Slide set used during the 7th Post Graduate Symposium of the Northern Mindanao Medical Center held 3 October 2015 in Cagayan De Oro City.

1. MANAGING LUPUS
IN PREGNANCY
A Practical Approach
Sidney Erwin T. Manahan, MD, FPCP, FPRA
Medical Specialist (Rheumatology)
Department of Medicine
East Avenue Medical Center

2. OBJECTIVES
• Describe adverse events
observed in SLE patients who
become pregnant
• Discuss the management of
lupus pregnancies
• Discuss briefly the management
of Anti-Phospholipid Syndrome
(APS) in pregnancy

3. 1997 ACR Classification Criteria
• Malar rash
• Discoid rash
• Photosensitivity
• Oral ulcers
• Arthritis
• Serositis
• Renal disorder
• Neurologic disorder
• Hematologic disorder
• Immunologic disorder
• Anti-nuclear antibodies
SYSTEMIC LUPUS ERYTHEMATOSUS
• Chronic
Inflammatory
Autoimmune
Disorder
• Predominantly
affecting women in
their reproductive
years
Hochberg MC. Updating the ACR revised criteria for the classification of SLE. Arthritis Rheum 1997; 40: 1725.

4. SYSTEMIC LUPUS ERYTHEMATOSUS
2012 SLICC Classification Criteria
CLINICAL
• Acute cutaneous
• Chronic cutaneous
• Oral ulcers
• Non-scarring alopecia
• Synovitis
• Serositis
• Renal
• Neurologic
• Hemolytic anemia
• Leucopenia / Lymphopenia
• Thrombocytopenia
IMMUNOLOGIC
• ANA
• Anti-dsDNA
• Anti-Sm
• Anti-Phospholipid
• Low complement
• Direct Coomb’s test
Petri M, Orbai AM, Alarcon GS, et al. Derivation and vallidation of the SLICC Classification Criteria for SLE.
Arth & Rheum 2012; 64 (8): 2677-86.

5. Pregnancy/ Fetal Loss in SLE
43%
17%
0%
10%
20%
30%
40%
50%
1960-65 2000-03
Clark CA, Spitzer KA, Laskin CA. Decrease in pregnancy loss rates in patients
with SLE over a 40-year period. J Rheumatol 2005; 32 (9): 1709-12.

6. Adverse Events During Pregnancy
Maternal
Mortality
Odds Ratio 20
Lupus
Flares
Frequency
27-70%
Cesarean
Section
Odds Ratio 1.7
Preterm
Labor
Odds Ratio 2.4
Pre-
eclampsia
Odds Ratio 3.0
Premature
Birth
Frequency
39.4%
Abortion
Frequency
16%
Stillbirth
Frequency 3.6%
Neonatal
Death
Frequency 2.5%
IUGR
Odds Ratio 2.6
Neonatal
Lupus
Congenital
Heart Block
1-2% of Ro+
Clowse ME, Jamison M, Myers E, et al. A national study of the complication of lupus in pregnancy. Am J Obstet Gynecol 2008;
199 (2): 127.31-e6. Smyth A, Oliveira GH, Lahr BR, et al. A systematic review and metaanalysis of pregnancy outcomes in
patients with SLE and lupus nephritis. Am Soc Nephrol 2010; 5 (11): 2060-8.

7. The Health Care Team
Expertise in
• High-risk pregnancies
• Systemic Lupus Erythematosus
• Neonatal medicine
Care should be performed in a
controlled setting
Stojan G, Baer AN. Flares of SLE during pregnancy and the puerperium: prevention,
diagnosis and management. Expert Rev Clin Immunol 2012; 8 (5): 439-53. Ramires de
Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing
Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.
Lateef A, Petri M. Managing lupus patient during pregnancy. Best Pract Res Clin
Rheumatol 2013; 27 (3): doi: 10.1016.

8. Risk Factors for POOR
Pregnancy Outcomes
• Active disease within 6 months
prior to conception
• Active disease during pregnancy
• SLE onset during pregnancy
• Anti-phospholipid syndrome
• Hypocomplementemia
• Presence of anti-dsDNA
• Thrombocytopenia
• Chronic hypertension
• Pre-existing renal disease
• First trimester proteinuria
Stojan G, et al. Flares of SLE during pregnancy and the puerperium: prevention, diagnosis
and management. Expert Rev. Clin Immunol 2012; 8(5): 439-453.

9. Domains in Managing Lupus in Pregnancy
Pre-pregnancy Pregnancy
Choice of Therapy Anti-Phospholipid Syn

10. Yang H,Liu H, Xu D, et al. Pregnancy-related SLE: clinical features, outcome and risk factors
of disease flares – a case control study. PLoS ONE 2014; 9(8): 3104375
14%
32%
5%
37%
49%
5%
20%
49%
24%
2%
42%
54%
7%
12%
10% 10%
0%
6%
58%
0% 0%
Pre/eclampsia Abortion Neonatal
death
Preterm birth Live birth Maternal
death
Severe organ
damage
New onset SLE during pregnancy (n 41) Flare of SLE during pregnancy (n 41)
Stable SLE in preganancy (n 73)
Outcomes in Pregnant SLE Patients

11. Before Conception
1
2
3
4
Monitor organ involvement
Target disease remission; Delay pregnancy if
high disease activity OR SLEDAI>8
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.
Check for autoantibody profile
Determine anti-PL, anti-Ro/ La

12. Risk factors for Flares
during Pregnancy
TYPE OF FLARE RISK FACTORS
Mucocutaneous Anti-Ro, previous involvement
Articular Anti-dsDNA
Hematologic Anti-PL, Coombs+, previous involvement
Renal Anti-dsDNA, Low C3/C4, previous involvement
CNS Previous involvement
Vascular Previous involvement
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.

13. Before Conception
1
2
3
4
Monitor organ involvement
Target disease remission; Delay pregnancy if
high disease activity OR SLEDAI>8
Identify organ damage
Look into contraindications to pregnancy
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.
Check for autoantibody profile
Determine anti-PL, anti-Ro/ La

14. CONTRAINDICATIONS
to Pregnancy
• Severe pulmonary HPN (PAP >50mmHg)
• Advanced heart failure
• Severe restrictive lung disease
• Chronic renal failure (sCrea >2.8mg/dl)
Consider DEFERRING Pregnancy When
• Current use of CTX, MMF, LEF
• Active renal or CNS disease <6 months
• Recent major thrombosis (i.e. stroke) <2 years
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing
Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.
Lateef A, Petri M. Managing lupus patients during pregnancy. Best Prac Res Clin Rheumatol 2013; 27 (3): doi:10/1016.

15. Before Conception
1
2
3
4
Monitor organ involvement
Target disease remission; Delay pregnancy if
high disease activity OR SLEDAI>8
Identify organ damage
Look into contraindications to pregnancy
Check for autoantibody profile
Determine anti-PL, anti-Ro/ La
Review treatment regimen
Replace contraindicated meds with safer ones
Wait for 2-3 months on new regimen to ensure
disease control is maintained
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490.

16. When Do We Allow?
• No evidence of active disease >6 months
• Prednisone <10mg/d
• May take Hydroxychloroquine
• No contraindicated meds being taken >6mo
• No evidence of active disease for 2-3 months
if placed on a new regimen

17. Following Conception
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al.
Understanding and Managing Pregnancy in Patients with Lupus
. Autoimmune Dis 2015; 2015: Article ID 943490.
1
2
3
Monitor disease activity
Differentiate symptoms of pregnancy vs SLE

18. Flares During Pregnancy
New onset lupus
during pregnancy
(n 41)
Flare of lupus
during pregnancy
(n 41)
Non pregnant
SLE patients
(n 164)
Mucocutaneous 20 (49%) 15 (37%) 98 (60%)
Musculoskeletal 14 (34%) 3 (7%) 56 (34%)
Renal 27 (66%) 35 (85%) 102 (62%)
Cardiovascular 8 (20%) 9 (22%) 48 (29%)
Pulmonary 9 (22%) 2 (5%) 26 (16%)
Nervous system 7 (17%) 6(15%) 40 (24%)
Gastrointestinal 10 (24%) 10 (24%) 30 (19%)
Hematologic 25 (61%) 23(56%) 71 (44%)
Yang H,Liu H, Xu D, et al. Pregnancy-related SLE: clinical features, outcome and risk factors
of disease flares – a case control study. PLoS ONE 2014; 9(8): 3104375

19. WHAT causes these findings?
Facial flush / Melasma
Palmar erythema
Post partum hair loss
Photosensitive rash
Malar rash
Alopecia / lupoid hair
Arthralgias, Myalgias
Bland effusion of knees
Synovitis
Fatigue
Mild edema
Pleuritis
Pericarditis
Fever (T>38oC)
Lymphadenopathy
Yang H,Liu H, Xu D, et al. Pregnancy-related SLE: clinical features, outcome and risk factors
of disease flares – a case control study. PLoS ONE 2014; 9(8): 3104375
Lateef A, Petri M. Managing lupus patients during pregnancy. Best Prac Res Clin Rheumatol 2013; 27 (3): doi:10/1016.

20. WHAT causes these findings?
ESR 18-46mm/hr <20 weeks
30-70mm/hr >20 weeks
ESR Increased
Hgb >11 during 1st 20 weeks
Hgb >10.5 beyond 20 weeks
Hemoglobin <10.5
Mild thrombocytopenia in <8% Platelet <95,000
Proteinuria <300mg/24hours Proteinuria >300mg/24hours
Rare hematuria from vaginal
contamination
Hematuria or
cellular casts
Anti-dsDNA Negative or stable Anti-dsDNA Rising
Normal or increasing complement Low or >25%drop in complement
Yang H,Liu H, Xu D, et al. Pregnancy-related SLE: clinical features, outcome and risk factors
of disease flares – a case control study. PLoS ONE 2014; 9(8): 3104375
Lateef A, Petri M. Managing lupus patients during pregnancy. Best Prac Res Clin Rheumatol 2013; 27 (3): doi:10/1016.

21. Hypertension, Proteinuria in Pregnancy?
Features Lupus nephritis Pre-eclampsia
Hypertension Onset any time Onset after 20 weeks
Proteinuria >300mg/d >300mg/d
Urinary sediment Active Inactive
Uric acid <5.5mg/dl >5.5mg/dl
Anti-dsDNA level Rising Stable or negative
24 hr urine calcium >195mg/d <195mg/d
Complement levels >25% drop Normal
Other organs Active non-renal SLE CNS or HELLP
Stojan G, Baer AN. Flares of SLE during pregnancy and the puerperium: prevention, diagnosis and management. Expert Rev Clin
Immunol 2012; 8 (5): 439-53. Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing
Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015: Article ID 943490. Lateef A, Petri M. Managing lupus patient during
pregnancy. Best Pract Res Clin Rheumatol 2013; 27 (3): doi: 10.1016.

22. SLE Disease Activity Indices(SLEDAI)
in Pregnancy (SLEPDAI)
Feature Score
Seizure 8
Psychosis 8
Organic Brain syndrome 8
Visual disturbance 8
Cranial nerve disorder 8
Lupus Headache 8
CVA 8
Vasculitis 8
Arthritis 4
Myositis 4
Urinary casts 4
Hematuria 4
Feature Score
Proteinuria 4
Pyuria 4
Rash 2
Alopecia 2
Mucosal ulcers 2
Pleurisy 2
Pericarditis 2
Low complement 2
Anti-dsDNA increasing 2
Fever 1
Thrombocytopenia 1
Leucopenia 1
Buyon JP, et al. Assessing disease activity in SLE patients during pregnancy. Lupus 1999; 8(8): 677-84.

23. Follow up of the
Pregnant SLE Patient
OBSTETRICIAN
• Monthly until week 20
• Every 2 weeks until week 28
• Weekly until delivery
RHEUMATOLOGIST
• Support the obstetrician
during prenatal care
• Every 4-6 weeks

24. Lab Evaluation in Pregnant SLE Patients
First Visit
• CBC with platelet count
• PT/ PTT
• Anti-Phospholipid Abs
• Anti-Ro/ La/ Sm
• Anti-dsDNA titers/ C3/ C4/
CH50
• Chemistry (include BUA)
• Urinalysis, 24 hour urine
protein or urine protein/
creatinine ratio in a single
sample
Quarterly Visits
• CBC with platelet count
• Anti-ds DNA titers/ C3/ C4/
CH50
• Chemistry (include BUA)
• Urinalysis, 24 hours urine
protein or urine protein/
creatinine ratio in a single
sample
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding
and Managing Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015: Article ID 943490
Lateef A, Petri M. Managing lupus patient during pregnancy. Best Pract Res Clin Rheumatol 2013; 27 (3): doi: 10.1016.

25. Specific Investigations
ULTRASOUND
• Screen for fetal anomalies – between week 16-20
• Monitoring fetal growth – every 4 weeks
FOR ANTI-RO+ MOTHERS
• Fetal echocardiography every week from week 16-26 and
biweekly thereafter until delivery
FOR PRE-ECLAMPSIA
• Uterine artery doppler study – Week 20 then every 4 weeks
• Fetal umbilcal artery doppler velocimetry – Week 26 then weekly
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding
and Managing Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015: Article ID 943490
Lateef A, Petri M. Managing lupus patient during pregnancy. Best Pract Res Clin Rheumatol 2013; 27 (3): doi: 10.1016.

26. Following Conception
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al.
Understanding and Managing Pregnancy in Patients with Lupus
. Autoimmune Dis 2015; 2015: Article ID 943490.
1
2
3
Monitor disease activity
Differentiate symptoms of pregnancy vs SLE
Consider low-dose Aspirin
To reduce risks of pre-eclampsia esp in those
with lupus nephritis

27. Up to 30% may develop pre-eclampsia
Risk factors for Pre-
eclampsia in SLE
• Pre-existing hypertension
• Anti-phospholipid
syndrome
• Obesity
• Anti-dsDNA
• Anti-RNP
• Low Complement
• Thrombocytopenia
Consider low dose ASA (40-
160mg/d) before 16 weeks
AOG in high risk patients
• Preeclampsia (RR 0.6 95%
CI 0.27- 0.83)
• Severe preeclampsia (RR
0.3 95% CI 0.11-0.69)
Schramm AM, Clowse MEB. Aspirin for the prevention of pre-eclampsia in
lupus pregnancy. Autoimmune Dis 2014; 2014: ID 920467.

28. Following Conception
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al.
Understanding and Managing Pregnancy in Patients with Lupus
. Autoimmune Dis 2015; 2015: Article ID 943490.
1
2
3
Monitor disease activity
Differentiate symptoms of pregnancy vs SLE
Consider low-dose Aspirin
To reduce risks of pre-eclampsia esp in those
with lupus nephritis
Treat for APAS
Will discuss later

29. Risks from Medications Used
in Pregnancy
• Concerns over teratogenic risks lead
to women not taking meds during
pregnancy and lactation
• Actual estimated risk for major
malformations from meds <5%
• Background rate for congenital
anomalies ranges from 1-5%
Koren G, Bologa M, Long D, et al. Perception of teratogenic risks by pregnant women exposed to
druugs and chemical during the fist trimester. Am J Obstet Gynecol 1989; 160: 1190-4.
Koren G, Pastuszak A. Prevention of unnecessary pregnancy terminations by counselling women
on drug, chemical and radiation exposure during the first trimester. Teratology 1990; 41: 657-61.
Loebstein R, Addis A, et al. Pregnancy outcomes following gestational exposure to fluoroquinolones: a
multicenter prospective controlled study. Antimicrob Agents Chemother 1998; 42: 1336-9
Bird TM, Hobbs CA, et al. National rates of birth defects among hospitalized newborns. Birth Def Res
Clin Mol Teratol 2006: 76: 762-9

30. Gaps in Medication Use
During Pregnancy
• Only half of all pregnancies are
planned and, as a result, many women
are already taking medications when they
become pregnant
• In 2006, US Data shows that in >6
Million pregnancies
>90% were taking at least 1 medication
50% were taking 3-4 medications
Finer LB, Zolna MR. Unintended pregnancies in the US 2006. Contraception 2011; 84: 478-85

31. ACR Reproductive
Health Summit
The GREATEST RISKS to the outcome
of the mother and the fetus comes from
• Uncontrolled disease activity
• Disease flares during pregnancy
• Disease flares during the post partum
period
Kavanaugh A, Cush JJ, Ahmed MS, et al. Proceedings from the ACR Reproductive Health Summit: The management of fertility,
pregnancy and lactation in women with autoimmune and systemic inflammatory diseases. Arthritis Care Res 2015; 67 (3): 313-25.

32. What medications to give?
US FDA CLASSIFICATION
A
Studies in pregnant women failed to
demonstrate a risk to the fetus
B
No studies in pregnant women but animal
studies failed to show risk OR No studies in
pregnant women but animal studies show a
risk
C
No studies in pregnant women but animal
studies show an adverse event but benefits
outweigh risks in humans OR No studies in
humans and animals
D
Evidence of fetal risk in humans but benefits
outweigh risks
X
Evidence of fetal risk in humans or animals
and risks outweighs benefits
US FDA Pregnancy Categories: http://chemm.nlm.nih.gov/pregnancycategories.htm

33. Towards Better
Understanding of
Medication Use in
Pregnancy
FDA
Amendments
Act of 2007

34. Medications in Pregnancy
LOW RISK NO DATA HIGH RISK
Steroids
Hydroxychloroquine
Azathioprine
Ciclosporin
Tacrolimus
Aspirin
Heparin or LMWH
IVIG
TNF-inhibitors*
Rituximab
Belimumab
Tofacitinib
Tocilizumab
Ustekinumab
Methorexate
Leflunomide
Mycophenolate MMF
Cyclophosphamide
Warfarin
* Generally safe in 1st and 2nd trimester; drug specific recommendations: Mabs – discontinue before 30
weeks and avoid live vaccine in infant until 6 months , ETN – discontinue 4 weeks before dellivery,
certolizumab can be continued.
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490. Kavanaugh A, Cush JJ, Ahmed MS, et al. Proceedings from the ACR
Reproductive Health Summit: The management of fertility, pregnancy and lactation in women with autoimmune and systemic
inflammatory diseases. Arthritis Care Res 2015; 67 (3): 313-25.

35. Medications When Breast Feeding
LOW RISK NO DATA HIGH RISK
Steroids
Hydroxychloroquine
Aspirin
Heparin or LMWH
IVIG
Azathioprine
Ciclosporin
Tacrolimus
Rituximab
Belimumab
Tofacitinib
Tocilizumab
TNF-inhibitors
Methorexate
Leflunomide
Mycophenolate MMF
Cyclophosphamide
Warfarin
Ramires de Jesus G, Mendoza-Pinto C, Ramires de Jesus N, et al. Understanding and Managing Pregnancy in Patients with
Lupus. Autoimmune Dis 2015; 2015: Article ID 943490. Kavanaugh A, Cush JJ, Ahmed MS, et al. Proceedings from the ACR
Reproductive Health Summit: The management of fertility, pregnancy and lactation in women with autoimmune and systemic
inflammatory diseases. Arthritis Care Res 2015; 67 (3): 313-25.

36. Anti-Phospholipid Syndrome (APS)
NON CRITERIA FEATURES
• Thrombocytopenia
• Hemolytic Anemia
• Livedo reticularis
• Cardiac valve vegetations
• Renal thrombotic
microangiopathy
• Cognitive dysfunction
• Catastrophic APS (CAPS)
Lockshin MD. Anticoagulation in Management of Anti-Phospholipid Antibody Syndrome in Pregnancy. Clin Lab Med 2013;
33(2): 267-476. Asheron RA, et al. Catastrophic Antiphospholipid Syndrome: International Consensus Statement on
classification and treatment guidelines. Lupus 2003; 12 (7): 530-4.
Pregnancy
Morbidity
Vascular
Thrombosis
Anti-Phospholipid (aPL)
Antibodies

37. 2006 Sydney (modified Sapporo) Criteria
Pregnancy
Morbidity
Vascular
Thrombosis
• Arterial thrombosis (e.g. stroke)
• Venous thrombosis (e.g. DVT, PTE)
• Small vessel occlusion
• >3 consecutive spontaneous abortions (REM)
<10 weeks
• >1 fetal death beyond 10 weeks
• >1 premature birth <34 weeks due to severe
pre-eclampsia, eclampsia or placental
insufficiency
Anti-Phospholipid (aPL)
Antibodies
Documented 12 weeks apart
• Positive Lupus anticoagulant (LAC)
• Anti-Cardiolipin (aCL) IgM / IgG (> 40 GPU/ MPU)
• Anti-2 Glycoprotein I (a2GPI) IgM/ IgG (>40 units)
Lockshin MD. Anticoagulation in Management of Anti-Phospholipid Antibody Syndrome in Pregnancy. Clin Lab Med 2013;
33(2): 267-476. Asheron RA, et al. Catastrophic Antiphospholipid Syndrome: International Consensus Statement on
classification and treatment guidelines. Lupus 2003; 12 (7): 530-4.

38. Nuances of aPL Testing
Anti-Phospholipid
Pregnancy
Morbidity
Vascular
Thrombosis
Lupus anticoagulant (LAC)  
Anti-Cardiolipin (aCL)  
Anti-2 Glycoprotein I (a2GPI)  
Giannalopoulos B, et al. How we diagnose the antiphospholipid syndrome. Blood 2009; 113: 985-994
Lockshin MD. Anticoagulation in Management of Anti-Phospholipid Antibody Syndrome in Pregnancy. Clin Lab Med 2013;
33(2): 267-476. Asheron RA, et al. Catastrophic Antiphospholipid Syndrome: International Consensus Statement on
classification and treatment guidelines. Lupus 2003; 12 (7): 530-4.
59.6
42.3
11.4
OR Thrombosis
LAC + aCL + 2GPI
LAC + a2GPI
LAC
34.3
5
OR Pregnancy Morbidity
LAC + aCL + 2GPI
aCL + a2GPI

39. TREATMENT
THROMBOSIS
VENOUS EVENT
Warfarin to target INR 2-3
? Long term treatment
ARTERIAL EVENT
Warfarin to target INR 3-4 OR
Target INR 1.5-2.5 and ASA 325
mg/day
Indefinitely
PREGNANCY MORBIDITY
WITHOUT PRIOR THROMBOSIS
Heparin 5000 u SC BID +
ASA 75-81mg/d
Conception to 6-12 weeks
postpartum
WITH PRIOR THROMBOSIS
Heparin 10000 u SC BID
+ ASA 75-81-100mg/d
Conception to Indefinitely
NO PRIOR EVENTS
?? ASA 81mg/d for SLE Patients (both pregnant / non-pregnant)
Lim W. Antiphospholipid Syndrome. Hematology 2013; 675-80.
Lockshin MD. Anticoagulation in Management of APS in Pregnancy. Clin Lab Med 2013; 33(2): 367-376.
Lim W, Crowther MA, Eikelboom JW. Management of APAS: A Systematic Review. JAMA 2006; 295: 1050-57.

40. SUMMARY
• Pregnant SLE patients are high risk
for having multiple adverse events
• Care of the pregnant SLE patient
should be a collaborative effort
• Care starts before conception until
the post partum period with specific
concerns needing to be addressed
• APAS may complicate lupus
pregnancies and is managed
differently from non-pregnant
patients