Skip to main content
SpringerLink
Log in

Treatment of Systemic Lupus Erythematosus (SLE) in Pregnancy

  • Lupus (S Keeling, Section Editor)
  • Published:
Current Treatment Options in Rheumatology Aims and scope Submit manuscript

Abstract

Purpose of review

To identify known teratogenic medications that may be used to treat SLE and discuss alternative therapeutics that can be used throughout pregnancy in order to manage maternal autoimmune diseases.

Recent findings

Teratogenic immunosuppressive medications include methotrexate, mycophenolatemofetil, and cyclophosphamide. In anticipation of pregnancy, such medications should be discontinued and replaced with immunosuppressive medications including azathioprine and cyclosporine and assessed for disease stability.

Summary

Pregnancy is an important aspect to women’s lives, and a diagnosis of SLE should not necessarily preclude the ability to bear children. Pregnancy outcomes among SLE women are favorable when disease is well controlled prior to conception and teratogenic medications are avoided. Several immunosuppressive therapies that are compatible with pregnancy are available to treat flares that may occur during pregnancy. Hydroxychloroquine use throughout pregnancy is associated with improved outcomes for both mother and infant. Risks of medication use need to be balanced with risks of active maternal disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Recently published papers of particular interest have been highlighted as:• Of importance •• Of major importance

  1. Centers for Disease Control and Prevention(CDC). Update on overall prevalence of major birth defects, Atlanta, Georgia, 1978-2005. MMWR Morb Mortal Wkly Rep. 2008;57:1–5.

    Google Scholar 

  2. Ostensen M. Preconception counseling. Rheum Dis Clin N Am. 2017;43(2):189–99. https://doi.org/10.1016/j.rdc.2016.12.003.

    Article  Google Scholar 

  3. Knight CL, Nelson-Piercy C. Management of systemic lupus erythematosus during pregnancy: challenges and solutions. Open Access Rheumatol 2017; Nar 10. https://doi.org/10.2147/OARRR.S878(.

  4. •• Buyon JP, Kim MY, Guerra MM, Laskin CA, et al. Predictors of pregnancy outcomes in patients with lupus: a cohort study. Ann Intern Med. 2015;163(3):153–63. This is an outstanding prospective study of pregnancies in women with SLE. The study was designed to exclude pregnancies with known risk factors so that the role of underlying SLE on pregnancy outcomes could be examined more closely

  5. Tedeschi SK, Guan H, Fine A, Costenbader KH, Bermas B. Organ-specific systemic lupus erythematosus activity during pregnancy is associated with adverse pregnancy outcomes. ClinRheumatol. 2016;35(7):1725–32.

    Google Scholar 

  6. Peart E, Clowse ME. Systemic lupus erythematosus and pregnancy outcomes: an update and review of the literature. CurrOpinRheumatol. 2014;26(2):118–23.

    CAS  Google Scholar 

  7. https://www.mycophenolaterems.com/

  8. Kozma C, Ramasethu J. Methotrexate and misoprostol teratogenicity: further expansion of the clinical manifestations. Am J Med Genet A. 2011;155A(7):1723–8. https://doi.org/10.1002/ajmg.a.34037.

    Article  PubMed  Google Scholar 

  9. Lewden B, Vial T, Elefant E, Nelva A, Carlier P, Descotes J, et al. Low dose weekly methotrexate in the first trimester of pregnancy: results of a French collaborative study. J Rheumatol. 2004;31(12):2360–5.

  10. •• Weber-Schoendorfer C, Chambers C, Wacker E, Beghin D, Bernard N, et al. Pregnancy outcome after methotrexate treatment for rheumatic disease prior to or during early pregnancy: a prospective multicenter cohort study. Arthritis Rheumatol. 2014;66:1101–10. This is a well performed, prospective study of pregnant outcomes following early exposure to methotrexate at doses typically used for rheumatic diseases

    Article  CAS  PubMed  Google Scholar 

  11. Sifonis NM, Coscia LA, Constantinescu S, Lavelanet AF, Moritz MJ, Armenti VT. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolatemofetil or sirolimus. Transplantation. 2006;82(12):1698–702. https://doi.org/10.1097/01.tp.0000252683.74584.29.

    Article  Google Scholar 

  12. Anderka MT, Lin AE, Abuelo DN, Mitchell AA, Rasmussen SA. Reviewing the evidence for mycophenolatemofetil as a new teratogen: case report and review of the literature. Am J Med Genet. 2009;149A(6):1241–8. https://doi.org/10.1002/ajmg.a.32685.

    Article  PubMed  Google Scholar 

  13. Coscia LA, Constantinescu S, Davison JM, Moritz MJ, Armenti VT. Immunosuppressive drugs and fetal outcome. Best Pract Res Clin Obstet Gynecol. 2014;28(8):1174–87. https://doi.org/10.1016/j.bpobgyn.2014.07.020.

    Article  Google Scholar 

  14. Coscia LA, Armenti DP, King RW, Sifonis NM, Constantinescu S, Moritz MJ. Update on the teratogenicity of maternal mycophenolatemofetil. J Pediatr Genet. 2015;4(2):42–55. https://doi.org/10.1055/s-0035-1556743.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Clowse ME, Madger LS, Petri M. Cyclophosphamide for lupus during pregnancy. Lupus. 2005;14(8):593–7. https://doi.org/10.1191/0961203305lu2169oa.

    Article  CAS  PubMed  Google Scholar 

  16. Mok CC, Ying KY, Tang S, Leung CY, Lee KW, Ng WL, et al. Predictors and outcomes of renal flares after successful cyclophosphamide treatment for diffuse proliferative lupus glomerulonephritis. Arthritis Rheum. 2004;50(8):2559–68. https://doi.org/10.1002/art.20364.

  17. Saarikoski S, Seppala M. Immunosuppression during pregnancy: transmission of azathioprine and its metabolites from mother to fetus. Am J ObstetGynecol. 1973;115(8):1100–6. https://doi.org/10.1016/0002-9378(73)90559-0.

    Article  CAS  Google Scholar 

  18. Shah S, Verma P. Overview of pregnancy in renal transplant patients. Int J Nephrol 2016; doi/https://doi.org/10.1155/2016/4539342.

  19. Ostensen M, Khamashta M, Lockshin M, Parke A, et al. Anti-inflammatory and immunosuppressive drugs and reproduction. Arthritis Res Ther. 2006;8(3):209. https://doi.org/10.1186/ar1957.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Stanhope TJ, White WM, Moder KG, Smyth A, Garovic VD. Obstetric neprhology: lupus and lupus nephritis in pregnancy. Clin J Am SocNeprhol. 2012;7(12):2089–99. https://doi.org/10.2215/CJN.12441211.

    Article  CAS  Google Scholar 

  21. • Mok CC. Pro: The use of calcinurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Trans. 2016;31(10):1561–6. This is a very well written review article on the use of calcinurin inhibitors for lupus nephritis by one of the worldwide experts in the field. While it does not discuss pregnancy per se, it provides an excellent guideline of how to use the medications in SLE

    Article  CAS  Google Scholar 

  22. Webster P, Wardle A, Bramham K, Webster L, Nelson-Piercy C, Lightstone L. Tacrolimus is and effective treatment for lupus nephritis in pregnancy. Lupus. 2014;23(11):1192–6. https://doi.org/10.1177/0961203314540353.

    Article  CAS  PubMed  Google Scholar 

  23. Ruiz-Irastorza G, Danza A, Perales I, Villar I, Garcia M, Delgado S, et al. Prednisone in lupus nephritis: how much is enough? Autoimmun Rev. 2014;13(2):206–14. https://doi.org/10.1016/j.autrev.2013.10.013.

  24. Venkataramanan R, Koneru B, Wang CCP, et al. Cyclosporine and its metabolites in mother and baby. Transplantation. 1988;46(3):468–9. https://doi.org/10.1097/00007890-198809000-00032.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Pickrell MD, Sawers R, Michael J. Pregnancy after renal transplantation: severe intra-uterine growth retardation during treatment with cyclosporine. Br Med J. 1988;296(6625):825. https://doi.org/10.1136/bmj.296.6625.825.

    Article  CAS  Google Scholar 

  26. Paziana K, Del Monaco M, Cardonick E, Moritz M, Keller M, Smith B, et al. Ciclosporin use during pregnancy. Drug Saf. 2013;36(5):279–94. https://doi.org/10.1007/s40264-013-0034-x.

  27. Schen FP, Stalloone G, Schena A, et al. TransplImmunol. 2002;9:161–4.

    CAS  Google Scholar 

  28. • Sandhu VK, Wallace DJ, Weisman MH. Monoclonal antibodies, systemic lupus erythematosus, and pregnancy: insights from an open label study. J Rheumatol. 2015;42(4):728–30. A well written editorial discussing theoretical risks and benefits of ongoing use of belimumab in pregnancy

    Article  CAS  PubMed  Google Scholar 

  29. Chakravarty EF, Murray ER, Kelman A, Farmer P. Pregnancy outcomes after maternal exposure to rituximab. Blood. 2011;117(5):1499–506. https://doi.org/10.1182/blood-2010-07-295444.

    Article  CAS  PubMed  Google Scholar 

  30. Skuladottir H, Wilcox AJ, Ma C, Lammer EJ, Rasmussen SA, Werler MM, et al. Corticosteroid use and risk of orofacial clefts. Birth Defects Res A ClinMolTeratol. 2014;100(6):499–506. https://doi.org/10.1002/bdra.23248.

  31. Stone CT. Safety of chloroquine in pregnancy. JAMA. 1965;192(3):260. https://doi.org/10.1001/jama.1965.03080160080030.

    Article  CAS  PubMed  Google Scholar 

  32. Canadian Hydroxychloroquine Study Group. A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus. N Engl J Med. 1991;324(3):150–4.

    Article  Google Scholar 

  33. Levy RA, Vilela VS, Cataldo MJ, Ramos RC, et al. Hydroxychloroquine (HCQ) in lupus pregnancy: double-blind and placebo-controlled study. Supus. 2001;10(6):401–4.

    CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Oklahoma School of Medicine, Oklahoma City, OK, USA

    Erin Shirley BS

  2. Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK, 73104, USA

    Eliza F. Chakravarty MD, MS

Authors
  1. Erin Shirley BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eliza F. Chakravarty MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eliza F. Chakravarty MD, MS.

Ethics declarations

Conflict of Interest

Erin Shirley declares that she has no conflict of interest. Eliza F. Chakravarty declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Lupus

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shirley, E., Chakravarty, E.F. Treatment of Systemic Lupus Erythematosus (SLE) in Pregnancy. Curr Treat Options in Rheum 4, 110–118 (2018). https://doi.org/10.1007/s40674-018-0085-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40674-018-0085-3

Keywords

Search

Navigation