Fertility is usually normal in systemic lupus erythematosus. However, cyclophosphamide therapy has been associated with an increased risk for sustained amenorrhea in these patients. There is still debate as to whether pregnancy increases systemic lupus erythematosus activity. We have known for decades that systemic lupus erythematosus is associated with an increased risk for pregnancy loss. Now we know that most excess fetal loss in women with systemic lupus erythematosus occurs in association with antiphospholipid antibodies, which also are associated with pregnancy loss in otherwise healthy women. Prematurity, intrauterine growth retardation, and preeclampsia are common features of lupus pregnancy, especially in women with antiphospholipid antibodies. Pregnancy complicated by antiphospholipid syndrome requires expert care and a team approach involving obstetricians, obstetric physicians, rheumatologists, and clinical hematologists. Treatment and close monitoring including uterine artery Doppler scans and timely delivery may improve fetal outcome in these cases. Although there is no evidence that maternal prednisone should be used prophylactically, fluorinated steroids may be efficacious after in utero identification of congenital heart block, especially in fetuses with associated myocarditis.