Antiphospholipid Syndrome in Pregnancy
Section snippets
Pathogenesis
Several mechanisms have been proposed to explain the occurrence of recurrent thrombosis and pregnancy losses in patients with APS, including interference with the prostacyclin/thromboxane balance at the endothelial level, inhibition of annexin V (a natural placental anticoagulant), inhibition of antithrombin, protein C and protein S, and activation of platelets [1]. The pathologic findings in placentas of women with APS reinforce the role of thrombosis leading to placental insufficiency as the
Pharmacologic management of pregnancy losses in antiphospholipid syndrome
Historically, prednisone, aspirin, heparin, and immunoglobulins have been used in the treatment of pregnancy losses in women with APS. In the above-mentioned recent review by Petri and Qazi [7], the final recommendation for women with APS and one fetal loss or multiple first trimester losses is aspirin plus heparin, either unfractionated heparin (UFH) or low-molecular weight heparin (LMWH). Also in 2006, a Cochrane collaboration review on the therapy of miscarriage in women with aPL has been
Thromboprophylaxis in antiphospholipid syndrome during pregnancy
This group has been excluded systematically from clinical trials. However, good clinical sense indicates that all women with APS and previous thrombosis should maintain antithrombotic treatment throughout their entire pregnancy and during the postpartum period [36]. Therefore, combined treatment with low-dose aspirin and full antithrombotic doses of LMWH should be given to these patients. Moreover, postpartum LMWH is also mandatory in all women with purely obstetric APS and is also recommended
Hypertensive disorders
Hypertension is a cause of major complications in both the mother and the baby [42]. This is defined as a systolic or diastolic blood pressure of 140/90 mm Hg or higher, which can be present before or develop as a complication of pregnancy, usually after 20 weeks' gestation [42]. Preeclampsia is defined as the presence of pregnancy-induced hypertension plus proteinuria of at least 300 mg/d [42].
Positivity for aPL has been shown to be one of the most significant risk factors for preeclampsia in
Pulmonary hypertension
Connective tissue diseases, particularly systemic sclerosis, mixed connective tissue disease, SLE, and APS [51], can be a direct cause of pulmonary hypertension (PHT)—class 1.3.1 of the World Health Organization classification for PHT. In addition, chronic thromboembolic disease—classes 4.1 and 4.2—can be the consequence of hypercoagulability states, including APS [51].
The prognosis of untreated PHT is poor, with median survival rate less than 3 years after diagnosis [51]. Fortunately, several
Pregnancy, heparin, and osteoporosis
The complex relationship between pregnancy, osteoporosis, and heparin treatment has been recently reviewed [54]. Calcium demands rise during pregnancy. This may result in an increased turnover from bone, especially during the first and second trimesters. However, the process usually reverses during the third trimester, resulting in only minor reductions of bone mineral density (BMD) after normal pregnancy. Lactation may result in a delayed recovery of BMD. Although the risk for symptomatic
General care of pregnancy in women with antiphospholipid syndrome
Ideally, preconceptual counseling should be performed to explain the risks of pregnancy within the specific context of each patient. In general, women with APS should know that, under correct management, the likelihood of a live birth is around 75% to 80%. However, they must also be informed that there is an increased risk of serious complications (eg, hypertension/preeclampsia, prematurity, or thrombosis) that can take place during pregnancy and the puerperium. A complete aPL profile,
References (56)
- et al.
Antiphospholipid syndrome: obstetric diagnosis, management and controversies
Obstet Gynecol
(2003) - et al.
International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)
J Thromb Haemost
(2006) - et al.
Management of antiphospholipid syndrome in pregnancy
Rheum Dis Clin North Am
(2006) - et al.
Anticardiolipin antibodies: clinical consequences of “low titers.”
Obstet Gynecol
(1996) - et al.
Antiphospholipid antibodies in healthy pregnant women
Rheum Dis Clin North Am
(1997) - et al.
Prednisone does not prevent recurrent fetal death in women with antiphospholipid antibody
Am J Obstet Gynecol
(1989) - et al.
Comparative trial of prednisone plus aspirin versus aspirin alone in the treatment of anticardiolipin antibody-positive obstetric patients
Am J Obstet Gynecol
(1993) - et al.
Repeated fetal losses associated with antiphospholipid antibodies: a collaborative randimized trial comparing prednisone with low-dose heparin
Am J Obstet Gynecol
(1992) - et al.
A multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy
Am J Obstet Gynecol
(2000) - et al.
Antiphospholipid syndrome in pregnancy: a randomized, controlled trial of treatment
Obstet Gynecol
(2002)
Clinical study of 100 patients with the antiphospholipid syndrome
Semin Arthritis Rheum
Do low-risk pregnant women with antiphospholipid antibodies need to be treated? Organizing Group of the Antiphospholipid Antibody Treatment Trial
Am J Obstet Gynecol
Does aspirin have a role in improving pregnancy outcome for women with the antiphospholipid syndrome? A randomized controlled trial
Am J Obstet Gynecol
Aspirin to treat obstetric manifestations of the antiphospholipid syndrome
Am J Obstet Gynecol
Antiphospholipid antibodies associated with recurrent pregnancy loss: prospective, multicenter, controlled pilot study comparing treatment with low-molecular-weight heparin versus unfractionated heparin
Fertil Steril
Treatment of antiphospholipid antibody syndrome (APS) in pregnancy: a randomized pilot trial comparing low molecular weight heparin to unfractionated heparin
J Obstet Gynaecol Can
Use of antithrombotic agents during pregnancy. The seventh ACCP conference on antithrombotic and thrombolytic therapy
Chest
Treatment of pregnancy loss in Hughes syndrome: a critical update
Autoimmun Rev
Underlying disorders associated with severe early onset pre-eclampsia
Am J Obstet Gynecol
Association between antiphospholipid antibodies and recurrent fetal loss in women without autoimmune disease: a metaanalysis
J Rheumatol
High thrombosis rate after fetal loss in antiphospholipid syndrome: effective prophylaxis with aspirin
Arthritis Rheum
International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop
Arthritis Rheum
Revision of the Sapporo criteria for the antiphospholipid syndrome—coming to grips with evidence and Thomas Bayes?
Thromb Haemost
Placentation, antiphospholipid syndrome and pregnancy outcome
Lupus
Antiphospholipid antibodies affect trophoblast gonadotrophin secretion and invasiveness by binding directly and through adhered β2glycoprotein I
Arthritis Rheum
Requirement of activation of complement C3 and C5 for antiphospholipid antibody-mediated thrombophilia
Arthritis Rheum
Heparin prevents antiphospholipid antibody-induced fetal loss by inhibiting complement activation
Nat Med
A study of sixty pregnancies in patients with the antiphospholipid syndrome
Clin Exp Rheumatol
Cited by (33)
Treatment of Pregnancy Complications in Antiphospholipid Syndrome
2017, Handbook of Systemic Autoimmune DiseasesCitation Excerpt :Thromboprophylaxis may pose a risk intrapartum, especially in women requiring epidural anaesthesia. Therefore, to reduce the risk of bleeding at the time of delivery an adequate management plan would be to electively induce labour at 37 weeks of gestation and at least 12 hours after discontinuing prophylactic LMWH [26]. Variations on these recommendations include the use of therapeutic UFH after 37 weeks, allowing spontaneous labour.
Desensitisation to aspirin in antiphospholipid antibody syndrome
2013, Allergologia et ImmunopathologiaClinical Aspects of the Antiphospholipid Syndrome
2013, Dubois' Lupus Erythematosus and Related Syndromes: Eighth EditionAntiphospohlipid syndrome in obstetrics
2012, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :Likewise, calcium and vitamin D are safe during pregnancy and lactation. Taking these considerations into account, and in order to prevent osteoporosis, the recommendation is to associate calcium (1000 mg/day) plus vitamin D3 (800 IU/day) and to use low-molecular-weight rather than unfractionated heparin in all women with antiphospholipid syndrome.50 A recent retrospective study of 16 cases of HELLP syndrome in 15 women (14 during pregnancy, two postpartum) showed that treatment with low-dose aspirin and low-molecular-weight heparin substantially decreased the risk of HELLP in subsequent pregnancies.59