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Autoimmune Disease in Pregnancy

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Powerpoint presentation by Dr Max Mongelli on autoimmune disease in pregnancy

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Autoimmune Disease in Pregnancy

  1. 1. AUTOIMMUNE DISEASES IN PREGNANCY Dr Max Mongelli Department of Obstetrics & Gynaecology Nepean Hospital University of Sydney
  2. 2. Autoimmune disorders: More common among pregnant women Abnormal antibodies can cross the placenta andaffect the fetus Pregnancy affects autoimmune diseases indifferent ways
  3. 3. Most common conditions: Thyroid Disease Crohn’s Disease SLE Myasthenia Gravis Immune Thrombocytopenic Purpura Rheumatoid Arthritis Pemphigoid Gestationis
  4. 4. Thyroid Disease in Pregnancy Graves’ Disease Hashimotos’ Disease
  5. 5. Graves’ Disease Hyperthyroidism Goitre Ophthalmopathy Pretibial myxedema Antibodies to TSH receptor
  6. 6. Hashimotos’ Thyroiditis “Chronic autoimmune thyroiditis” Most common cause of hypothyroidism Gradual thyroid failure or goitre Autoimmune destruction of thyroid gland Sex ratio 7:1 Antibodies against TG, TPO, TSH receptor
  7. 7. Diagnosis of Hyperthyroidism inPregnancy TSH < 0.01 Raised free T4 +/- raised free T3 Difficult to ascertain cause in pregnancy
  8. 8. Causes of Hyperthyroidism in Pregnancy Graves’ Disease Gestational Transient Thyrotoxicosis - HCGmediated Molar pregnancy Familial gestational thyrotoxicosis
  9. 9. Hyperthyroidism in Pregnancy Increased risk of - Miscarriage Premature labour Low birth weight Stillbirth Pre-eclampsia Heart failure
  10. 10. Hypothyroidism in Pregnancy Usually subclinical rather than overt PET and PIH Placental abruption Non-reassuring CTG Preterm delivery Increased risk of C/S PPH
  11. 11. Thyroid Peroxidase (TPO) Antibodies Increased risk of miscarriage Increased risk of preterm delivery 20% develop hypothyroidism if untreated Risks may be reduced by T4 therapy
  12. 12. T4 therapy in pregnancy: Hypothyroid women need more T4replacement As much as 50% dose increase Aim at normalising the TSH levels Important for normal fetal cognitivedevelopment
  13. 13. Postpartum Thyroiditis: Occurs in 5-10% of all pregnancies May occur after delivery or pregnancy loss May decrease milk volume Transient hyperthyroidism followed bytransient hypothyroidism May recur in subsequent pregnancies Risk may be reduced by seleniumsupplements
  14. 14. Crohn’s Disease
  15. 15. Crohn’s Disease: effect of pregnancy. Pregnancy has no effect on disease activity Perianal disease not worsened by vaginaldelivery Fistulas may occur during pregnancy Elective c/s controversial
  16. 16. Crohn’s Disease: effect on pregnancy. Increased risk of preterm delivery and IUGR Comparable to effect of moderate smoking Higher risk if disease active at conception Careful monitoring during pregnancy
  17. 17. Systemic Lupus Erythematosus
  18. 18. SLE features associated with high maternaland fetal risks – pregnancy relativelycontraindicated: Severe pulmonary hypertension Restrictive lung disease Heart failure History of severe HELLP or PET Stroke within previous 6/12 Lupus flare within previous 6/12
  19. 19. SLE complications in pregnancy: Disease exacerbation Miscarriage, stillbirth IUGR, preterm labour Neonatal lupus Drugs and breast-feeding
  20. 20. Neonatal Lupus: Occurs in up to 2% of mothers with SLE Targets skin and cardiac tissue,rarely other tissues Congenital partial or complete heart block Heart block detected in utero Complete heart block: PNM of 44% Rash: erythematous annular lesions Rash clears within 6/12 Maternal dexamethasone may prevent progressionof heart block Neonatal pacemaker if HR<55
  21. 21. Antiphospholipid antibodies Anti-cardiolipin Lupus anticoagulant Increased risk of miscarriage Risk may be reduced with aspirin +heparin
  22. 22. Investigations for SLE in pregnancy: Physical examination and BP FBC, renal function Anti-Ro/SSA abs and anti-La/SSB abs LA and aCL assays Anti-dsDNA abs Complement
  23. 23. Myasthenia Gravis
  24. 24. Myasthenia Gravis: Typically presents with fluctuating skeletalmuscular weakness May be ocular or generalised May have antibodies to the AChR 10-15% have a thymoma Respiratory muscle involvement may leadto respiratory failure
  25. 25. Myasthenia Gravis in Pregnancy: Pregnancy has a variable effect on thecourse of MG Post-partum exacerbations in 30% Infections can trigger exacerbations Steroids can cause transient worsening MgSO4 is contraindicated
  26. 26. Myasthenia Gravis – Effect on the Fetus Transplacental passage of IgG anti-AChR Neuromuscular junction disordersTransient neonatal MG in 10-20% Decreased FM’s and breathing Polyhydramnios Arthrogryposis multiplex congenita
  27. 27. Myasthenia Gravis – Labour & Delivery First stage of labour not affected Second stage: expulsive efforts mayweaken Assisted vaginal delivery may be indicated Pre-labour anaesthetic assessmentindicated
  28. 28. Immune Thrombocytopenic Purpura ITP
  29. 29. ITP – Diagnostic Criteria: Isolated thrombocytopenia No drugs or other conditions that mayaffect platelet count Exclude HIV, Hep C, SLE
  30. 30. ITP – Pathology: Increased platelet destruction Inhibition of platelet production atmegakaryocyte level Mediated by IgG Abs against plateletmembrane glycoproteins Usually a chronic condition
  31. 31. ITP – Clinical Features: Petechiae, purpura, easy bruising Epistaxis, menorrhagia, bleeding fromgums GIT bleeding, hematuria: rare Intracranial hemorrhage – very rare
  32. 32. ITP and Pregnancy May affect fetus in up to 15% of cases Neonatal count may drop sharply several days afterbirth Difficult to differentiate from gestationalthrombocytopenia Epidurals safe if count > 50000 Prednisone +/- IVIG if count < 50000 Manage delivery according to standard obstetricpractice Avoid NSAIDS post-partum
  33. 33. Gestational Thrombocytopenia Incidence about 5% Occurs late in pregnancy Mild (>70 000) No fetal neonatal thrombocytopenia Postpartum resolution
  34. 34. Rheumatoid Arthritis
  35. 35. Rheumatoid Arthritis in Pregnancy Affects 1-2% of the general population More common in women RA in pregnancy is a common challenge Sex hormones have effects on disease activity 70-80% of cases improve during pregnancy Post-partum flare common
  36. 36. Effect of Pregnancy on RA Minimal effects on fetal morbidity andmortality Steroids may increase risk of IUGR andPPROM Active disease correlates with lower birthweights
  37. 37. Treatment of RA in Pregnancy Avoid NSAIDS and high dose aspirin Low-dose aspirin safe Use lowest doses of prednisone Sulfasalazine, hydroxychloroquine inrefractory cases
  38. 38. RA Medications and Breast-feeding –Avoid: Aspirin Azathioprine Cyclosporin Cyclophosphamide Methotrexate Chlorambucil High dose prednisone
  39. 39. Pemphigoid Gestationis
  40. 40. Pemphigoid Gestationis Blistering disease associated with increased fetal risk Incidence 1:1700 to 1: 50000 pregnancies Associated with HLA-DR3 and HLA-DR4 Caused by IgG1 against basement membrane of skin Bullous pemphigoid antigen 2 Eosinophilic infiltration
  41. 41. Pemphigoid Gestationis – Fetal Risks Preterm delivery in 1/3 of cases SGA in 1/3 of cases Worse prognosis if onset in 1st or 2nd trimesters Neonatal pemphigoid in up to 10% Mild disease that resolves in weeks
  42. 42. Concluding Remarks For rare autoimmune diseases limited data toguide decision-making Occasionally antibodies found incidentallywithout any clinical features Indication for close monitoring rather thantreatment Notify pediatrician if neonatal morbidity is apossibility

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