Autoimmune disorders in pregnancy

OBG-Speculum:    2024                       ISSN no.

Vol -2, Issue -1  

Dr Neelam Aggarwal, Professor, Obstetrics and Gynaecology, PGIMER, Chandigarh

Background:

The word autoimmune refers to the diseases where there is evidence of auto antibodies i.e., immune response to self –constituents. These may be organ specific as type1 Diabetes Mellitus, Graves Disease, Autoimmune pernicious anemia or systemic as in Systemic Lupus Erythematosus (SLE), Primary Sjogren’s syndrome etc. The hallmark is formation of auto antibodies resulting in immune complex deposition, inflammation and end organ failure. Auto immune diseases are more common in females and that too in reproductive age group, therefore co-existence of pregnancy and the autoimmune diseases is far from rare. Some autoimmune diseases can have profound effects on pregnancy, some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             may be influenced, and others are unique to pregnancy. Obstetricians should be well versed with what happens to pregnancy in these and vice versa so as to have optimal feto-maternal outcome.

Immunological changes in pregnancy

Normal pregnancy is a potentially unique physiological challenge to the immune response. Immune system adopts a complex strategy to sustain immune quiescence via promoting maternal immune tolerance to foetal antigens. Phasic changes occur in each trimester to serve the purpose of safely growing the fetus. The first trimester is Pro- inflammatory phase to regulate trophoblast invasion, proliferation, tissue remodelling, and angiogenesis, implantation and placentation. The second trimester is immunologically tolerant to promote foetal allograft tolerance and protect the trophoblasts from pathogens. The third trimester is again pro inflammatory to support myometrial contractions and delivery. Maximum chances of flare are there at this time.

Effects on Pregnancy& Management

There is a higher chance of adverse maternal and foetal outcome in the form of miscarriages, foetal growth restriction (FGR), preterm labour, still births, pre-eclampsia, foetal malformation, congenital heart block .The multidisciplinary care is needed to manage these high risk pregnancies. Attention needs to be shifted from post to preconception issues. Safe pregnancy starts with adequate planning and therefore need of a proper contraception must be discussed in detail. Pregnancy should be monitored in a multidisciplinary setting ideally in a one stop AID in pregnancy clinic. First antenatal visit should be as early as possible to determine disease activity both clinically and laboratory parameters. Aim should also be to determine subclinical or silent disease in the heart and lungs. Factors affecting pregnancy outcome include disease activity at the beginning of pregnancy, coexistence of other medical or obstetrical disorders and APLA. Conception should not be planned till the disease is quiescent for 6-12 months as active disease at conception is associated with adverse outcomes. Apart from routine antenatal, maternal care needs aassessment and management of 4 areas: Hypertension and renal function, Disease activity, associated thrombophilia and anticoagulation & review of medication. Vigilant for detection of hypertension, preeclampsia, flare. and IUGR is must. Flare may not always be clear cut, sometimes its not possible to differentiate it from preeclampsia. Fetal growth and surveillance should continue throughout. Corticosteroids are central to management, HCQ is safe. Azathiaprine is a steroid sparing drug, Mycophenolate, Methotrexate & cyclophosphamide are contraindicated.

Termination of pregnancy timing and mode is to be individualized. Postpartum period is also prone to flares. Proper contraception should be advised.

Summary

Autoimmune disorders are frequently encountered in pregnancy, affect different organs and have significant effect on maternal and foetal outcomes. The disease activity is the most important prognostic factor, therefore preconception counselling is very important and supervision in a multi-speciality clinic helps in achieving optimal feto-maternal outcome.