**6. Disease activity assessment during pregnancy**

As mentioned above, a strict assessment and control of disease activity before and throughout pregnancy is fundamental. Physiological changes in pregnancy may mimic a lupus flare (e.g. constitutional symptoms, non-inflammatory joint pain, skin rash, alopecia), as well as, laboratory changes (e.g. anemia, thrombocytopenia, proteinuria, increase of ESR and complement levels).

In order to reduce confounding features from physiological pregnancy and SLE exacerbations, three scores were modified in order to adapt to these changes: the SLE-Pregnancy Disease Activity Index (SLEPDAI), the LAI (Lupus Activity Index) in Pregnancy (LAI-P), and the modified SLAM (Systemic Lupus Activity Measure) (m-SLAM). Two other pregnancy-adapted scores have been introduced more recently, the modified-European consensus lupus activity measurement (m-ECLAM) and the British Isles Lupus Assessment Group-2004 for pregnancy (BILAG2004-P)*.*

In all the above-mentioned indices, modifications were made to address influential items: some were eliminated (e.g. ESR, asthenia) and others were adapted to physiological pregnancy changes (e.g. proteinuria levels), emphasizing the need to differentiate those changes from pregnancy comorbidities (e.g. PE/E). The scoring of each index is calculated in the same way as the original version, except for the LAI-P, in which the weighted score given to each item has been modified. Although many attempts have been made to have a reliable tool, the clinical judgment of an experienced physician remains the gold standard in the management of pregnant women with SLE. As recently recommended, these women should be frequently monitored (every 2 to 8 weeks). During each visit, prostaglandin A (PGA) in conjunction with at least one of the activity tools and pregnancy-specific SLE activity indices (such as SLEPDAI, LAI-P, BILAG 2004- P) should be applied [20].
