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Autoimmune diseases with pregnancy



By
Dr Tahani Ali


auto-immune

This lecture contain headlines to simplify the subject

For more information and details you can return to the text books .
NOTE

The term autoimmune disease is said when there is evidence of immune response to self constituents

Evidence of immune response is confirmed by detection of characteristic auto antibody in the patient circulation


Co-existence of pregnancy with autoimmune is far from rare
Some autoimmune diseases can have profound effect on pregnancy
Some may be influenced by pregnancy
Other are unique to pregnancy or have unique features associated with pregnancy

Maternal risk

Exacerbation of SLE
Lupus nephritis
PIH , PE
Fetal risk
Pregnancy loss
Preterm labour
IUGR
Neonatal lupus
Drug effect
Congenital and neonatal heart block.

SLE
auto-immune




Establish good control of SLE adjust maintenance medication
If possible stop azithioprine . MTS, and cyclophosphomide before conception UNDER carful supervision
LAB assessment of anemia, low platelets , underlying renal disease and APS

MANAGEMENTprepregnancy

Joint obestetrition and rheumatological assesment
Encourage early pregnancy care
Accurate dating with US
Close follow up every2 weeks in the first and second trimester every week in the third
Watch for sign and symptoms of SLE flare, PIH, IUGR
Monthly 24 hr urine collection for protein in patient with renal involvement
Drugs cortisone is safe
Azathioprin are second line therapy
MTS and cyclophosphomide as third line After 1st trimester
AVOID antimalarials and full dose NSAID
Serial US for fetal growth . Umbilical art. Doppler, and amniotic fluid volume
Begin fetal surveillance at 30-32weeks of gestation

antenatal


Deliver at term in the absence of complication ( avoid post term )
Continuous fetal monitoring
Steroid boluses at delivery for patient on chronic steroid therapy
Pediatric and anasthesiology notification Post natal
Watch for SLE exacerbation
Restart maintenance therapy
Evaluate neonate for SLE associated manifestation

Labour and delivery

this is an autoimmune disease characterized by the production of moderate to high levels of antiphospholipid antibody and certain clinical features
Anti phospholipid syndrom

Vascular thrombosis

Pregnancy morbidity
One or more death of normal fetus at or after 10 weeks of gestation
One or more preterm labour of normal neonate before 34 weeks from PE. Eclampsia, placental insufficiency
3 or more consecutive spontaneous abortion before 10 weeks of gestation with no maternal anatomic , hormonal or paternal chromosomal abnormalities

APS criteria(clinical)


Lupus anticoagulante
Elevated anticardiolipin ab
Elevated anti B2glycoprotien ab

Lab. criteria

At least 1 of both criteria is needed for definitive classification . Lab.result must be present on 2 occasion 12 weeks apart, but no more than 5 years

Thrombosis and stroke

Postpartum syndrome
PE (30-50%)
Fetal risk
Pregnancy loss
IUGR
Preterm labour
Maternal risk

Pre-pregnancy

Counseling regarding risk
Check for anemia, platelets, renal compromise
Thromboprophylaxis for all
Prenatal
Joint obs. And rheumatological surveillance
Low dose aspirin And SC heparin
Increase frequency of attendance
Surveillance for fetal growth
Screen for PE
management


Maternal risk
RA and pregnancy have major relation ship
At least 50% of patient show improvement in their symptoms in at least 50% of their pregnancy
25% of RA with have no improvement in their disease during pregnancy and in small number of cases the disease may worsen
Rheumatoid Arthritis

Controversial higher rate of spontaneous abortion

RA probably does not affect fertility
No increase risk of preterm IUGR, PE
Fetal risk

Pre pregnancy

Counseling regarding risk
Review of therapy to improve disease control
Reduce dosage to the lowest level achieving therapeutic effect
management

Regular review

Rest
Physiotherapy
Drugs: try and avoid full dose aspirin and NSAID, steroid for worsening disease, avoid MTS in first trimester . D penicillamine contraindicated
Labour and delivery
individualized care according to physical ability
Prenatal


THANK YOU



رفعت المحاضرة من قبل: Harir Radhwan
المشاهدات: لقد قام 9 أعضاء و 89 زائراً بقراءة هذه المحاضرة








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