Preconception counseling regarding congenital heart block in her child is appropriate for this patient with systemic lupus erythematosus (SLE) who is positive for anti-Ro/SSA antibodies. Patients with SLE experience miscarriage, stillbirth, preeclampsia and premature delivery two to five times more often than patients without the disease. This patient has mild SLE, and her disease has been quiescent for 18 months; therefore, this is an appropriate time to attempt pregnancy. Expert opinion recommends conception when SLE has been quiescent for at least 6 months. A major risk to her child would be congenital heart block, which affects approximately 2% of pregnancies in which the mother is positive for anti-Ro/SSA or anti-La/SSB antibodies. Some of these newborns require pacing from birth if there is complete heart block at delivery. Pregnancies in mothers who are positive for anti-Ro/SSA or anti-La/SSB antibodies should be monitored closely and should include input from high-risk obstetrics and neonatology because these antibodies can pass the placenta and affect the developing cardiac conduction system. If the mother has had a previously affected child, subsequent pregnancies carry a 12% risk of congenital heart block. Positivity for anti-Ro/SSA or anti-La/SSB antibodies also confers a risk for neonatal lupus erythematosus, which is characterized by rash as well as hematologic and hepatic abnormalities that generally resolve when the antibody dissipates. The use of phototherapy for neonatal hyperbilirubinemia may cause the rash to develop because the antibody is associated with photosensitivity.
Hydroxychloroquine is thought to be safe in pregnancy and has been shown to reduce the risk of congenital heart block in newborns whose mothers are positive for anti-Ro/SSA or anti-La/SSB antibodies. It should therefore not be discontinued in this patient.
This patient is not at an increased risk of lupus nephritis because it has not been a feature of her disease to date, and she is negative for anti–double-stranded DNA antibodies.
Although anti-Ro/SSA antibodies increase the risk of developing subacute cutaneous lupus, pregnancy does not increase this risk further and does not need to be part of preconception counseling. Because a photosensitive rash has been one of the features of this patient's illness, she is aware of the hazard of sun exposure.