Chapter 22 Autoimmune Diseases In Pregnancy

Question 0

11 criteria for diagnosis of sle

Answer 0

Malar (butterfly) rash
Discoud rash
Photo sensitivity
Oral ulcers
Arthritis
Serositis
Renal disorder persistent proteinuria or cellular casts)
Neurological disorder (seizures/psychosis)
Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia)
Positive Ana
>=3 clinical or lab findings

Question 1

Diagnosis of systemic lupus erythematosus

Answer 1

1. 9:1 females 4xincrease in African Americans
2. Malaise, arthritis, serositis, rash, fever, alooecia, oral ulcers, reynauds phenomenon, seizures
3. Lab findings: anemia, protein iris, elevated creatinine
4. Antinuclear antibodies (Ana) always present in high titers

Question 2

First line therapy for sle

Answer 2

Oral prednisone

Hydroxychloroquine

Question 3

Asa or heparin recommended in sle why?

Answer 3

Present fetal loss an maternal thrombosis in pt with anti phospholipid syndrome

Question 4

Surveillance of maternal symptoms include

Answer 4

Blood pressure, renal function, platelets, hematocrit,
Serologic studies for anti phospholipid antibodies (apa) and ss-a (anti ro) or ss-b (anti la) antibodies associated with congenital heart block and baseline urine protein excretion and creatinine clearance should be obtained.

Question 5

How to distinguish superimposed preeclampsia from an exacerbation of lupus nephritis?

Answer 5

-extracranial symptoms (rash, arthralgia)
-rising antidsdna antibody titers
-falling complement levels
-urinary erythrocytes
Favor diagnosis of lupus flare over preeclampsia

Question 6

Regular monitor of fetal growth and antenatal testing are recommended.why?

Answer 6

Risks of fetal growth restriction and stillbirth

Question 7

Does pregnancy alter course of lupus?

Answer 7

No. 1/3 improve, 1/3 deteriorate,

Remaining no change.

Question 8

Disease activity prior to conception is best predictor of prognosis likelihood of a severe lupus flare increased 60%-70% in women with active disease in 6 months prior to conception, in those with poorly controlled lupus in year prior to conception and in those who discontinue medications because of pregnancy.

Answer 8

True

Question 9

Women with quiescent Dx in 6 months prior to conception,

Answer 9

Less than 10% will have moderate sle durin pregnancy

Question 10

PTs with lupus were _ more likely to have preeclampsia, __ more likely to have a growth restricted infant and ___ more likely to have preterm labor.

Answer 10

3x preeclampsia
2.6x growth restricted infant
2.4x preterm labor
Stroke, dvt, pneumonia, increases 6.5, 7.9, 4.3
Maternal death 20x higher

Question 11

Anti phospholipid antibody syndrome is defined as a combination of

Answer 11

1. One or more persistent high titer anti phospholipid antibodies
   -anticardiolipin antibody (igG or
   IgM)
   -lupus anticoagulant
   -antibeta2 glycoprotein-I (igG or igM)
2. One or more clinical events
   - >=3 unexplained embryonic losses =1 unexplained fetal death >10wks
   -early <34 weeks preeclampsia, eclampsia, intrauterine growth restriction

Question 13

Management in pregnancy (antiphospholipid antibody syndrome), Therapy is directed to reduce risk of primary or recurrent thrombosis and pregnmcy loss.

Answer 13

Heparin 7500-10,000 units sq bid and low dose aspirin 80mg/day

Question 14

obstetrical complications in patients with antiphospholipid antibody syndrome (APAS)

Answer 14

1. 80% of women with antiphospholipid antibody syndrome have experienced at least ONE fetal death.
2. risk of preeclampsia as high as 50%
3. risk of IUGR as high as 15-30%
4. preterm birth in 33% of women due to placental insufficiency.

Question 15

Rheumatoid Arthritis (RA) is one of the few maternal diseases that may actually IMPROVE during pregnancy and outcomes are generally good

Answer 15

true

Question 16

rheumatoid arthritis remission is about __ in pregnancy

Answer 16

75%

Question 17

postpartum flaes are

Answer 17

common, up to 90%

Question 18

active disease of rheumatoid arthritis treated with

Answer 18

prednisone, sulfasalazine, or hydroxychloroquine.

Question 19

sjogren’s syndrome

Answer 19

autoimmune destruction of exocrine glands of the:

1. eye: keratoconjunctivitis
2. mouth: xerostomia
3. mucosa: vaginal or gastrointestinal.

Question 20

sjogren’s syndrome frequently arises in setting of mixed connective tissue disorders including:

Answer 20

lupus and rheumatoid arthritis.

Question 21

sjogren’s syndrome has a high prevalence of autoantibodies including:

Answer 21

antinuclear antibodies
antismooth muscle antibody
rheumatoid factor
anti-ro (ss-a) and anti-la (ss-b) nuclear antigens.

Question 22

can SS-A and SS-B antibodies cross the placenta?

Answer 22

yes. SS-A and SS-B antibodies can cross the placenta and induce fetal cardiac injury leading to congenital heart block (CHB). CHB is approximately 2% in women with no previously affected infant, but as high as 20% in those with such a history.

Question 23

sjrogen’s syndrome should have __ during pregnancy:

Answer 23

fetal echocardiography and frequent fetal heart rate monitoring between 16-26weeks.

Question 24

thyroid stimulating immunoglobulins (TSIg) activate the thyroid stimulating hormone receptor (TSH-R) leading to hyperthyroidism (Graves disease).

Answer 24

true. thyroid stim immunoglobulins -> thyroid stimulating hormone receptor -> hyperthyroidism (Graves dx)

Question 25

hyperthyroidism (graves disease) often ___ during late gestation but ____

Answer 25

hyperthyroidism often improves during pregnancy but flares in postpartum.

Question 26

graves disease affects ___ per 1000 pregnancies

Answer 26

1-2 per 10000

Question 27

pregnancy complications of graves disease:

Answer 27

thyroid storm, miscarriage, preeclapsia, heart failure, preterm birth, growth restriction.

Question 28

neonatal hyperthyroidism resulting from transplacental passage of

Answer 28

thyroid stimulating immunoglobulins affect up to 1% of newborns.

Question 29

treatment of hyperthyroidism with ___ at LOWEST DOSE necessary to keep free T4 concentration in the HIGH-NORMAL range

Answer 29

thionamides

Question 30

hypothyroidism (Hashimoto’s disease) affects __ of pregnancies

Answer 30

0.2%-0.3%

Question 31

hypothyroidism characterized by presence of:

Answer 31

anti-thyroid peroxidase (TPO) or anti-thyroglobulin (TG) antibodies,
an ELEVATED thyroid stimulating hormone (TSH), and LOW thyroglobulin hormone (free T4)

Question 32

hypothyroidism should begin treatment when?

Answer 32

prior to conception, or at least by 5th week of pregnancy.

Question 33

Hashimoto thyroiditis is NOT typically associaated with fetal thyroid dysfunction; only

Answer 33

1:180,000 offspring of affected pregnancies have hypothyroidism.

Question 34

postpartum thyroiditis is a manifestation of altered autoimmunity following pregnancy.

Answer 34

risk as high as 5-10% in 1st year after delivery. risk is related to presence of antithyroid antibodies in 1st trimester. 20-50% of euthyroid woemn with anti-TPO antibodies in 1st trimester experience postpartum thyroiditis.

Question 35

postpartum thyroiditis characterized by:

Answer 35

initial hyperthyroid (1-4 months postpartum) followed by hypothyroid phase (4-12mths pp)

Question 36

hyperthyroid sumptoms:

Answer 36

fatigue, palpitations, heat intolerance, anxiety, irritability

Question 37

hypothyroid:

Answer 37

fatigue, hair loss, depression, dry skin, inability to concentrate.