Autoimmune diseases with pregnancy

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Autoimmune diseases with pregnancy
Prof.Dr. El Sayed El Badawy Mohamed Obs Gyn,
Fetal Maternal Medicine Department Alexandria
University Dr Amr Silliman Ass. Lecturer ,Alex
University
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• The term Autoimmune disease is used when there is
  evidence of immune response to self-constituents.
• Evidence of immune response is confirmed by the
  detection of characteristic auto antibodies in
  the patients circulation.
• Theories of autoimmunity
• Failure in the normal deletion of lymphocytes
  that recognized self-antigens.
• Failure in the normal regulation of the immune
  system.

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• Co-existence of pregnancy and autoimmune disease
  is far from rare.
• Some autoimmune diseases can have profound
  effects on pregnancy.
• Some may be influenced by pregnancy.
• Others are unique to pregnancy or have unique
  features associated with pregnancy.

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Systemic Lupus Erythematosus

• Maternal risks
• Exacerbation of SLE during pregnancy.
• Lupus Nephritis
• Pregnancy Induced Hypertension and Pre-eclampsia

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Systemic Lupus Erythematosus

• Fetal Risks
• Pregnancy loss.
• Preterm delivery.
• Fetal growth impairment.
• Neonatal Lupus Erythematosus.
• Drug Effects
• Congenitalneonatal heart block

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Systemic Lupus Erythematosus Management

• Pre-pregnancy
• Establish good control of SLE adjust maintenance
  medications
• If possible, discontinue azathiprine,
  methotrexate and cyclophosphamide therapy before
  conception. UNDER CAREFUL SUPERVISION.
• Lab assessment for anemia, thrombocytopenia,
  underlying renal disease and antiphopholipid
  antibodies.
• Counseling SLE exacerbations, PIH risks,
  Fetal/Neonatal risks.

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Systemic Lupus Erythematosus Management

• Prenatal
• Joint obstetrician and rheumatologist
  surveillance.
• Encourage early pregnancy antenatal care.
• Accurate dating with U/S in early pregnancy.
• Close follow up every 2 weeks in first and second
  trimester every week in third trimester.
• Watch for signs and symptoms of SLE flare, PIH
  and IUGR.
• For those with renal involvement perform monthly
  24 h urine collections for creatinine clearance
  and total protein.

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Systemic Lupus Erythematosus Management

• Prenatal
• Drugs corticosteroids are safe,
• azathioprines are second line
  therapy
• methotrexate and cyclophophamide as
  third line
• AFTER THE FIRST TRIMESTER,
• AVOID antimalarials and full dose NSAIDs.
• Serial U/S examinations for fetal growth,
  umbilical artery doppler and amniotic fluid
  volume.
• Begin fetal surveillance at 30 to 32 weeks
  (earlier in patients with worsening disease,
  evidence of fetal compromise, BOH
• Consider low dose aspirin therapy

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Systemic Lupus Erythematosus Management

• Labor/Delivery
• Deliver at term in absence of complications
  AVOID POST TERM.
• Continuous electronic fetal monitoring.
• Steroid boluses at delivery for patients on
  chronic steroid therapy.
• Pediatric and anesthesiology notification.

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Systemic Lupus Erythematosus Management

• Postnatal
• Watch for SLE exacerbation.
• Restart maintenance therapy.
• Evaluate neonate for SLE-associated
  manifestations.

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Anti-phospholipid syndrome
This is an autoimmune condition characterized by
the production of moderate to high levels of
anti-phospholipid antibodies and certain clinical
features.
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Anti-phospholipid syndrome

• Clinical features
• Pregnancy loss fetal death, recurrent pregnancy
  loss.
• Thrombosis venous, arterial, including stroke.
• Autoimmune thrombocytopenia
• Coombs positive hemolytic anemia.
• Livedo reticularis.

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Anti-phospholipid syndrome

• Lab features
• Lupus Anticoagulant (LA).
• Anticardiolipin antibodies IgG, medium to high
  positive.
• Anticardiolipin antibodies IgM, medium or high
  positive and LA.
• At least one clinical feature with moderate or
  high levels of anti phopholipid antibodies, are
  required for diagnosis.

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Anti-phospholipid syndrome

• Maternal risks
• Thrombosis and stroke.
• Postpartum syndrome.
• Pre-eclampsia (30-50)

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Anti-phospholipid syndrome

• Fetal risks
• Pregnancy loss. (abortionstillbirth)
• Fetal growth impairment and fetal distress.
• Preterm birth.

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Anti-phospholipid syndrome Management

• Pre-pregnancy
• Counseling regarding risks
• Check for Anemia, Thrombocytopenia, Renal
  Compromise
• Thromboprophylaxis for all (controversial)

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Anti-phospholipid syndrome Management

• Prenatal
• Joint obstetrician and rheumatologist
  surveillance.
• Low dose aspirin and subcutaneous heparin.
• Increased frequency of attendance.
• Surveillance for fetal growth and health.
• Screen for pre-eclampsia.

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Rheumatoid Arthritis

• Maternal risks
• RA and pregnancy have a unique relationship.
• At least 50 of patients show improvement in
  their symptoms in at least 50 of their
  pregnancies.
• A quarter of RA patients will have no improvement
  in their disease during pregnancy and in a small
  number of cases the disease may actually worsen.

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Rheumatoid Arthritis

• Fetal risks
• Controversial higher rate of spontaneous
  abortion.
• RA probably does not affect fertility.
• NO increased risk of preterm birth, IUGR,
  pre-eclampsia.

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Rheumatoid Arthritis Management

• Pre-pregnancy
• Counseling regarding risks
• Review of therapy to improve disease control
• Reduce dosages to lowest levels achieving
• therapeutic effect.

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Rheumatoid Arthritis Management

• Prenatal
• Regular review
• Rest
• Physiotherapy
• Drugs try and avoid full-dose aspirin and
  NSAIDs, steroids for
• worsening disease, AVOID methotrexate in
  first trimester,
• D-penicillamine contraindicated.
• Labor/Delivery
• Individualize care according to physical
  abilities.

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Myasthenia Gravis

• This disorder is characterized by variable
  weakness
• and fatigability of skeletal muscles.
• Increasing weakness with repetitive use of the
• muscle is an outstanding feature.
• Autoantibodies to human acetyl-choline receptors
• is recognized in around 75 of patients.

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Myasthenia Gravis

• Maternal risks
• Size of the growing uterus can cause respiratory
• embarrassment.
• Affection of bearing down effort during labor and
• delivery, thus operative delivery is common.
• Exertion during labor and delivery may lead to
• respiratory embarrassment.

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Myasthenia Gravis

• Fetal risks
• Arthrogryposis Multiplex Congenita multiple
  joint contractures due to long standing muscle
  weakness and joint non use. However, most MG
  pregnant women report normal fetal movements.
• Fetal/Neonatal MG transplacental passage of
  a-AChR antibodies to the fetus. Symptoms usually
  develop several days after delivery.

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Myasthenia Gravis, Management

• Pre-pregnancy
• Counseling regarding risks
• Review of therapy
• Consider thymectomy

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Myasthenia Gravis, Management

• Prenatal
• Joint obstetrician and rheumatologist
  surveillance
• Continue pre-existing drugs anticholinesterase,
  steroids, azathioprine.
• Plasmapheresis for drug-resistant cases.
• Fetal surveillance, especially activity (BPP
  score)
• AVOID/MINIMIZE physical/emotional stress.

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Myasthenia Gravis, Management

• Labor/Delivery
• Minimize stress
• Continue anticholinesterase drugs
• Steroid cover if on steroids
• Regional analgesia preferable to narcotics for
  pain relief and general anesthesia
• Experienced anesthetists if general anesthesia
  needed
• Assisted second stage more likely
• Avoid magnesium sulfate in patients with
  pre-eclampsia

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Myasthenia Gravis, Management

• Postnatal
• Review dosage of drugs
• Special care and surveillance of newborn
• may need short term anticholinesterases

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