Relationship of lupus nephritis and pregnancy: A narrative review

Table 1 The relationship between lupus nephritis and pregnancy

Risk of lupus to pregnancy	Risk of pregnancy to lupus
Pregnancy loss	Lupus flares
Pre-term delivery	Progressive renal disease
Eclampsia	Maternal thromboembolism
Neonatal lupus due to Ro and La antibodies

Table 2 Lupus nephritis in pregnancy: Evaluation and monitoring

Before pregnancy	Every 6-8 weeks (adjustable)1
Complete metabolic panel	Complete metabolic panel
Prothrombin time/partial thromboplastin time
24-h urinary protein and creatinine clearance2
sPCR	sPCR
Anti-dsDNA	Anti-dsDNA
Anti-Ro/SS-A and anti-La/SS-B antibodies
Lupus anticoagulant3
Anticardiolipin IgG, IgM, IgA3
Anti-β2 glycoprotein I IgG, IgM, IgA3
Complement levels (C3, C4)	Complement levels (C3, C4)
Uric acid	Uric acid
Urine detailed report with microscopy	Urine detailed report with microscopy

¹Adjust monitoring intervals based on the clinical situation.

²For patients with proteinuria, consider repeating the 24-hour urine test each trimester.

³If the test is positive for the first time, repeat it after 12 weeks.

Anti-dsDNA: anti-double stranded DNA; sPCR: Spot protein/creatinine ratio.

Table 3 Medication compatibility with pregnancy and lactation

Medications	Before conception	During pregnancy	Lactation
Stop at conception
Abatacept	Stop with the positive pregnancy test		+
Belimumab	Stop with the positive pregnancy test		+
Rituximab	Stop with the positive pregnancy test		+
Compatible drugs
Hydroxychloroquine	+	+	+
Azathioprine	+	+	+
Cyclosporine	+	+	+
Tacrolimus	+	+	+
Sulfasalazine	+	+	+
Prednisone	Dose < 20 mg/day	Dose < 20 mg/day	Dose < 20 mg/day
NSAIDs	Discontinue w/difficulty conceiving	Stop at week 20	+
Non-compatible drugs
Cyclophosphamide	Stop 3 months before conception	x	x
MMF/mycophenolic acid	Stop 6 weeks before conception	x	x
Methotrexate	Stop 1-3 months before conception	x	x low transfer into breast milk

NSAIDs: Non-steroidal anti-inflammatory drugs; MMF: Mycophenolate mofetil.

Table 4 Features important in differentiating lupus nephritis from pre-eclampsia

Features	Lupus nephritis	Pre-eclampsia
Timing	Any time during pregnancy	After 20 weeks of gestation
Hypertension	Can be present or absent	Always present
Other organ involvement	Present (e.g., skin, joints)	Absent
Complement levels (C3, C4)	Decreased or normal	Normal
Anti-dsDNA	Positive	Negative
Lupus serology	Active disease markers present	Usually absent
Active urinary sediment Urinary calcium Response to steroids	Present	Absent
	> 195 mg/d	< 195 mg/d
	Generally responsive	No response
Platelet count	Usually normal or mildly low	Often low (thrombocytopenia)
Liver enzymes	Usually normal	Elevated (HELLP syndrome)

HELLP: Hemolysis, elevated liver enzymes, and low platelets.