All women contemplating pregnancy should take a pre-natal multivitamin prior to conception. Women who have taken methotrexate or sulfasalazine may be folate deficient, and therefore in particular need of extra folic acid prior to pregnancy.
Low-dose aspirin has been studied extensively in pregnancy, primarily as a preventive measure against preeclampsia. In a Cochrane Collaboration report of more than 20 such studies, the risk of preeclampsia, preterm birth, and fetal demise were all modestly – but significantly – decreased.15 The Cochrane report recommends that all women at high risk for preeclampsia consider taking a low dose of aspirin throughout pregnancy. Aspirin at this dose has proven safe and does not increase congenital abnormalities in the offspring. In studies of SLE pregnancies, preeclampsia may occur in 10% to 25% of all pregnancies, compared with 5% to 10% of healthy pregnancies.7,16 For this reason, it may be argued that all women with SLE should take a low-dose aspirin throughout pregnancy.
The maintenance of normal blood pressure is important throughout pregnancy. Women with hypertension in the first trimester have a several-fold increased risk for pregnancy loss.12 In the Hopkins Lupus Cohort, this risk was eliminated by the maintenance of normal blood pressure with anti-hypertensive medication. Most obstetricians prefer to avoid ACE inhibitors and diuretics during pregnancy. For this reason, modification of a woman’s anti-hypertensive regimen may be required – preferably prior to conception.
Hydroxychloroquine is considered safe during pregnancy. More than 300 pregnancies in patients on this drug have been reported, with no increased risk for congenital abnormalities identified. Ophthalmologic and cardiac abnormalities have not been identified in offspring after systematic exams.17 Further, in the Hopkins Lupus Cohort, there was an increase in lupus activity during pregnancy among women who discontinued hydroxychloroquine early in pregnancy.18 These women had more arthritis and cutaneous disease and required higher doses of corticosteroids to control their disease during pregnancy. Based on this data, I recommend that all women continue hydroxychloroquine ≤400 mg per day throughout pregnancy.
Azathioprine may be the safest immunosuppressant in pregnancy. There are extensive reports of pregnancies exposed to azathioprine among women with kidney transplantation or inflammatory bowel disease.19 These studies did not find an increased risk for congenital abnormalities among infants exposed in utero to azathioprine. They did find, however, an increased rate of preterm births after azathioprine exposure. It is unclear if this was caused by the drug or the underlying disease it was used to treat.
