Autoimmune disease in Pregnancy

Autoimmune disorders:
More common among pregnant women
Abnormal antibodies can cross the placenta and affect the
foetus
Pregnancy affects autoimmune diseases in different ways
Most common conditions
Thyroid disease
o Graves disease
o hashimotos
ITP
Chrons disease
UC
SLE
Myasthemia gravis
RA
Thyroid
Gravess disease
o Hyperthyroidism
o Goitre
Hashimotos thyroiditis
o Chronic autoimmune thyroiditis
o Most common cause of hypo
o Gradual thyroid failure or goitre
o Autoimmune
Hyperthyroidism
o Diagnosis
TSH <0.01
Raised free T4
+/- Raised free T3
Difficult to ascertain in pregnancy
o Causes of hyperthyroidism
Graves
Gestation transient thyrotoxicosis HCG mediated
Molar pregnancy
Familial gestation thyrotoxicosis
o Increased risk of
Miscarriage
Premature labour
LBW
Still birth
Pre-eclampsia
Heart failure

Hypothyroidism
o Usually subclinical rather than overt
o PET and PIH
o Placental abruption
o Non-reassuring CTG
o Preterm delivery
o Increased risk of C/S
o PPH due to uterine atony
Thyroid peroxidase antibodies
o Increased risk of miscarriage
o Increased risk of preterm delivery
o 20% develop hypothyroidism
o May be reduced by T4 replacement
T4 therapy in pregnancy
o Hypothyroid women need more T4 in pregnancy 50%
o Aim at normalising TSH levels
o Important for foetal brain development
Post-partum thyroiditis
o Occurs in 5-10% of all pregnancies
o May occur after delivery or pregnancy loss
o May decrease milk volume
o Transient hyperthyroidism followed by transit hypo
o May recur n subsequent pregnancies
o Risk may be reduced by selenium supplements

Immune thrombocytocic Purpura

Diagnostic
o Isolated thrombocytopenia
o No other drugs or conditions that may affect platelet
count
o Exclude HIV, Hep C, SLE, B12 deficiency
Pathology
o Increased platelet destruction
o Inhibition of platelet production
o Mediated by IgG abs against platelet membrane
glycoproteins
o Usually chronic
Features
o Petechiae, purpure, easy bruising
o Epistaxis, menorrhagia, bleeding from gums
o GIT bleeding, haematuria, intracranial bleed rare
o Most picked up on regular screen
Pregnancy
o May affect foetus in up to 15% of cases
o Neonatal count may drop sharply several days after
birth

o Difficult to differentiation from gestational

thrombocytopenia
o Epidural safe if count > 50000
o Prednisone +/- IVIG if count <50000
o Manage delivery according to standard obstetric
practice
o Avoid NSAIDs post-partum
Gestational Thrombocytopenia
Incidence about 5%
Late pregnancy symptoms/ onset
Mild >70000
No foetal neonatal thrombocytopenia
Post partum resolution
Crohns disease
Pregnancy
o Pregnancy has no effect on disease activity
o Perianal disease not worsened by vaginal delivery
o Fistulas may occur during pregnancy
o Elective C/S controversial
o Increased risk of preterm delivery and IUGR
o Comparable to effect of moderate smoking
o Higher risk of disease active at conception
o Careful monitoring during pregnancy
Ulcerative Colitis
Pregnancy
o Related to disease activity at time of conception
o If in remssion at conception likelt to stay in remission
during the pregnancy
o Higher risk is disease active at conception
o Some studies suggest increase in preterm birth weight
Investigation
o Flexible sigmoidoscopy safe in pregnancy
o Colonoscopy and xrays should be avoided
Rx
o Sulphasalzine safe during pregnancy and breastfeeding
o 5-ASA drugs (e.g. mesalamine) probably safe
o Glucocorticoids should not be withheld if clinically
indicated
SLE

Worry about kidneys, heart and lung symptoms in pregnancy

Pregnancy contraindicated in
o Severe pulmonary hypertension
o Restritictvie lung disease

o HF
o Hx of severe HELLP or PET
o Stroke within previous 6/12
o Recent flare in previous 6/12
Complications
o Disease exacerbating
o Miscarriage, still birth
o IUGR, low birth weight
o Drugs
Antiphospholipid antibodies
o Anti-cardiolipin
o Lupus anticoagulant
o Increased risk of miscarriage
Investigations
o Exam and BP
o RBC, renal function
o Anti-Ro/ SSA abs and anti-La/SSB abs
o LA and aCL assays
o Anti-dsDNA abs
o Complement
Complement tells us the disease activity of SLE
(goes down in more disease)

Myasthenia Gravis
Typically presents with fluctuating skeletal muscular weakness
May be ocular or generalised
May have antibodies to the AChR
Main problems is with respiratory involvement
Pregnancy
o Variable effect
o Post-partum exacerbation in 30%
o Infections can trigger exacerbations
o Steroids can cause transient worsening
o MgSO4 is contraindicated
Effect on fetus
o Trans placental passage of IgG anti-AChR
o Neuromuscular junction disorders
o Transient neonatal MG in 10-20%
o Decreased FMs and breathing
o Polyhydramnios
o Arthrogyposis multiplex congenital
Limb anomalies
Labour and delivery
o First sage not affected
o Second stage: expulsive efforts may weaken
o Assisted vaginal deliver may be indicated

o Pre-labour anaesthetic assessment indicated

Rheumatoid arthritis
Pregnancy
o Affects 1-2% of general pop
o More common in women
o RA in pregnancy is common challenge
o Sex hormones have effects
o 70-80% of cases improve in pregnancy
o may have flare after baby born
Fetal
o Minimal effects
o Steroids may increase risk of IUGR and PROM
Rx
o Avoid NSAIDs and high dose aspirin
o Low-dose aspirin safe
o Use lowest does of prednisone
o Sulfasalazine, hydroxychloroquinine in refractory cases
RA meds and breastfeeding
o Avoid
Aspirin
Azathioprine
Cyclosporine
Cyclophosphamide
Methotrexate
Chloribul??
Pemphigoid gestationis
Blistering disease associated with increased foetal risk
Incidence 1:1700 to 1:50000 pregnancies
Associated with HLE-DR3 and HLA-DR4
Fetal risk
o Preterm in 1/3
o SGA in 1/3
o Worse prognosis if onset in 1st or 2nd trimester
Dx via skin biopsy