Pregnancy is an altered immunologic state in which hormonal changes affect the immune system to enable maternal tolerance of the fetus. These hormonal and immunologic changes may influence systemic lupus erythematosus disease activity. Managing lupus nephritis in pregnancy presents diagnostic and therapeutic challenges for healthcare providers. Pregnancy induces a series of physiological changes in the immune system and kidneys, increasing the risk of disease flare and adverse maternal and fetal outcomes, such as preeclampsia, fetal loss, and preterm delivery. Kidney biopsy can be risky due to the high risk of complications and should be considered if its results would influence management. The risks associated with kidney biopsy are relatively low in early pregnancy. Pregnancy should be planned during periods of well-controlled lupus nephritis. The antimalarial drug hydroxychloroquine should be continued, and the only permitted immunosuppressive drugs are azathioprine and tacrolimus. Preconception preparation could prevent maternal-fetal complications.
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