Maternal and fetal morbidity and mortality

AI in pregnancy was associated with maternal mortality rates of 35% in the 70-year period before 1930, which improved to 18% between 1940 and

1947 [28]. The present authors believe there have been no reports of maternal deaths from AI in pregnancy since the 1950s, with the introduction of cortisone, earlier diagnosis, and improved antenatal care. However, a reported case of maternal death at 8 months after delivery illustrates the importance of careful postpartum follow-up [26]. Some cases that were not diagnosed during pregnancy had normal maternal and fetal outcomes, suggesting that women with unrecognized AI benefit from transplacental passage of cortisol from the fetus. Therefore, AI may only become apparent in the immediate postpartum period [29]. In women known to have the disease, careful titration of glucocorticoid and mineralocorticoid replacement are required to avoid an adrenal crisis and potential side effects, including hypertension and exacerbation of preeclampsia [26,30].

Gestational AI has been associated with high rates of intrauterine growth retardation, low birth weight [31,32], and fetal mortality [33]. A recent Italian series reported improved miscarriage rates (16 of 104 pregnancies) compared with intrauterine death rates in the 1950s of 40% to 50% [34]. Most of the earlier reports consisted of previously unrecognized cases or preceded the availability of modern glucocorticoid regimens [35]. These differences have led to the speculation that, treated properly, women do not have increased complications of gestation. There does not appear to be an increased risk of preterm abortion or congenital anomalies resulting from AI alone, when patients are treated adequately [36]. However, when AI is associated with other autoimmune conditions, including positive circulating anticar-diolipin antibodies, lupus anticoagulant, and diabetes, there may be additional risks of preterm abortion [37-39].

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