Connective tissue, bone and joint disorders

- Most connective tissue disorders are autoimmune

Systemic lupus erythematosus

- Female to male ratio is 9:1

- Most common multisystem autoimmune disease in childbearing age
- 1 in 500 women
- 30% of women with SLE have APLA
- FGR occurs in 1 in 4 women with SLE

Risks
- active disease in 6 months prior to conception, during pregnancy or at first
presentation
- active lupus nephritis (risk for fetal loss 8-36%)
- secondary antiphospholipid syndrome
- chronic hypertension
- serum creatinine levels >280 at conception has a 70-80% risk of adverse pregnancy
outcome
- thrombocytopenia
- pre existing renal disease in first trimester with proteinuria >500
- hypocomplimentaemia
- double stranded DNA antibodies

Maternal risks
- 20 fold increased risk of maternal death
- increased risk of PET OR 3.0 and eclampsia 4.4
- increased risk of CS
- VTE
- Lupus flares

Fetal risks
- Spontaneous miscarriage
- Preterm labour
- FGR
- Stillbirth
- Neonatal deaths
- Neonatal lupus syndromes

Sjogrens syndrome

- Increased association with anti-Ro and anti-La antibodies (70-80% of cases), which
can cross the placenta and cause congenital heart block
- Presence of anti-ro and anti-la gives a 2% risk of congentital fetal heart block. This
increases to 16-18% if previous baby affected
Rheumatoid arthritis

- Females three times more affected than males

- Improves in pregnancy with remission in 25%
- Disease may relapse in a severe form in postpartum period
- Approx. 80-90% are rheumatoid factor +ve but this may also be positive in SLE
- Antinuclear antibodies present in 30%
- Rheumatoid arthritis with secondary sjogrens syndrome is associated with anti-Ro
and anti-La antibodies
- 5-10% may have antiphospholipid antibodies

Marfans syndrome

- Autosomal dominant – risk of transmission to offspring 50%

- For most women vaginal delivery is safe but it may be wise to limit second stage
- During pushing, the Valsalva manoeuvre leads to fluctuations in blood pressure,
aggravating shear stresses in the aorta.
- B blockers are recommended to control heart rate in labour