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Autoimmune Disease in Pregnancy
1. AUTOIMMUNE DISEASES IN PREGNANCY
Dr Max Mongelli
Department of Obstetrics & Gynaecology
Nepean Hospital
University of Sydney
2. Autoimmune disorders:
More common among pregnant women
Abnormal antibodies can cross the placenta and
affect the fetus
Pregnancy affects autoimmune diseases in
different ways
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. Diagnosis of Hyperthyroidism in
Pregnancy
TSH < 0.01
Raised free T4
+/- raised free T3
Difficult to ascertain cause in pregnancy
9. Hyperthyroidism in Pregnancy
Increased risk of -
Miscarriage
Premature labour
Low birth weight
Stillbirth
Pre-eclampsia
Heart failure
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. 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. T4 therapy in pregnancy:
Hypothyroid women need more T4
replacement
As much as 50% dose increase
Aim at normalising the TSH levels
Important for normal fetal cognitive
development
13. Postpartum Thyroiditis:
Occurs in 5-10% of all pregnancies
May occur after delivery or pregnancy loss
May decrease milk volume
Transient hyperthyroidism followed by
transient hypothyroidism
May recur in subsequent pregnancies
Risk may be reduced by selenium
supplements
15. Crohn’s Disease: effect of pregnancy.
Pregnancy has no effect on disease activity
Perianal disease not worsened by vaginal
delivery
Fistulas may occur during pregnancy
Elective c/s controversial
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
18. SLE features associated with high maternal
and fetal risks – pregnancy relatively
contraindicated:
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. SLE complications in pregnancy:
Disease exacerbation
Miscarriage, stillbirth
IUGR, preterm labour
Neonatal lupus
Drugs and breast-feeding
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 progression
of heart block
Neonatal pacemaker if HR<55
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
24. Myasthenia Gravis:
Typically presents with fluctuating skeletal
muscular weakness
May be ocular or generalised
May have antibodies to the AChR
10-15% have a thymoma
Respiratory muscle involvement may lead
to respiratory failure
25. Myasthenia Gravis in Pregnancy:
Pregnancy has a variable effect on the
course of MG
Post-partum exacerbations in 30%
Infections can trigger exacerbations
Steroids can cause transient worsening
MgSO4 is contraindicated
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. Myasthenia Gravis – Labour & Delivery
First stage of labour not affected
Second stage: expulsive efforts may
weaken
Assisted vaginal delivery may be indicated
Pre-labour anaesthetic assessment
indicated
29. ITP – Diagnostic Criteria:
Isolated thrombocytopenia
No drugs or other conditions that may
affect platelet count
Exclude HIV, Hep C, SLE
30. ITP – Pathology:
Increased platelet destruction
Inhibition of platelet production at
megakaryocyte level
Mediated by IgG Abs against platelet
membrane glycoproteins
Usually a chronic condition
32. ITP and Pregnancy
May affect fetus in up to 15% of cases
Neonatal count may drop sharply several days after
birth
Difficult to differentiate from gestational
thrombocytopenia
Epidurals safe if count > 50000
Prednisone +/- IVIG if count < 50000
Manage delivery according to standard obstetric
practice
Avoid NSAIDS post-partum
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. Effect of Pregnancy on RA
Minimal effects on fetal morbidity and
mortality
Steroids may increase risk of IUGR and
PPROM
Active disease correlates with lower birth
weights
37. Treatment of RA in Pregnancy
Avoid NSAIDS and high dose aspirin
Low-dose aspirin safe
Use lowest doses of prednisone
Sulfasalazine, hydroxychloroquine in
refractory cases
38. RA Medications and Breast-feeding –
Avoid:
Aspirin
Azathioprine
Cyclosporin
Cyclophosphamide
Methotrexate
Chlorambucil
High dose prednisone
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. 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. Concluding Remarks
For rare autoimmune diseases limited data to
guide decision-making
Occasionally antibodies found incidentally
without any clinical features
Indication for close monitoring rather than
treatment
Notify pediatrician if neonatal morbidity is a
possibility
