Medicine Matters rheumatology

D is the correct answer. MMF is a teratogenic drug that should be stopped at least 6 weeks before conception. It may be replaced with antirheumatic drugs compatible with pregnancy such as cyclosporine or azathioprine, both of which are effective in controlling SLE manifestations, including renal disease. Hydroxychloroquine should be part of the treatment protocol in the absence of contraindications. Any SLE patient can gain benefit from hydroxychloroquine as this drug has been shown to decrease the risk of maternal flare during pregnancy and adverse pregnancy outcomes. It should preferably be started prior to conception. After the treatment with a teratogenic drug has been switched to a ’safe’ drug, a waiting period of 6–12 months should be recommended prior to pregnancy, especially if there is a history of major organ involvement, in order to ensure proper disease control. Since the patient has a high risk aPL profile (triple positivity), prophylactic enoxaparin should be added to LDASA at positive pregnancy test in order to prevent first maternal thromboembolic event and/or obstetrical adverse outcome. Angiotensin converting enzyme inhibitors such as ramipril should be stopped as soon as the pregnancy test is positive.

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