**9. Postpartum and neonate complications**

Maternal and fetal complications after pregnancy can result not only from SLE (disease), but also from other factors frequently associated with SLE. Maternal flares can occur in any trimester of pregnancy or after delivery, but it seems to be more prevalent in the 3rd trimester and until one year after delivery. Thus, the importance of maternal (and newborn) monitoring in the first year after delivery is of extreme importance [71–74].

#### **9.1 Maternal complications of postpartum SLE**

In a healthy SLE pregnancy, the woman should be offered the chance to a spontaneous labor, at term, with vaginal delivery [75]. Maternal medication may need a special adjustment for labor: intravenous hydrocortisone to overcome its physiological stress, discontinuation of LMWH, for which the timing will condition regional anesthesia.

As mentioned, SLE is associated with a higher incidence of maternal complications, both during pregnancy and in the postpartum period. Pregnant women with SLE are more likely to have a cesarean section (unplanned), high blood pressure, pre-eclampsia, spontaneous abortion, thromboembolic events, and infections [20]. In patients under corticosteroids at immunosuppressive dose (≥1 mg/Kg), prophylactic antibiotics is recommended, due to the risk of infections and sepsis [75].

HELLP syndrome (characterized by hemolysis, elevated liver enzymes and a low platelet count in the context of pregnancy) can, by definition, occur in the postpartum period. This occurs in one third of the cases, being more prevalent in women with severe pre-eclampsia [43]. Catastrophic antiphospholipid syndrome (CAPS), characterized by acute thrombotic micro-angiopathy, was also recorded in the postpartum period [76]. These syndromes are more frequent in patients with SLE, thus increasing the risk of complications in this population.

The postpartum period demands a rigorous monitoring for maternal complications, as SLE flare [75]. Although no increased risk of lupus flares between 2 and 6 months postpartum, compared to during pregnancy, was found, which rate is about 24%, flares can reach almost every patient in the first 6 months after delivery [39]. The treatment for these situations is similar for non-pregnant SLE patients, but the risks of breastfeeding under aggressive therapy should be outweighed. LMHW should be continued for 6 weeks after delivery, due to the increased risk of venous thromboembolism (VTE) during puerperium. Contraception should be encouraged, but estrogen-containing pills must not be used by women with aPL antibodies or APS, moderate to severe SLE and other conditions, as previous VTE, hypertension, obesity or smoking.
