1. Autoimmune disease in pregnancy
An autoimmune disease is one in which antibodies are developed against the host's own tissue .

2. I – Autoimmune thrombocytopenic purpura ( ITP ) :
Autoimmune antibodies are produced against platelet surface antigens , leading to platelet destruction by reticulo- endothelial system .
The incidence in pregnancy is 1 :

3. Differential diagnosis :
1. Gestational thrombocytopenia
Hypertensive disorder of pregnancy .
3. Others ( DIC , HELLP , acute fatty liver , thrombotic , thrombocytopenia ) .

4. Management : - Serial platelet counts
- If platelet count < 50 x 109 / L approaching term :
1. corticosteroids
2. Intravenous immunoglobulin G
3. Final treatment : is splenectomy (risky )
4. Platelet transfusion

5. Management :
- In pregnancy , these antibodies may cross the placenta and destroy the fetal platelets . in < 5% of fetuses of women with ITP .
So : 1) traumatic delivery should be avoided .
2) Platelet count of the neonate should be monitored .

6. II – Systemic lupus erythematosus ( SLE ) and antiphospholipid syndrome ( APS)
- SLE : is a multi-system chronic autoimmune inflammatory disease .
- SLE is a relapsing condition , and pregnancy increases the risk of flare.

7. Diagnosis :
-By presenting > 4 of the 11 revised criteria of American Rheumatism Association
- By finding of a positive assay for antinuclear antibodies , and the presence of antibodies to double- stranded DNA
-anti Ro and anti La

8. Antiphospholipid syndrome ( APS ) :
Is used to describe the association of :
anticardiolipin antibodies and / or lupus anticoagulant .
with typical clinical features of arterial or venous thrombosis .
Fetal loss after 10 wks gestation or delivery before 34 wks due to IUGR or pre- eclampsia .
> 3 miscarriages at less than 10 week's gestation .
- APS may be primary or found in association with SLE

9. Maternal risks: - Lupus flare .
- worsening nephropathy , proteinuria .
- Thrombosis DVT , or even in unusual site ex. retinal vein .
- Thrombocytopenia .
- Placenta abruption .

10. Fetal risk: - Miscarriage . - Fetal death .
- Growth restriction ( IUGR ).
- Preterm labour .
- Neonatal lupus due to transplacental passage of anti Ro/ anti .
- Congenital heart block 1 – 2 % of babies of Ro-positive female .

11. Management of SLE and APS :
*intensive monitoring for both maternal and fetal indications
-baseline renal studies
-The blood pressure
-Serial U/S
-steroids and azathioprine
- NSAIDS should be avoided
- warfarin LMW Heparin
-aspirin + heparin

12. III – Rheumatoid arthritis ( RA ) :
Chronic inflammatory , symmetrical arthritis causing joint pain , stiffness & deformity .
30 % antinuclear antibody + ve
20 – 30 % Anti Ro / anti La + ve
5 – 10 % A PL + ve

13. Its course
3/4 of them experience improvement of symptoms during pregnancy .
R.A. has no adverse effect on pregnancy outcome, but the adverse effects may be due to treatment of the disease or passing abnormal antibodies through the placenta .

14. Treatment : Paracetamol corticosteroids
NSADs avoided in pregnancy Azathioprine :
Gold and pencillamine avoided in pregnancy .
6. Cytotoxic agent teratogenic & should be discontinued before pregnancy .