Am J Obstet Gynecol. 2023 Mar;228(3):B41-B60. doi: 10.1016/j.ajog.2022.09.001. Epub 2022 Sep 6.
Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B).
系统性红斑狼疮（SLE）是一种慢性、多系统、炎症性自身免疫性疾病，其特征为复发（通常称为“发作”）和缓解。许多器官可能受到影响，尽管临床表现高度可变，但肾脏、关节和皮肤通常受到影响。免疫异常，包括抗核抗体的产生，也是该疾病的特征。患有系统性红斑狼疮的母亲发病率和死亡率大大增加，并且在怀孕期间最初诊断为系统性红斑狼疮与发病率增加有关。系统性红斑狼疮的常见并发症包括肾炎、血小板减少等血液学并发症以及各种神经病变。本文件的目的是检查潜在的妊娠并发症，并提供关于系统性红斑狼疮在怀孕期间的治疗和管理的建议。以下是母胎医学学会的建议：（1）我们建议在妊娠 12 周开始至分娩时，使用低剂量阿司匹林，以降低子痫前期的发生（GRADE 1B）；（2）我们建议除了静止性疾病患者外，所有系统性红斑狼疮患者均继续或开始在怀孕期间使用羟氯喹（HCQ）（GRADE 1B）；（3）我们建议对于没有服用 HCQ 或其他药物且静止性疾病活动的其他患者，在与患者的风湿病专家咨询后，合理地共同决策是否开始使用这种药物进行新的治疗（GRADE 2B）；（4）我们建议一般避免在怀孕期间长时间（>48 小时）使用非甾体抗炎药（NSAIDs）（GRADE 1A）；（5）我们建议避免在怀孕期间使用 COX-2 抑制剂和全剂量阿司匹林（GRADE 1B）；（6）我们建议在尝试怀孕前至少 1-3 个月停止甲氨蝶呤和吗替麦考酚酯/麦考酚酸（GRADE 1A）；（7）我们建议与风湿病专家合作，共同决定在怀孕期间开始、继续或停止生物制剂的使用，并根据患者的情况进行个体化治疗（GRADE 2C）；（8）我们建议对于没有血栓形成事件但符合抗磷脂综合征（APS）产科标准的患者，使用预防性普通肝素或低分子量肝素和低剂量阿司匹林联合治疗（GRADE 2B）；（9）我们建议对于有血栓形成和抗磷脂（aPL）抗体病史的患者，使用普通肝素或低分子量肝素治疗（GRADE 1B）；（10）我们建议对于没有临床事件符合抗磷脂综合征标准但有抗系统性红斑狼疮相关抗原 A 或 B（抗-SSA/SSB）抗体的系统性红斑狼疮患者，单独使用低剂量阿司匹林治疗（GRADE 2C）；（11）我们建议由于其未经证实的益处以及对孕妇和胎儿都已知的风险，因此不常规使用类固醇治疗抗 Sjögren 综合征相关抗原 A 或 B（抗-SSA/SSB）抗体引起的胎儿心脏传导阻滞（GRADE 1C）；（12）我们建议在临床试验环境之外，不常规进行抗-SSA/SSB 抗体患者的胎儿心电图评估 PR 间隔的系列胎儿超声心动图检查（GRADE 1B）；（13）我们建议患有系统性红斑狼疮的患者接受母胎医学和风湿病专家的孕前咨询，包括讨论母婴风险（GRADE 1C）；（14）我们建议一般不鼓励患有严重母婴风险的患者怀孕，包括患有活动性肾炎的患者；严重的肺、心脏、肾脏或神经系统疾病；最近的中风；或肺动脉高压（GRADE 1C）；（15）我们建议由于胎儿生长受限（FGR）和死胎的风险增加，患有系统性红斑狼疮的孕妇进行产前检查和系列生长扫描（GRADE 1B）；和（16）我们建议患有系统性红斑狼疮的患者应遵守疾病控制和预防中心的避孕使用医学资格标准（GRADE 1B）。
