, preterm birth, intrauterine growth restriction, and pregnancy loss, concentrated in active disease, lupus nephritis, hypertension, and antiphospholipid antibody positivity.^{[1, 3]}

Fertility ●●○○low evidenceconditional

Fertility is generally preserved. Exceptions include cyclophosphamide-related ovarian toxicity and the effect of active disease or significant organ involvement.^{[1, 3]}

Contraception ●●●○moderate evidencestrong

Discuss contraception and pregnancy planning at an early visit; patients with rheumatic disease underutilise effective contraception (good practice statement). Long-acting reversible contraception (copper or progestin IUD, progestin implant) is safe in all patients, including those on immunosuppression, and is preferred (strongly recommended in aPL-negative non-SLE disease; conditionally recommended in SLE). In aPL-positive patients, combined estrogen-progestin contraceptives are strongly recommended against because of thrombotic risk; use an IUD or a progestin-only method. Avoid combined estrogen methods and the estrogen patch in active SLE. Mycophenolate requires an IUD or two concurrent alternative methods. Avoid DMPA where osteoporosis risk is high. Offer barrier methods where more effective options are contraindicated, and emergency contraception when needed.^[1]

Planning ahead ●●●○moderate evidencestrong

Target at least 6 months of quiescence. Test anti-Ro/La and antiphospholipid antibodies. Transition off incompatible agents (mycophenolate, methotrexate, cyclophosphamide, leflunomide) with adequate lead time. Continue hydroxychloroquine.^{[1, 3]}

Medicines ●●●○moderate evidencestrong

Continue hydroxychloroquine. Add low-dose aspirin for pre-eclampsia prophylaxis. Azathioprine, tacrolimus, or ciclosporin may be used if needed. Avoid mycophenolate, methotrexate, cyclophosphamide, and leflunomide.^{[1, 2, 3]}

Monitoring in pregnancy ●●○○low evidencestrong

Monitor blood pressure, urinalysis, anti-dsDNA and complement, CBC and creatinine, with serial fetal growth assessment. Arrange fetal echocardiography if anti-Ro/SSA positive (approx weeks 16-26).^{[3, 4]}

Flare or pregnancy complication? ●●○○low evidenceconditional

Distinguishing a lupus nephritis flare from pre-eclampsia is a core challenge. Active urinary sediment, rising anti-dsDNA with falling complement, and extrarenal lupus activity favour flare; a raised sFlt-1/PlGF ratio favours pre-eclampsia.^[3]

After birth ●●○○low evidenceconditional

Anticipate postpartum flare risk; plan medication resumption and a breastfeeding-compatible regimen; provide contraception counselling (avoid estrogen-containing methods if antiphospholipid antibody positive).^{[1, 3]}

Key points

Point	Evidence
Conception during sustained quiescence on pregnancy-compatible therapy is the strongest modifiable predictor of good outcomes.^{[1, 3]}	●●●○moderate evidencestrong
Continue hydroxychloroquine throughout unless contraindicated.^{[1, 3]}	●●●○moderate evidencestrong
Effective contraception is under-used in RMD; prefer LARC, and strongly avoid combined estrogen-progestin contraceptives in aPL-positive patients.^[1]	●●●○moderate evidencestrong

Key numbers

Tarter & Bermas: in >300 patients with mild-to-moderate disease at conception, <10% had mild flares and 3% severe flares. Denominator is that subgroup, not all SLE pregnancies.^[3]
Brucato 2001 (verified, primary text): prevalence of congenital complete heart block was 2% (2/100) in prospectively followed anti-Ro/SSA-positive women with known connective tissue disease. Both cases were detected at 20 and 22 weeks' gestation.^[5]

References

Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
Ruegg L, et al. EULAR recommendations for use of antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
Tarter L, Bermas BL. Expert Perspective: Lupus and Pregnancy. Arthritis Rheumatol. 2024;76(3):321-331. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42756
Izmirly P, et al. Hydroxychloroquine to Prevent Recurrent Congenital Heart Block in Fetuses of Anti-SSA/Ro-Positive Mothers (PATCH). J Am Coll Cardiol. 2020;76(3):292-302. https://www.jacc.org/doi/10.1016/j.jacc.2020.05.045
Brucato A, et al. Risk of congenital complete heart block in newborns of mothers with anti-Ro/SSA antibodies. Arthritis Rheum. 2001;44(8):1832-1835. https://pubmed.ncbi.nlm.nih.gov/11508435/