Autoimmune conditions in pregnancy

Raheel Sikandar Fcps

High progesterone /estrogen (P/E) ratio

The post partum is critical for some autoimmune and inflammatory diseases

C. Confavreux et al. New Engl J Med 1998 339:285

Examples of Autoimmune Diseases

Multiple sclerosis Myasthenia gravis Crohns disease Graves disease Type 1 Diabetes mellitus Rheumatoid arthritis Psoriasis Scleroderma Systemic lupus erythematosus

Management options

PRE PREGNANCY Counsell regarding the risks RA-No risks SLE-Flare,abortion,SB,Neonatal lupus APS-Abortions,IUGR,Placental abruption SLARODERMA-Cardiopulmonary risks,avoid pregnancy

Management options

Myasthenia Gravis-close supervision, fetal risks PRENATAL CARE JOINT OBSTETRITIAN & PHYSICIAN CLINIC Encourage early booking Frequent visits

Monitor for

Signs of flare, joint stiffness, fatigue,anaemia and hypertension Fetal anomalies Fetal growth labs e.g Ro in maternal circulation

DRUGS
NSAIDs Low dose asprin Steroids Antimalarial Anti coagulants Cytotoxics Methotraxate,Azathyioprine.cyclophosphamide ,Penicllimine Anticholinestrase Plasma pheresis

Labour & delivery

TIME as near term as possible never postdate MODE according to obstetrical indication MONITORING continuous electronic POST NATAL Neonatal monitoring for disease expression ,CA,speciality care

THANK U

Rheumatoid arthritis
causing Chronic inflammatory, symmetrical arthritis Joint stiffness and anaemia Associated with 30% presence of ANA,Ro/La

No effect on pregnancy usually

Management
PRE-PREGNANCY Counseling regarding risks Review of therapy to improve disease control Reduce dosage to lowest maintenance Avoid terotegens PRENATAL Regular,with advise for rest andphysitherapy

Drugs
Paracetamol Hydroxy chloroquine Sulphasalazizine Corticosteroids Methotraxate Avoided in first trimester Penicillimine Contraindicated LABOUR & DELIVERY According to physical abilities

Systemic lupus erythematous SLE

Chronic inflammatory disease that can effect various organs of the body Characterized by production of antibodies to components of cell nucleus Whos affected:
Young women, peak incidence age 15-40 years with female: male ratio 5:1 African Americans have higher lupus mortality risk compared to Hispanics and Caucasians

Organs involved
90% joints 80% skin, serous membranes, lungs 67% kidneys, heart 25% CNS, small vessels Risk factors Genetic predisposition (i.e. black race, 25-50% monozygotic twin concordance, 5% dizygotic twin concordance Postmenopausal hormone replacement therapy associated with increased risk for developing SLE

Diagnosis is clinical and may be made with 4 classification criteria present

Criteria is (96% specific, 96% sensitive)
any 4 or more of 11 criteria, serially or simultaneously, during any interval of observation

1. malar (butterfly) rash - fixed erythema, flat or raised, over malar eminences, tending to spare nasolabial folds

 2. discoid lupus - erythematous raised patches with adherent keratotic scaling and follicular plugging, atrophic scarring may occur 3. photosensitivity - skin rash resulting from unusual reaction to sunlight
4. oral or nasopharyngeal ulcers - usually painless, observed by physician 5. non-erosive arthritis - involving 2 or more peripheral joints with tenderness, swelling or effusion

 6. serositis - pleuritis (pleuritic pain, pleuritic rub or pleural effusion) or pericarditis (on ECG, rub or pericardial effusion) 7. renal involvement - persistent proteinuria (> 500 mg/day or 3+ on dipstick) or cellular casts (red cell, hemoglobin, granular, tubular or mixed) 8. seizures or psychosis without other organic cause 9. hematologic disorder
hemolytic anemia with reticulocytosis, OR WBC < 4,000 at least 2 times, OR absolute lymphocyte count < 1,500/mm3 at least 2 times, OR platelet count < 100,000/mm3 without thrombocytopenic drugs

 10. immunologic disorder

anti-DNA, antibody to dsDNA [native DNA] in abnormal titer, OR anti-Sm Ab (antibody to Sm nuclear antigen), OR positive finding of antiphospholipid antibodies based on abnormal serum level of IgG or IgM anticardiolipin antibodies, OR positive test for lupus anticoagulant using standard method, OR

 false positive serologic test for syphilis for at least 6 months and confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody absorption test

11. positive ANA of abnormal titer in absence of drugs associated with "drug-induced lupus"