**8.6 Management of SLE treatment and APS/aPLs positive patients in breastfeeding**

Breastfeeding should be encouraged for all women and SLE patients are not an exception. However, some medications are transferred into the breast milk and can be harmful for the infant. Additionally, premature or ill infants are more susceptible to some medication's exposure [63, 69].

#### *8.6.1 Drugs that are compatible with breastfeeding*

Hydroxychloroquine is transferred to human breast milk, but only in an insignificant amount, about 2%, which is considered safe. Glucocorticoids, as prednisone or methylprednisolone, are considered compatible with breastfeeding,

**99**

*Systemic Lupus Erythematosus Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.99008*

after maternal ingestion [63, 64].

is very low [63, 64].

during lactation [63, 70].

breastfeeding mothers.

of extreme importance [71–74].

regional anesthesia.

since they are excreted in the breast milk in very low quantities. It is accepted by the American Academy of Pediatrics and the British Society of Rheumatologists. Lactation is recommended to be avoided in the first 4 hours after ingestion of ≥20 mg of prednisone, as the peak concentration in breast milk is achieved 2 hours

Azathioprine, cyclosporine and tacrolimus, IVIG, heparin and warfarin are compatible with nursing, since the evidence shows that the excretion in breast milk

Antihypertensive medications are commonly used, though evidence about the use of ACEIs and breastfeeding are lacking. Some data point out that captopril and/or enalapril seems to be selectively barred from blood to breast milk, so it is unlikely to cause adverse effects in nursing newborns. Nifedipine is considered safe

NSAIDs are not recommended, since there is not enough information about the safety of these drugs. Ibuprofen is the preferred drug, but only because it appears to be excreted in very small amounts in breast milk. Once more, LDA seems to be the

Methotrexate is excreted in low concentrations into breast milk, but it can accumulate in neonatal tissues, so guidelines strongly advise to avoid MTX in

There is no sufficient data on the transmission of mycophenolate mofetil, leflunomide, RTX, BEL and in cyclophosphamide into breast milk, so these drugs

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

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

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

*8.6.2 Drugs that are not compatible or should be avoided when breastfeeding*

exception, but there is no robust data about LDA and nursing.

should be avoided during lactation [58, 63, 70].

**9. Postpartum and neonate complications**

**9.1 Maternal complications of postpartum SLE**

#### *Systemic Lupus Erythematosus Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.99008*

*Lupus - Need to Know*

situations: [23, 52]

*8.5.2 Obstetric APS*

delivery [23, 52].

*8.5.3 Thrombotic APS*

*8.5.4 Refractory obstetric APS*

pregnancy loss can occur [23].

tible to some medication's exposure [63, 69].

*8.6.1 Drugs that are compatible with breastfeeding*

**breastfeeding**

**8.5 Management of maternal antiphospholipid syndrome**

*8.5.1 Asymptomatic aPL-positive patients "aPL carriers"*

APL carriers or APS pregnancy represent a great challenge and require an additional monitoring and therapy to prevent maternal and/or fetal complications. Below is the clinical management according to the different clinical

In SLE *aPL carriers* prophylaxis with LDA daily, is recommended during pregnancy. Combination therapy with prophylactic-dose heparin and LDA, even for those pregnant with triple-positive aPL or high LAC concentration, is not recommended [23, 52]. These women should be treated with prophylactic-dose low

In SLE women with history of obstetric complications prophylactic or therapeutic-dose heparin (usually LMWH) and LDA during gestation is recommended. Prophylactic or therapeutic-dose LMWH should continue until 6 weeks after

Women with previous thrombosis have a high risk of recurrent thrombotic event during pregnancy. Therefore, as soon as pregnancy is confirmed, vitamin K antagonists should be stopped, due to the fetotoxicity, and should be switched to therapeutic LMWH and LDA). LMWH and LDA should be stopped before delivery. Women with thrombotic APS are at very high risk of recurrent venous thromboembolism during post-partum. Therapeutic LMWH dose is recommended. Other possible option is to return to warfarin, which is safe during breastfeeding [23].

Refractory Obstetric APS is a delicate and challenging situation, as there is no response to standard therapy. Some alternatives can be tried such as increased-dose of heparin (LMWH), low-dose prednisone (10 mg/day in the 1st trimester), IVIG, plasmapheresis, HCQ (5-6 mg/Kg/day). In 25% of obstetric APS, despite treatment,

Breastfeeding should be encouraged for all women and SLE patients are not an exception. However, some medications are transferred into the breast milk and can be harmful for the infant. Additionally, premature or ill infants are more suscep-

Hydroxychloroquine is transferred to human breast milk, but only in an insignificant amount, about 2%, which is considered safe. Glucocorticoids, as prednisone or methylprednisolone, are considered compatible with breastfeeding,

**8.6 Management of SLE treatment and APS/aPLs positive patients in** 

molecular weight heparin (LMWH) until, at least, 6 weeks after delivery.

**98**

since they are excreted in the breast milk in very low quantities. It is accepted by the American Academy of Pediatrics and the British Society of Rheumatologists. Lactation is recommended to be avoided in the first 4 hours after ingestion of ≥20 mg of prednisone, as the peak concentration in breast milk is achieved 2 hours after maternal ingestion [63, 64].

Azathioprine, cyclosporine and tacrolimus, IVIG, heparin and warfarin are compatible with nursing, since the evidence shows that the excretion in breast milk is very low [63, 64].

Antihypertensive medications are commonly used, though evidence about the use of ACEIs and breastfeeding are lacking. Some data point out that captopril and/or enalapril seems to be selectively barred from blood to breast milk, so it is unlikely to cause adverse effects in nursing newborns. Nifedipine is considered safe during lactation [63, 70].

#### *8.6.2 Drugs that are not compatible or should be avoided when breastfeeding*

NSAIDs are not recommended, since there is not enough information about the safety of these drugs. Ibuprofen is the preferred drug, but only because it appears to be excreted in very small amounts in breast milk. Once more, LDA seems to be the exception, but there is no robust data about LDA and nursing.

Methotrexate is excreted in low concentrations into breast milk, but it can accumulate in neonatal tissues, so guidelines strongly advise to avoid MTX in breastfeeding mothers.

There is no sufficient data on the transmission of mycophenolate mofetil, leflunomide, RTX, BEL and in cyclophosphamide into breast milk, so these drugs should be avoided during lactation [58, 63, 70].
