Obstetric management of antiphospholipid syndrome

Arterial/venous thrombosis, fetal loss and stillbirth in pregnant women with systemic lupus erythematosus versus primary and secondary antiphospholipid syndrome: a systematic review and meta-analysis

BACKGROUND

We aimed to systematically compare arterial/venous thrombosis, fetal loss and stillbirth in pregnant women with systemic lupus erythematosus (SLE), primary anti-phospholipid syndrome (PAPS) and secondary anti-phospholipid syndrome (SAPS).

METHODS

Online databases were carefully searched for relevant publications comparing SLE with PAPS and/or SAPS in pregnancy. Studies were included if: they compared SLE with APS [SLE versus PAPS or SLE versus SAPS or SLE versus PAPS and SAPS respectively] in pregnant women; and they reported specific adverse outcomes as their clinical endpoints including arterial/venous thrombosis, fetal loss and stillbirth. Risk ratios (RR) with 95% confidence intervals (CIs) were used as statistical parameters and the analysis was carried out by the RevMan 5.3 software.

RESULTS

A total number of 941 pregnant women were included: 556 were candidates of SLE; 200 were candidates of PAPS; and 185 were candidates of SAPS. APS was associated with a significantly higher risk of fetal loss (RR: 4.49, 95% CI: 2.09-9.64; P = 0.0001). In addition, stillbirth and arterial/venous thrombosis were also significantly increased with APS (RR: 6.65, 95% CI: 2.14-20.60; P = 0.001) and (RR: 3.95, 95% CI: 1.28-12.16; P = 0.02) respectively. When patients with PAPS were compared with patients who suffered from SLE alone, fetal loss and arterial/venous thrombosis were still significantly higher with the former. When SAPS were compared with SLE (without anti-phospholipid antibodies), arterial/venous thrombosis, stillbirth and fetal loss were still significantly higher with SAPS. However, no significant difference was observed in arterial/venous thrombosis and fetal loss between PAPS and SAPS.

CONCLUSIONS

PAPS and SAPS were associated with significantly higher arterial/venous thrombosis, fetal loss and stillbirth in comparison to SLE. However, no significant difference was observed when PAPS was compared to SAPS.

Antiphospholipid Syndrome in Greece: Clinical and Immunological Study and Review of the Literature

The aim of this paper is to analyze the epidemiologic, clinical, and immunologic characteristics of the antiphospholipid syndrome (APS), primary or secondary, in autoimmune patients from Northern Greece. Sixty-seven patients with APS were included (9 men, 13.4%, and 58 women, 86.6%). Fifty-two (77.6%) patients had secondary APS and 15 had primary APS (22.4%). The mean age was 46.0 ±15.4 years and the mean follow-up period was 62.7 ±15.0 months. Medical records were retrospectively analyzed from January 1994 until December 2001, according to a preestablished protocol. Eight patients (11.9%) had arterial thrombosis, 12 (17.9%) had vein thrombosis, 12 (17.9%) had thrombocytopenia, 20 (29.8%) had neurologic disorders, and 51.6% of the women in reproductive age had, at least 2 fetal losses (higher frequency in primary APS). Thirty-six patients (53.7%) had increased levels of both immunoglobulin G (IgG) and IgM anticardiolipin antibodies (ACA), 19 (28.4%) had IgG ACA only, and 12 (17.7%) had IgM ACA only. Antinuclear antibodies (ANA) were detected in 46 (68.6%) patients, and antineutrophil cytoplasmic antibodies (ANCA) in 29 (43.3%). All patients were prophylactically treated with aspirin (50-100 mg/day) and low-molecular-weight heparin and/or intravenous immunoglobulins-IVIGs occasionally (pregnant women). The findings of this study are, generally, similar to those described by others. Miscarriages seem to be more frequent in women with primary APS (p<0.05), compared to other studies. Differences between these findings and those described by others concerning epidemiologic, clinical, or immunologic data are discussed.

Feasibility of an easy-to-use risk score in the prevention of venous thromboembolism and placental vascular complications in pregnant women: a prospective cohort of 2736 women

INTRODUCTION

Management of pregnant women at increased risk of venous thromboembolism (VTE) remains complex in the absence of an easy-to-use tool allowing individualised, risk-adapted prophylaxis. Our objective was to assess whether treatment based on risk score is feasible in these women.

MATERIALS AND METHODS

A scoring system for VTE risk in pregnant women was developed, each score being associated with a specific treatment. This system was implemented in a prospective cohort of 2736 consecutive women delivered in our teaching hospital from July 2002 to June 2003. Thromboembolic and obstetrical outcomes during pregnancy and the early post-partum period were recorded.

RESULTS

Treatment based on risk score was implemented in 2685 of the 2736 women included (98.1%). The scoring system identified 2431 women with no risk factor and 305 women (11%) with at least one risk factor. Eight women not at risk (0.3%, [95% CI: 0.1-0.5]) and one at risk (0.4%, [95% CI: 0-1.1]) experienced a VTE. This low event rate precluded estimation of the discriminatory power of the score. However, the benefit of the scoring system was evaluated indirectly by assessing VTE incidence in the 46 women at risk in whom it was not used (15.2%, [95% CI: 4.8-25.6]).

CONCLUSIONS

Our simple scoring system offers an easily implemented procedure for risk-based VTE prophylaxis of pregnant women and the proposed therapeutic strategy appears to be effective and safe in reducing VTE. The discriminatory power of the score is currently being evaluated in a randomized, controlled trial.

Antiphospholipid antibodies and pregnancy

Antiphospholipid antibodies, i.e. lupus anticoagulants and anticardiolipin antibodies, are associated with obstetric complications. Fetal death and recurrent spontaneous abortions represent the obstetric criteria of the antiphospholipid syndrome. They occur with similar frequences and have an overall prevalence of 15-20%. Lupus anticoagulants carry a risk 3.0 to 4.8 times, and anticardiolipin antibodies 0.86 to 20 times higher than controls. The mechanism(s) by which antiphospholipid antibodies cause these events still has to be defined: thrombosis in the placental vessels, and impairment of embryonic implantation have been proposed. Unfractionated or low-molecular-weight heparin, alone or in combination with low-dose aspirin, represent the current standard treatment of pregnant antiphospholipid-positive women for preventing recurrent obstetric complications. Upon treatment, the live birth rate increases from 0-40% to 70-80%. However, there is still an excessive frequency of maternal and/or fetal complications, indicating the necessity of a better calibration of the dosage, duration and timing of administration of heparin treatment.

Antiphospholipid Antibody Syndrome

Antiphospholipid antibody syndrome (APS) is a recently defined autoimmune disorder characterized by recurrent vascular thromboses or recurrent pregnancy morbidity; these features are linked to the presence in blood of autoantibodies against negatively charged phospholipids or phospholipid-binding proteins. Thrombosis can occur in any tissue, in veins, arteries, or the microvasculature. Pregnancy morbidity in APS includes miscarriages or premature birth. Criteria that define the major clinical and laboratory features of APS were published in 1999. In patients with antiphospholipid antibodies and prior thrombosis or pregnancy morbidity, there is a high risk of recurrence that persists as long as antiphospholipid antibodies occur in blood. This risk for recurrence of thrombosis or pregnancy morbidity is greatly reduced by preventive anticoagulant therapy. Patients presenting with thrombosis in APS are initially managed in much the same way as are patients with vascular thrombosis owing to other causes. However, in patients with APS, high-intensity anticoagulation is usually needed to prevent recurrences of thrombosis. Thrombosis in APS is often multifactorial, as with non-APS thrombosis. Therefore, in all patients with APS, other reversible risk factors for thrombosis should be sought. The pregnancy outcome of women with APS who have had prior miscarriages is greatly improved by treatment during pregnancy with a combination of heparin and low-dose aspirin.

Importance of planning ovulation induction therapy in systemic lupus erythematosus and antiphospholipid syndrome: a single center retrospective study of 21 cases and 114 cycles

OBJECTIVE

To analyze the results and complications of ovulation induction therapy (OIT) in women with systemic lupus erythematosus (SLE) and/or the antiphospholipid syndrome (APS).

METHODS

A retrospective study of 21 women followed in a single tertiary-referral French center who underwent 114 OIT cycles with or without in vitro fertilization and embryo transfer (IVFET).

RESULTS

Before OIT, SLE was present in 6 women, APS in 3, SLE-related APS in 3, and discoid lupus in 1. Eight women had no identified disease and underwent 36 cycles of OIT. Diagnosis (SLE, n = 3; primary APS, n = 5) was made after OIT complication: spontaneous abortion (n = 5), SLE flare (n = 2), and thrombophlebitis (n = 1). Five women with known disease intentionally concealed their history from their gynecologists and underwent 34 cycles. Forty-four cycles were planned in 11 women, in 3 of them after complications of prior OIT performed without particular therapy and monitoring. Eighteen pregnancies occurred, which ended in 9 live births, 4 fetal deaths, and 5 embryonic losses. The pregnancy rate was higher with gonadotropin and/or gonadotropin-releasing hormone analog (GnRHa) (25% of cycles) than with clomiphene (4% of cycles, P <.0001). When the gynecologists did not know the underlying disease, three-quarters of pregnancies induced by OIT with IVFET ended in embryonic losses or fetal deaths. In contrast, 6 of 7 pregnancies induced by planned OIT with IVFET ended in live births (P <.0001). Phlebothromboses were observed only with gonadotropin treatment. The SLE flare rate was higher with gonadotropin and/or GnRHa (27% of cycle) than with clomiphene (6%, NS). It also was higher (30%) when the gynecologists did not know the underlying disease than in the planned procedures (10%, NS).

CONCLUSIONS

The OIT may precipitate SLE or APS. A careful review of the patient's history and appropriate laboratory tests should be undertaken before OIT. Clomiphene complications are rare. When gonadotropins are prescribed, preventive anti-inflammatory therapy should be considered in women with SLE, in addition to heparin and/or anti-aggregant therapy in patients with asymptomatic anti-phospholipid antibodies or prior thrombotic events.

Antibody specificity and related clinical features in antiphospholipid syndrome

Abstract The concept of antiphospholipid syndrome (APS) has been widely accepted. Antiphospholipid antibodies originally included anticardiolipin antibodies and lupus anticoagulants. However, recent advances have shown that most pathogenic antiphospholipid antibodies are directed to phospholipid binding proteins such as β2-glycoprotein I (β2-GPI) and prothrombin. Other candidates for antigens of so-called antiphospholipid antibodies are protein C, protein S, factor V, factor X, annexin V, high and low molecular weight kininogens, and complex with β2-GPI and oxidized low-density lipoprotein (LDL). These autoantibodies directed to different phospholipid binding proteins are present in the blood stream, and contribute to triggering procoagulant effects on endothelial cells and platelets, leading to thrombosis. The heterogeneity of these antiphospholipid antibodies appears to explain various clinical manifestations in patients with APS. The preliminary classification criteria for definite APS and a general management policy have been proposed, although successful treatment of patients with antiphospholipid antibodies have only been shown by retrospective studies. Further prospective investigations are required to confirm the diagnostic and therapeutic criteria for patients with APS.

Factor V Leiden and acquired activated protein C resistance among 1000 women with recurrent miscarriage

Activated protein C (APC) resistance, both in its congenital form, due to the factor V Leiden mutation, and in its acquired form, are important risk factors for systemic venous thrombosis. In view of the suspected thrombotic aetiology of some cases of recurrent miscarriage, the prevalence of APC resistance was determined among 1111 consecutive Caucasian women with a history of either recurrent early miscarriage (three or more consecutive pregnancy losses at <12 weeks gestation; n = 904) or a history of at least one late miscarriage (>12 weeks gestation; n = 207). A control group of 150 parous Caucasian women with no previous history of adverse pregnancy outcome was also studied. Acquired APC resistance was significantly more common among both women with recurrent early miscarriage (8.8%: 80/904; P = 0.02) and those with late miscarriage (8.7%: 18/207; P = 0.04) compared with controls (3.3%: 5/150). In contrast, the frequency of the factor V Leiden allele was similar among (i) women with recurrent early miscarriage (3.3%:60/1808; 58 heterozygotes and one homozygote), (ii) those with late miscarriage (3.9%:16/414; 14 heterozygotes and one homozygote) and (iii) the control group (4.0%:12/300; 12 heterozygotes). Acquired but not congenital APC resistance (due to the factor V Leiden mutation) is associated with both early and late miscarriage.