autoimmune diseases in pregnancy .. I represent this lecture in OB/GYN as part of my internship ...

1. Autoimmune diseases in pregnancy
Abdullah Al-Harthy

2. • For years, women with potentially serious
systemic autoimmune diseases have been
advised not to get pregnant.
• We now know that, with careful medical and
obstetric management, most of these women
can have successful pregnancies.

3. Autoimmune disease
•inappropriate immune response of the body
against substances and tissues normally
present in the body
•In other words, the immune system
mistakes some part of the body as a pathogen
and attacks its own cells
•The treatment of autoimmune diseases is
typically with immunosuppression medication
which decreases the immune response.

5. Objectives:
• Why Rheumatic Diseases Important in
Pregnancy ?
• effect of rheumatic diseases in the mother on
fertility
• discuss the maternal and fetal effects of
pregnancy

6. Risk of Transmission From Mother to Fetus
Fetal Outcome
 USE OF RHEUMATIC DRUGS DURING PREGNANCY AND
LACTATION
 DVT vs. Back pain

7. Why Rheumatic Diseases
Important in Pregnancy ?
Rheumatic diseases often affect women
during their childbearing years, when
pregnancy is an expected event.
Careful medical and obstetric prepared to
handle the possible complications.
Effect on Fetal Outcome .

8. Effect of rheumatic diseases in the mother
on fertility
• SLE, RA, the vasculitides and the
spondyloarthropathies are not known to
directly affect fertility. Although SLE patients
are as fertile as the general population .
• There is a reported reduced fertility rate in
patients with active disease who are treated
with high dose corticosteroid therapy, as
menstrual irregularities and anovulatory
cycles may occur.

9. Effect of rheumatic diseases in the mother
on fertility
• End-stage renal failure secondary to
lupus nephritis can result in
amenorrhoea.
• Amenorrhoea in renal patients may also
be due to ovarian failure secondary to
cyclophosphamide or it may be of
autoimmune origin.

11. Discuss the maternal and fetal effects of
pregnancy
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
 (a) Flares : many patients used to stop all their therapy upon
discovering that they were pregnant, which may have contributed to an
increased risk of flare in pregnancy.
 (b) Hypertension : 25% of pregnancies in women with SLE are
complicated by hypertensive disorders and there is also a higher rate of
caesarean sections
 (c) Renal Lupus : kidney is one of the major target organs and up
to 60% of patients experience focal or diffuse renal involvement
Proteinuria without the presence of red cells or casts in the urine can be
difficult to distinguish from pre-eclampsia. features:
proteinuria greater than 500 mg/24 h, haematuria, red cell casts and
hypertension.

12. (d) Pre-eclampsia : pre-eclampsia and lupus nephritis
may co-exist in pregnancy, it is essential to differentiate
isolated pre-eclampsia from renal lupus during pregnancy, as
management will be very different depending on the
diagnosis.
 Pre-eclampsia can be defined as blood pressure over 140/90
or the rise of 30 mmHg systolic or 15 mmHg diastolic in
combination with proteinuria (>300 mg/24 h) and oedema at
greater than 20 weeks gestation
 proteinuria is more likely to be due to pre-eclampsia than
lupus nephritis. Lupus nephritis is more likely if there is a
positive urinary sediment

13. antiphospholipids Syndrome (APLS)
in SLE patient presented with CLOT
coangulation defect
livedo reticularis
obstetric complication - recurrent miscarriage & IUGR
thrombocytopenia

14. Discuss the maternal and fetal effects of
pregnancy
Anti-phospholipid Syndrome
 (a) Thrombosis : All women are in a prothrombotic state during
pregnancy and for 6 weeks postpartum and so are at increased
risk of deep vein thrombosis, pulmonary emboli and stroke , A
higher pregnancy success rate has been shown in women with
APS and recurrent miscarriages taking low dose aspirin in
pregnancy
 (b) Pre-eclampsia : Pre-eclampsia is most common in
pregnancies where the mother has APS. In patients with APS, it
often recurs and may present as very early onset pre-eclampsia
(<20 weeks)
 Patients with APS also have an increased incidence and severity
of the HELLP syndrome than the general population,
with or
without pre-eclampsia or eclampsia.

15. • (c) Thombocytopenia :It should be noted that
thrombocytopenia may occur for a variety of reasons in
pregnancy. Although APS, lupus or HELLP are the best known
associations in patients with rheumatic diseases, it should not
be forgotten that approximately 9% of healthy women
develop mild thrombocytopenia for non-autoimmune
reasons.
• Isolated anti-platelet antibodies can cause an idiopathic
thrombocytopenia. Thrombocytopenia associated with APS
may worsen in pregnancy or due to treatment with heparin.

17. Discuss the maternal and fetal effects of
pregnancy
• Rheumatoid Arthritis
• RA has been known to improve during pregnancy for many years.
Several studies have shown significant improvement in 75–95% of
pregnant women with RA. The improvement By Blood plasma
Expansion .
• Or If It Get worst mainly by patient when she stoped her
medications

18. DVT vs. Back pain
Wells score or criteria

19. • Wells score or criteria: (possible score −2 to 9)
• Active cancer (treatment within last 6 months or palliative): +1
point
• Calf swelling ≥ 3 cm compared to asymptomatic calf (measured
10 cm below tibial tuberosity): +1 point
• Swollen unilateral superficial veins (non-varicose, in
symptomatic leg): +1 point
• Unilateral pitting edema (in symptomatic leg): +1 point
• Previous documented DVT: +1 point
• Swelling of entire leg: +1 point
• Localized tenderness along the deep venous system: +1 point
• Paralysis, paresis, or recent cast immobilization of lower
extremities: +1 point
• Recently bedridden ≥ 3 days, or major surgery requiring regional
or general anesthetic in the past 12 weeks: +1 point
• Alternative diagnosis at least as likely: −2 points

20. • Those with Wells scores of two or more
have a 28% chance of having DVT, those
with a lower score have 6% odds.
Alternatively, Wells scores can be
categorized as high if greater than two,
moderate if one or two, and low if less
than one, with likelihoods of 53%, 17%,
and 5% respectively

21. Causes of Back Pain in Pregnant
• Pregnancy back pain typically happens where the pelvis meets
the spine, at the sacroiliac joint.
• Weight gain . During a healthy pregnancy, women typically gain
between 25 and 35 pounds. The spine has to support that
weight. That can cause lower back pain. The weight of the
growing baby and uterus also puts pressure on the blood
vessels and nerves in the pelvis and back.
• Posture changes. Pregnancy shifts The center of gravity.
• Hormone changes. During pregnancy, your body makes a
hormone called relaxin that allows ligaments in the pelvic area
to relax and the joints to become looser in preparation for the
birth process. The same hormone can cause ligaments that
support the spine to loosen, leading to instability and pain.
• Muscle separation.
• Stress

22. • sciatica is used to describe a symptom rather
than a specific disease. Some use it to mean
any pain starting in the lower back and going
down the leg.
• Spinal disc herniation
• Spinal stenosis
• Pregnancy
sciatica

24. Risk of Transmission From Mother to
Fetus
SLE and Sjögren's syndrome are the most widely
recognized rheumatic diseases in which
pathogenic antibodies can pass from mother to
infant through the transmission of anti-Ro
and/or anti-La across the placenta during
pregnancy
 The prevalence of these auto-antibodies in SLE patient is about
35% but transmission of IgG antibodies across the placenta
between weeks 16 and 32 gestation occurs in about 5% of
mothers.
 Neonatal transmission usually resolves within the first 6 months
of life, as maternal antibodies are destroyed in the infant.

25. The most severe complication of neonatal lupus
syndrome is congenital heart block (CHB).
Complete CHB is diagnosed when fetal bradycardia is
identified usually between 18 and 28 weeks.
 It is important to closely monitor these pregnancies
by serial Doppler echocardiography.
 Measurement of AV time intervals is a suggested
surveillance instrument, as incomplete block may
progress in utero or post-delivery and carries a 20%
mortality rate. Permanent pacemakers are required
by 67% of survivors with complete CHB.
Dexamethasone or betamethasone may be given to
try and reverse heart block, as it is able to cross the
placenta unlike prednisolone

26. Fetal Outcome
• Fetal Loss : The risk is increased in women who have previously
experienced fetal loss, active renal disease at conception, maternal hypertension
and the presence of anti-phospholipid antibodies.
• Recurrent fetal loss is also one of the criteria when diagnosing APS and the
presence of both lupus anticoagulant and anticardiolipin antibodies is associated
with the highest risk of fetal loss.
• Intrauterine Growth Restriction : In SLE patients,
hypertension, active lupus and APS are significant predictive factors for
IUGR.
• Fetal loss in early pregnancy in APS can be due to failure of the placenta to
implant, due to the effect of anti-phospholipid antibodies on anionic
phospholipids and the effect of B2-glycoprotein on trophoblasts. Thrombosis
in APS is also thought to have a role in pregnancy loss due to uteroplacental
insufficiency from multiple placental thromboses and infarcts

27. • Premature Delivery : is common in patients with lupus,
vasculitis, systemic sclerosis and especially antiphospholipid syndrome .
• There are several complications of prematurity, regardless of underlying
cause, such as breathing difficulties, infection, jaundice, feeding
difficulties, developmental abnormalities and neonatal death.
• Breathing difficulties are usually due to insufficient surfactant, which can
be reduced by a 48-h course of dexamethsone or betamethasone in cases
where there is a high chance of premature delivery, such as active
maternal disease or fetal distress.

28. USE OF RHEUMATIC DRUGS DURING
PREGNANCY AND LACTATION
Pregnancy Lactation
NSAID Yes
(avoid after 32 weeks(
Yes
Sulfasalazine Yes Yes
Antimalarials Yes Yes
Corticosteroids Yes Yes
Cyclosporin Yes probably yes
Azathioprine Yes probably yes
Mycophenolate No No
Methotrexate No No
Cyclophosphamide No No
Anti-tumor necrosis
factor (TNF(
No No
Rituximab No No
Warfarin No
(with caution, only after
first trimester(
Yes
Heparin Yes Yes

29. POINTS TO REMEMBER
All women should undergo counseling before
conception for their specific risk, depending on their
condition and the medications they are taking.
Each woman’s rheumatic disease should be well
under control for a period of at least 3-6 months
before attempting pregnancy.
Women with a low-risk profile can be managed with
usual visits to the rheumatologist as a precaution.
Those with a high-risk profile should be managed by
both the rheumatologist and obstetric team with
experience in high-risk pregnancies.

30. Summary
• Pregnancies in women with rheumatic diseases require a
multi-disciplinary, carefully monitored, coordinated approach
before, during and after pregnancy to ensure the best
possible success for mother and baby.
• In contrast to SLE, APS, vasculitis and systemic sclerosis there
is little evidence for poor maternal or fetal outcomes in RA or
other forms of inflammatory arthritis such as psoriasis and
seronegative spondyloarthropathies.
• Prior to pregnancy it is important to counsel the mother
concerning potential complications, establish disease activity
control, screen for hypertension and renal involvement,
exclude pulmonary hypertension and make appropriate
changes to the woman's therapy.

31. During pregnancy it is essential to monitor all
aspects of disease activity such as renal
involvement, as well as pregnancy complications
such as IUGR, thrombo-embolic disease and pre-
eclampsia, particularly in patients with SLE, APS,
vasculitis and systemic sclerosis.
After pregnancy it is essential to counsel the
mother on postpartum issues such as breast-
feeding and contraception, as well as to monitor
for and treat any postpartum flares as these are
common in all the rheumatic diseases.

32. References
• American college of rheumatology
• http://arthritis-research.com
• Medscape
• Current Diagnosis & Treatment in
Rheumatology, Third Edition