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Pregnancy in systemic lupus erythematosus — SCE Rheumatology MCQ

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ModerateSystemic Lupus ErythematosusPregnancy in systemic lupus erythematosusSCE Rheumatology

A 31-year-old woman with systemic lupus erythematosus is reviewed at 10+5 weeks’ gestation in her first pregnancy. Previous class III lupus nephritis has been in complete renal remission for 2 years. She takes hydroxychloroquine and azathioprine. Blood pressure is 112/68 mmHg, serum creatinine is 61 micromol/L and urine protein:creatinine ratio is 8 mg/mmol. She has no diabetes or chronic hypertension. Lupus anticoagulant, anticardiolipin and anti-beta-2-glycoprotein I antibodies have been negative on repeated testing, and she has no history of thrombosis or pregnancy morbidity. Which preventive pharmacological strategy is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Start aspirin 75–150 mg daily at 12 weeks and continue until birth

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

Systemic lupus erythematosus itself places a pregnant woman in the NICE high-risk category for pre-eclampsia, irrespective of current disease quiescence, renal remission or antiphospholipid-antibody status. NICE therefore advises aspirin 75–150 mg daily from 12 weeks until birth. ([nice.org.uk](https://www.nice.org.uk/guidance/ng133/chapter/recommendations?utm_source=openai)) Starting aspirin at 20 weeks (B) misses the recommended initiation point. Low-molecular-weight heparin alone (C) does not replace aspirin for prevention of hypertensive pregnancy complications and there is no venous thromboembolism or antiphospholipid-syndrome indication here. Combined aspirin and prophylactic heparin (D) would be appropriate in relevant obstetric antiphospholipid syndrome, but repeated antiphospholipid testing is negative and she has no qualifying morbidity. Waiting for hypertension or proteinuria (E) confuses prevention with treatment: aspirin should begin before clinical evidence of pre-eclampsia appears. Her previous nephritis increases the need for close multidisciplinary surveillance, but its sustained remission and pregnancy-compatible immunosuppression do not alter the indicated aspirin strategy.

Reference: Hypertension in pregnancy: diagnosis and management — Recommendations (Published 25 June 2019; updated 17 April 2023) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations