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Management of Systemic Lupus Erythematosus

           Oral contraceptive and intrauterine device (IUD) have no association
           with thrombosis, worsening of SLEDAI score and mortality in patients
           with  SLE. 15,  level  I;  109,  level  I  Refer to  Appendix  10 for the  Types of
           Contraception Recommended for Patients with SLE.

           Recommendation 12
           •  All women with systemic lupus erythematosus in the reproductive
             age should receive pre-pregnancy counselling.

           b.  Antenatal care
           The management principles for SLE during pregnancy are as follows:
             •  Obstetric Care: Standard pregnancy care protocols provided by
               the obstetric team shall be followed.
             •  Rheumatological  or  Subspecialty  Care:  The  rheumatologist
               or  a  subspecialty  team  will  co-manage  any  disease-related
               complications and ensure optimal care for the patient.
             •  Combined  Care:  Effective  communication  and  multidisciplinary
               care among healthcare providers co-ordinated by family medicine
               specialists are essential.
           The  management  of  pregnant  women  with  SLE  is  tabulated  below
           (refer to Table 4).
                 Table 4: Management of Pregnant Women With SLE
            Timeline      Monitoring               Action Plan
            First   •  Blood pressure     •  Start low dose aspirin
            trimester  •  SLE clinical assessment  •  Be vigilant for disease flares
                    •  Laboratory investigation*  •  Review medication compatibility
                    •  Foetal ultrasound to confirm    and adherence
                      intrauterine pregnancy and  •  Patients with obstetric-APS** - start
                      establish gestational age    prophylactic LMWH
                                          •  Patients with thrombotic APS** -
                                            switch from oral anticoagulants to
                                            full dose LMWH
                                          •  For active SLE:
                                              medication adjustment
                                              MDT discussion and shared
                                             decision-making
                                              for continuation of pregnancy in
                                              certain situations
                                          •  Schedule for combined care
            Second  •  Blood pressure     •  Be vigilant for disease flares
            trimester  •  SLE clinical assessment  •  Review medication adherence
                    •  Laboratory investigations*   •  Calcium supplementation for
                      with assessment for     pre-eclampsia prophylaxis if not
                      gestational diabetes and     started previously. The recommended
                      genetic screening     dose is calcium carbonate 1 g BD
                      (if applicable)       commenced before 20 weeks
                    •  Foetal echocardiogram    gestation.
                      between 16 - 25 weeks of  •  congenital heart block,

                                      37
                      gestation for mothers with     co-management with feto-maternal
                      positive anti-Ro/SSA or     specialist is required
                      anti-La/SSB by feto-maternal
                     specialist
                    •  Ultrasound to evaluate foetal
                      anatomy, foetal growth and
                      placental insufficiency
            Third   •  Blood pressure     •  Be vigilant for disease flares
            trimester  •  SLE clinical assessment  •  Review medication adherence
                    •  Laboratory investigations*  •  Review preparations for labour and
                    •  Regular ultrasound to   delivery
                      evaluate foetal growth,   •  Avoid NSAIDs
                      adequacy of amniotic fluid
                      and placental insufficiency
            Post-   •  Blood pressure     •  Be vigilant for disease flares
            partum and  •  SLE clinical assessment  •  For APS - continue LMWH for
            lactation  •  Laboratory investigations*    6 weeks
                                          •  Switch to lactation compatible
                                            medications if breastfeeding is
                                           desired
                                          •  For prednisolone ≥40 mg/day,
                                            delay breastfeeding at least four
                                            hours after consumption
                                          •  Refer neonate to paediatrician to
                                            rule out neonatal lupus
                                          •  Advise regarding contraception***
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