1. Immunological disorder during pregnancy
Dr.
Ahmed Jasim
Ass.Prof
MBChB.-DOG-FIBMS
Consultant of gyn.&obst.

2. Autoimmune disease refers to various disorders
characterized by immune mediated damage to
various tissues .
Normally the immune system discriminates
between self and non self antigen and is tolerant of
non-self antigen ,however failure of self tolerance can
lead to sever ,debilitating illness.
Pregnancy with autoimmune disease can be risky
because the fetus can be affected by maternal
autoimmunity.

3. Autoimmune disease can include:
Antiphospholipid syndrome
Systemic lupus erythematosis
Autoimmune thrombocytopenia
Mysthenia gravis
Rheumatoid arthritis
Autoimmune thyroid disease
Autoimmune diabetes mellitus

4. Antiphospholipid syndrome :
Autoimmune condition characterized by the
production of moderate to high level of Anti-
phospholipid antibodies and certain thrombotic
features as thrombotic phenomena ( venous or
arterial including stroke) , autoimmune
thrombocytopenia and pregnancy loss .
Others are :
-livedo reticularis .
-coombs positive haemolytic anaemia .
-cardiac valvular lesion .

5. APS can be classified as :
Primary APS. (unrelated to underlying Auto-
immune disease).
Secondary APS . (with underlying autoimmune
disease as SLE ).
Patient diagnosed as having Antiphosphlipid
Syndrome should have at least one clinical
feature of the syndrome along with moderate
to high levels of aPL .

6. There are three aPL for which well established
assay are available :
-Biological false – positive test for syphilis (BF-STS).
-Lupus anticoagulant (LA).
-Anticardiolipin antibody (aCL).
Serial assessment of the antibodies testing
(6 weeks apart) to confirm the high level of antibody
in patients with initial negative or low positive level of
antibody.

7. Maternal risks :
1.Thrombosis and stroke:
Venous thrombosis accounts for 65-70% of
episodes .
lower limbs is the single most common site
of involvement ,but no part of vasculature is immune.
aPL are the only identifiable factor
predisposing to 4-28% of cases of stroke in other
wise healthy women under age of 50 years .

8. Over half of cases of thrombotic episode in APS patient occurs in relation to pregnancy or the use of COC that warrant treatment with heparin .
2,Pre-eclampsia : there are high rate of cases
of PE in APS and not reduced by either
treatment of APS.

9. Fetal risk :
Pregnancy loss:
About 50% of pregnancy loss in women with
APS are fetal death ,there is high rate of aPL in
women with recurrent pregnancy.
The importance of identifying APS lies not in
it’s prevalence but in it’s implication for the
patient and that it is a potentially treatable
cause of pregnancy loss.

10. Fetal growth restriction : aPL are associated
with fetal growth restriction even in treated
pregnancies fetal growth restriction is up to
30% .
Fetal distress : FD appears relatively common
in aPL , and occurs in half of patients ( even
in treated pregnancy).
Preterm birth : 1/3 of patients delivered
preterm even in treated patients.

11. Management options: Prepregnancy: -confirm the high level of aPL.
-inform the mother of the potential fetal and
maternal problems.
-If the patient has SLE then the risk of
exacerbation can also be discussed ,and risk of
anaemia ,thrombocytopenia , and underlying
renal disease.
-anticoagulant therapy is given to prevent thrombosis
during pregnancy and 1 month postpartum.

12. weekly in the 2nd trimester .
Prenatal :
-Antenatal visit twice weekly in the 1st trimester,
weekly in the 2nd trimester .
-Fetal ultrasound every 3-4 weeks after 17-18
weeks to detect IUGR , oligohydramnios ,
doppler recording .
-Fetal surveillance : daily fetal movement
counts , once weekly non stress tests ,
amniotic fluid volume measurements are
started at weeks.

13. -Treatment options :
Glucocorticoid with low dose aspirin :
There are numerous minor adverse effects as
DM and PIH , increased neonatal
morbidity (preterm delivery ,low birth weight ).
High dose prednisone (40 mg/day)
Heparin and low dose aspirin :
It’s now the preferred option for improving
outcome . It prevent placental thrombosis and
infarction . Heparin prophylactic dose (5000 -
10000 U twice daily.

14. Heparin therapy is started after demonstration of
a live embryo by ultrasound (5-7 week gestation) .
Heparin therapy is not without risk , the most
common are :
Bleeding .
Heparin induced osteoporosis . (Ca suppl.)
Uncommon ideosyncratic thrombocytopenia.
(independent from the dose and route occur in <5%).
Occasionally associated with thromboembolic events
or DIC .
Heparin is preferred over prednisone because has
fewer side effects and can provide prophylaxis
against thrombosis .

15. Heparin and high dose prednisone should
not used simultaneously will predispose to
osteopenic fractures and combination of the
drugs is no better than either drugs alone.