in early pregnancy may be due to anti phospholipid antibodies. Later, thrombocytopenia may indicate preeclampsia.
Urine is tested frequently to detect new-onset or worsening proteinuria. The fetus is closely observed for adverse efects such as growth restriction and oligohydramnios. Many recommend screening for anti-SS-A (anti-Ro) and anti-SS-B (anti-La) antibodies, because of associated fetal complications described subsequently. Antepartum, the fetus is surveilled as outlined by the American College of Obstetricians and Gynecologists (2016a) and described in Chapter 17 (p. 331). Unless hypertension or evidence of fetal compromise or growth restriction develops, pregnancy is allowed to progress to term. Peripartum corticosteroids in "stress doses" are given to women who are taking these drugs or who recently have done so.
here is no cure for SLE, and complete remissions are rare. Approximately a fourth of pregnant women have mild disease, which is not life threatening, but may be disabling because of pain and fatigue. Arthralgia and serositis can be managed by nonsteroidal antiinflammatory drugs (NSAIDs). However, chronic or large intermittent dosing is avoided due to related oligohydramnios or ductus arteriosus closure (Chap. 12, p. 241). Low-dose aspirin can be used throughout gestation. Severe disease is managed with corticosteroids such as prednisone, 1 to 2 mg/kg/d orally. Mter the disease is controlled, this dose is tapered to a daily morning dose of 10 to 15 mg. Corticosteroid therapy can lead to gestational diabetes.
Immunosuppressive agents such as azathioprine are beneicial for active disease. These are usually reserved for lupus nephritis or disease that is corticosteroid resistant. Azathioprine has a good safety record during pregnancy (Fischer-Betz, 2013; Petri, 2007). Its recommended daily oral dose is 2 to 3 mg/kg. Teratogenic medications to be avoided include mycophenolate mofetil, methotrexate, and cyclophosphamide (Gotestam Skorpen, 2016). However, cyclophosphamide can be considered in the second or third trimester for severe disease (Lazzaroni, 2016). In some situations, mycophenolate is the only treatment that achieves disease stability. In these cases, counseling is essential regarding fetal risks described in Chapter 12 (p. 244) (Bramham, 2012).
Antimalarials reduced dermatitis, arthritis, and fatigue (Hahn, 2015). Although these agents cross the placenta, hydroxychloroquine is not associated with congenital malformations. Because of the long half-life of antimalarials and because discontinuing therapy can precipitate a lupus lare, most recommend their continuation during pregnancy (Borden, 2001).
'When severe disease supervenes-usually a lupus larehigh-dose glucocorticoid therapy is given. Petri (2007) recommends pulse therapy consisting of methylprednisolone, 1000 mg given intravenously over 90 minutes daily for 3 days, then a return to maintenance doses if possible.
In nonpregnant subjects, antihypertensive therapy oten includes an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker. For pregnancy, these should be changed to safer fetal options such as calcium-channel blockers, alpha methyldopa, or labetalol (Cabiddu, 2016).