Disease Activity & Treatment Approaches
Dr. Vinet stressed that treatment should aim for remission or low-disease activity before, during and after pregnancy. Although complete remission is ideal, achieving a lupus low disease activity state (LLDAS) can potentially reduce adverse pregnancy outcomes by about 50%, she noted.5 Ideally, pregnancy should be postponed during active disease until manifestations are optimally controlled.
Treatment of rheumatic diseases during pregnancy requires special considerations. Poorly controlled disease leads to worse outcomes, and patients are at risk of postpartum disease flare, yet medication safety is sometimes uncertain, and some medications are clearly contraindicated.
Low-Dose Aspirin
The ACR strongly recommends that all pregnant patients with SLE take low-dose aspirin, in line with non-rheumatology medical society recommendations for patients at high risk of preeclampsia.1 Low-dose aspirin is also advised for patients who are high risk because of aPL positivity, regardless of underlying rheumatic disease diagnosis. Dr. Vinet noted that aspirin should be started early in pregnancy (<16 weeks) and continued all the way to delivery.
Glucocorticoids
Although not associated with major risk of birth defects, glucocorticoids carry some other dose-related risks to the mother, and they also increase the risk of preterm birth and fetuses who are small for their gestational age. Current pregnancy guidelines from both the ACR and EULAR aim for lower doses of prednisone than used in the past by using pregnancy-compatible conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic DMARDs.1,6
The 2020 ACR guideline recommends continuing low-dose steroids during pregnancy if clinically indicated (≤10 mg of prednisone daily). The 2024 EULAR guideline relies on more recent data to recommend an even lower threshold (≤5 mg of prednisone daily), withdrawing completely if possible.1,6
Dr. Vinet emphasized, however, that higher doses can sometimes be critically important in managing very severe or life-threatening flares, for example, through intravenous high-dose methylprednisolone.
csDMARDs
Certain agents are believed to be safe in pregnancy due to sufficient experience in this population. These include the calcineurin inhibitors tacrolimus and cyclosporine, colchicine, azathioprine and hydroxychloroquine. Per ACR guidelines, the latter should be taken by all females with SLE during pregnancy, as randomized trials have shown that the low-risk agent decreases flares and improves pregnancy outcomes.1
Clinicians should also consider hydroxychloroquine for females with other autoimmune rheumatic diseases who are positive for anti-Ro/SSA antibodies, as it helps prevent complications from neonatal lupus.1,6 Dr. Izmirly shared results from studies by his group on heart block mediated by circulating maternal anti-SSA antibodies (neonatal lupus). In both a historical cohort study and a follow-up prospective study, hydroxychloroquine reduced the risk of heart block during subsequent pregnancies.4,7
