Autoimmune Conditions in Pregnancy

7/29/2019 Autoimmune Conditions in Pregnancy

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Autoimmune conditions in

pregnancy

Raheel Sikandar

Fcps


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High progesterone

/estrogen (P/E) ratio


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The post partum is critical for some autoimmuneand inflammatory diseases

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


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Examples of Autoimmune Diseases

Multiple sclerosis

Myasthenia gravis

Crohnsdisease

Graves disease

Type 1 Diabetes mellitus

Rheumatoid arthritis

PsoriasisScleroderma

Systemic lupus erythematosus


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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


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Management options

Myasthenia Gravis-close supervision, fetal risks

PRENATAL CARE

JOINT OBSTETRITIAN & PHYSICIANCLINIC

Encourage early booking

Frequent visits


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Monitor for

Signs of flare, joint stiffness, fatigue,anaemia and

hypertension

Fetal anomalies

Fetal growth

labs e.g Ro in maternal circulation


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DRUGS

NSAIDs Low dose asprin Steroids

Antimalarial

Anti coagulants Cytotoxics

Methotraxate,Azathyioprine.cyclophosphamide

,Penicllimine Anticholinestrase

Plasma pheresis


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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


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THANK U


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Rheumatoid arthritis

causing Chronic inflammatory, symmetricalarthritis

Joint stiffness and anaemia

Associated with 30% presence of ANA,Ro/La

No effect on pregnancy usually


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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


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Drugs

Paracetamol

Hydroxy chloroquine

Sulphasalazizine

Corticosteroids

Methotraxate Avoided in first trimester

Penicillimine Contraindicated

LABOUR & DELIVERY

According to physical abilities


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Systemic lupus erythematousSLE

Chronic inflammatory disease that can effect variousorgans of the body

Characterized by production of antibodies to

components of cell nucleus Whos affected:

Young women, peak incidence age 15-40 years withfemale: male ratio 5:1

African Americans have higher lupus mortality riskcompared to Hispanics and Caucasians


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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 twinconcordance

Postmenopausal hormone replacement therapyassociated with increased risk for developing SLE


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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 orsimultaneously, during any interval of

observation

1. malar (butterfly) rash - fixed erythema,

flat or raised, over malar eminences,

tending to spare nasolabial folds


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2. discoid lupus - erythematous raised patcheswith adherent keratotic scaling and follicularplugging, atrophic scarring may occur

3. photosensitivity - skin rash resulting fromunusual reaction to sunlight

4. oral or nasopharyngeal ulcers - usually painless,observed by physician

5. non-erosive arthritis - involving 2 or moreperipheral joints with tenderness, swelling oreffusion


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6. serositis - pleuritis (pleuritic pain, pleuritic rub or pleuraleffusion) 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, tubularor 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


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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 antibodiesbased on

abnormal serum level of IgG or IgManticardiolipin antibodies, OR

positive test for lupus anticoagulant using

standard method, OR


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Autoimmune Conditions in Pregnancy