Important pulmonary, renal and auto immune conditions in Pregnancy

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Pulmonary disease in pregnancy

AsthmaIncidence.  This is 1–4% of all pregnancies. • Pregnancy has a variable effect on asthma (25% improve, 25%worsen, 50% are unchanged). In general, women with mild, well controlled asthma tolerate pregnancy well. Women with severe asthma are at risk of symptomatic deterioration. • Management.  As for non-pregnant women. Hospitalization, steroids, and/or intubation may be required. • Complications.  IUGR, stillbirth, maternal death.

Amniotic fluid embolism • An obstetric emergency with 80–90% maternal mortality rate. • Risk factors.  Multiparity, prolonged labor, fetal demise, “excessive”oxytocin augmentation, placental abruption, cesarean section delivery. • Characterized by acute onset of dyspnea, hypotension, coagulopathy, and hypoxemia. Therapy is primarily supportive.

Pulmonary edema
• Classified as cardiogenic or non-cardiogenic. • Risk  factors.  Fluid overload, infection, pre-eclampsia, tocolytic therapy. • Management.  As for non-pregnant women. LMNOP: lasix (diuresis), morphine, Na2+ and water restriction, oxygen, and positionupright. Consider antibiotics.

Renal disease in pregnancy

Asymptomatic bacteriuriaIncidence.  This is 4–7% of all pregnancies, which is similar to that in non-pregnant women. • In pregnancy, asymptomatic bacteriuria is more likely to progress to pyelonephritis (20–30%). • Escherichia coli is the most common causative organism.

Chronic renal failure
Complications.  Infertility (usually due to chronic anovulation), spontaneous abortion, pre-eclampsia, IUGR, fetal death, and preterm birth. • Pregnancy outcome is dependent on baseline renal function (below), and presence and severity of hypertension. The degree of proteinuria does not correlate with pregnancy outcome. • In women with end-stage renal disease, renal transplantation offers the best chance of a successful pregnancy (especially if renal function is stable for 1–2 years and there is no hypertension). Triple-agent immunosuppression (cyclosporin, azathioprine, prednisone) should be continued in pregnancy.

Autoimmune diseases in pregnancy Systemic lupus erythematosus • Systemic lupus erythematosus (SLE) does not generally worsen in pregnancy. Pregnancy outcome is related primarily to the severity of underlying renal disease. • Complications.  Pre-eclampsia, IUGR, preterm birth.

Maternal anti-Ro and anti-La antibodies Associated with complete fetal heart block in 5–10% of cases. 

Immune (idiopathic) thrombocytopenic purpura • Immune thrombocytopenic purpura (ITP) is a maternal disease characterized by the presence of circulating antiplatelet antibodies. It should be distinguished from alloimmune thrombocytopenia (ATP) in which maternal platelet counts are normal, but antiplatelet antibodies (usually anti-PLA1/2) cross the placenta to cause fetal thrombocytopenia and possibly intraventricular hemorrhage. ATP is analogous to rhesus (Rh) disease of platelets. • Differential diagnosis.  Pre-eclampsia, coagulopathy, drugs, gestational thrombocytopenia. • Complications.  IgG can cross the placenta and cause fetal thrombocytopenia. However, the correlation between maternal and fetalplatelet counts is poor. Fetal intraventricular hemorrhage in the setting of ITP is rare. • Management.  Corticosteroids may be necessary if maternal thrombocytopenia is severe. Intravenous Ig, plasmapharesis, and splenectomy are rarely necessary in pregnancy. Cesarean section delivery has not been shown to improve perinatal outcome.

Rheumatoid arthritis • Improves in 75% of pregnancies, but >90% of women will relapsewithin 6 months of delivery. • Corticosteroids are safe in pregnancy. Gold salts, cytotoxic agents, penicillamine, and antimalarials may have adverse fetal effects, but may be used if indicated.

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