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Objectives To assess the prevalence of major bleeding (MB) at delivery in pregnant women with systemic lupus erythematosus (SLE) and to characterize MB cases, focusing on the use of antithrombotic prophylaxisMethods This prospective single-center study included 73 pregnancies in women with SLE followed between 2018 and 2022 at Karolinska University Hospital. Clinical, laboratory, and obstetric data were collected from medical records. Preeclampsia (PE) was defined as gestational hypertension with new-onset proteinuria (>=300 mg/24 h) after 20 weeks of gestation. MB was defined as >500 mL blood loss for vaginal delivery and >1000 mL for cesarean section.Results Early miscarriage occurred in 6 pregnancies (8.2%), and 1 was electively terminated. MB occurred in 14/66 (21.2%) successful pregnancies. Compared with those without MB, affected women had longer disease duration and significantly higher rates of lupus nephritis and active proteinuria at conception ( table 1). Most patients received LDASA prophylaxis, while LMWH use was more frequent among MB cases, although not statistically significant (p > 0.05). All LMWH-treated patients (24/66) had LDASA. Only 1 MB patient received a high LMWH thromboprophylaxis dose, with bleeding attributed to uterine atonia (UA). One additional UA and one placenta previa (PP) were recorded in the MB group, all treated with low LMWH prophylactic dose. Two MB and 5 non-MB patients experienced PE (p>0.05).MB occurred in 28.9% of vaginal deliveries, including 5 on LMWH. A total of 21 C sections were performed, with only one case (7.2%) in the MB group due to PP. After excluding cases with UA or PP, known to cause MB per se, three of the remaining 11 vaginal MB cases had received LMWH + LDASA therapy with no difference in median blood loss compared to LDASA only (913 vs. 729 mL, p>0.05).In the MB cohort a trend towards an association with bleeding volume and mean daily prednisolone dose was seen (r = 0.5, p = 0.06).Abstract PO:08:208 Table 1Characteristics of pregnant patients with SLE in regard to major bleeding at deliveryConclusions Major bleeding at delivery was relatively uncommon in SLE pregnancies despite the use of antithrombotic therapy, mainly affecting women with severe disease at conception. Larger studies are warranted to better define risk factors for obstetric complications in SLE.