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Systemic lupus erythematosus in preconception care — DFSRH MCQ

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EasyHydroxychloroquineSystemic lupus erythematosus in preconception careDFSRH

A 30-year-old woman with systemic lupus erythematosus attends for preconception counselling and removal of her 52 mg levonorgestrel intrauterine system. She had previously been clinically stable while taking hydroxychloroquine 200 mg daily but stopped it 8 weeks ago because she believed it could cause fetal malformations. She has since developed inflammatory small-joint pain and a photosensitive rash. Complement concentrations have fallen and anti-double-stranded DNA antibody titres have risen. Blood pressure, renal function and urine protein:creatinine ratio are normal. Antiphospholipid antibody testing is negative. She would prefer to conceive soon but is willing to retain the intrauterine system if pregnancy should be deferred. Which is the most appropriate reproductive plan?

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

Reveal the answer and explanation

Correct answer: D — Retain the intrauterine system, restart hydroxychloroquine and defer conception until disease stability is sustained

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

She has clinically and serologically active SLE following withdrawal of hydroxychloroquine. Active disease around conception predicts maternal flare and worse pregnancy outcomes; UK guidance therefore advises postponing pregnancy and maintaining effective contraception until disease has been stable, generally for about 6 months after treatment optimisation. Hydroxychloroquine should be restarted with rheumatology input and continued during a subsequent pregnancy. It reduces lupus disease activity, does not require a preconception washout and, in SLE, its maternal and fetal benefits outweigh the potential fetal risk. A is incorrect because avoiding hydroxychloroquine during the first trimester exposes her to continuing disease activity without an evidence-based reproductive benefit. B is initially plausible because prednisolone is pregnancy-compatible, but symptom resolution alone does not establish sustained clinical and serological stability, and corticosteroid monotherapy unnecessarily omits disease-modifying treatment. C correctly recognises hydroxychloroquine's pregnancy compatibility but conception should not be attempted while lupus remains active or before the drug has taken effect. E incorrectly treats hydroxychloroquine as a teratogen requiring washout; stopping it before conception may precipitate another flare. The intrauterine system can remain in place while disease control is re-established.

Reference: Rheumatology in Pregnancy Guideline (12 February 2021) — https://www.england.nhs.uk/wp-content/uploads/sites/48/2021/06/GMEC-SCN-Rheumatology-in-pregnancy-guideline-FINAL-V1.0-12.02.21.pdf Hydroxychloroquine 300 mg film-coated tablets: Summary of Product Characteristics (20 April 2026) — https://www.medicines.org.uk/emc/product/11732/smpc Executive Summary: British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding (2023) — https://pubmed.ncbi.nlm.nih.gov/36318965/