Pregnancy and Autoimmunity
Pregnancy and Autoimmunity
Pregnancy and Autoimmunity
Elisabetta Greco, MD
Rheumatology, Allergology and Clinical Immunology Unit
University of Rome Tor Vergata
elisabetta.greco@uniroma2.it
Autoimmune connective tissue diseases and pregnancy
• Rheumatic diseases occur preferentially in women, often during
childbearing age.
• The interaction of pregnancy and rheumatic diseases is varied.
• Risks for the mother and the child differ in regard to the presence of
organ manifestations, organ damage, disease activity, presence of
specific autoantibodies and therapy.
• Adverse pregnancy outcomes -> recurrent miscarriage, intrauterine
growth restriction and fetal demise.
• Pregnancy complications -> hypertension, preeclampsia, premature
delivery and side effects of therapy.
Maternal-fetal
interface
M. Østensen et al. Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 658-670
• Rheumatoid
arthritis
• Behçet disease
Ankylosing
spondylitis
Takayasu Arteritis
o SLE
Antiphospholipid
antibodies?
Checklist for risk
Anti-Ro/SSA and
pregnancy anti-La/SSB?
Previous pregnancy
complication?
Ongoing therapies
Severe pulmonary hypertension
Circumstances in
Severe heart failure
which women should
be advised against Chronic renal failure (stage 4-5)
pregnancy
Active disease
• Infliximab (IFX) may be continued until 16 weeks and etanercept (ETA) and
adalimumab (ADA) may be continued until the end of the second trimester (D).
• To ensure low/no levels of drug in cord blood at delivery, ETA and ADA should
be avoided in the third trimester and IFX stopped at 16 weeks. If these drugs
are continued later in pregnancy to treat active disease, then live vaccines
should be avoided in the infant until 7 months of age.
• Certolizumab pegol is compatible with all three trimesters of pregnancy and
has reduced placental transfer compared with other TNF inhibitors (D).
• Based on limited evidence IFX, ETA and ADA are compatible with paternal
exposure (D)
Risk factors for impaired female fertility
• Age related fertility (>35y)
• High disease activity (shown for RA, SLE)
• Organ damage (renal insufficiency, lupus nephritis)
• Drugs
- Risk of reversible infertility: NSAIDs, Prednisone >7.5 mg/die
- Risk of irreversible infertility: Cyclophosphamide
Anti-thyroglobulin (aTG) and thyroid peroxidase (aTPO), ANA, anti-laminin,
anti-prothrombin antibodies and anti-saccharomyces cerevisiae antibodies
(ASCA) have been associated to impaired fertility.
Ovarian stimulation can result in high concentrations of
estradiol, exceeding physiological levels, with a risk for
ovarian hyperstimulation syndrome (capillary leak-syndrome
and raised hematocrit which increases the risk of
thrombosis).
RD with predominant joint involvement, few organ manifestations, and few autoantibodies rarely
impair pregnancy outcomes.
aPL or APS increase risk of miscarriage, preeclampsia, IUGR, fetal death, and prematurity.
Active disease at conception, renal disease, aPL, and high-dose corticosteroids predict complications
in RD pregnancies.
Assessment of maternal and fetal risks is a prerequisite for preconceptional counseling.
Adjustment of medication instead of global drug withdrawal in the first trimester is appropriate.