Characteristics of pregnancy complications and treatment in obstetric antiphospholipid syndrome in China

Does adding hydroxychloroquine to empiric treatment improve the live birth rate in refractory obstetrical antiphospholipid syndrome? A systematic review

PROBLEM

The current standard prevention of obstetric complications in patients with antiphospholipid antibody syndrome (APS) is the use of combination low-dose aspirin and low molecular weight heparin. However, 20-30% of women still experience refractory obstetrical APS. Hydroxychloroquine (HCQ) is an immunomodulatory agent that has been shown in laboratory studies to decrease thrombosis risk, support placentation, and minimize the destructive effects of antiphospholipid antibodies. The objective of this study was to evaluate the risk of pregnancy loss upon treatment with HCQ among women with refractory obstetrical APS.

METHOD OF STUDY

A systematic review was conducted according to PRISMA guidelines. Studies that evaluated the use of HCQ during pregnancy in women with primary APS were included. The primary outcomes of interest were live birth and pregnancy losses after treatment with HCQ.

RESULTS

Twelve studies met inclusion criteria. Three retrospective cohort studies demonstrated improved live birth rate, and four studies demonstrated a reduction in pregnancy loss rate. Two case reports also demonstrated a benefit in the use of HCQ compared to previous obstetrical outcomes.

CONCLUSIONS

Our findings suggest a significant benefit of HCQ in addition to aspirin and heparin for patients with APS to mitigate the risk of antiphospholipid antibody mediated obstetrical complications. Randomized controlled trials with standardized patient selection criteria need to be conducted to corroborate these findings.

Clinical phenotype, treatment strategy and pregnancy outcome of non-criteria obstetric antiphospholipid syndrome

PROBLEM

To illustrate the clinical features, treatment strategy, and pregnancy outcome of patients with obstetric antiphospholipid syndrome (OAPS), non-criteria obstetric antiphospholipid syndrome (NC-OAPS) METHOD OF STUDY: A single-center nested case-control study was designed. Patients with a diagnosis of OAPS and NC-OAPS were enrolled. The medical history, coagulation status, and antibody profile data were collected. Patients were given standard anticoagulation therapy with or without glucocorticoids (GC) and/or hydroxychloroquine (HCQ) during pregnancy and were observed for their pregnancy outcome.

RESULTS

A total of 47 patients with OAPS and 120 patients with NC-OAPS were finally included, of whom 55 patients met the clinical criteria (subgroup C) and 65 met the laboratory criteria (subgroup L). Pregnancy morbidity showed significant differences: gravida, pregnancy loss in OAPS versus NC-OAPS. The coagulation function was not significantly different between OAPS and NC-OAPS groups, while TT and FIB were significantly higher in the subgroup C. Thromboelastography (TEG) results showed a significantly lower ANGEL in the NC-OAPS group, a higher ANGEL and lower EPL, LY30 in the subgroup L. No differences between groups were observed in treatment strategy. The pregnancy outcomes were not significantly different between NC-OAPS and OAPS groups.

CONCLUSIONS

Clinical and laboratory differences were found between OAPS and NC-OAPS groups in this study. Patients in different subgroups of NC-OAPS could be identified with different clinical phenotypes. A relatively hypercoagulable status existed in the OAPS group compared to NC-OAPS, and also in the subgroup L.

Antiphospholipid Antibodies Increase the Risk of Fetal Growth Restriction: A Systematic Meta-Analysis

OBJECTIVE

Antiphospholipid syndrome (APS) is a chronic autoimmune disease with a high prevalence in females. Published data have identified pregnant women with APS may suffer from recurrent miscarriage, fetal death. However, the association between antiphospholipid antibody (aPL) and fetal growth restriction (FGR) remains controversial. This study aims to systematically review the literature on population-based studies investigating an association between aPL and FGR.

METHODS

The literature was searched on 1 November, 2021, using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), following the MOOSE checklist. Study inclusion criteria focused on peer-reviewed published articles that reported an association between aPL and FGR. Quality assessment was performed based on the Newcastle-Ottawa scale. The between-study heterogeneity was assessed by the Q test. Publication bias was assessed by funnel plots.

RESULTS

Twenty-two studies (with 11745 pregnant women) were included in the final analysis. Pooled odds ratio for association of aPL, anticardiolipin antibodies (ACA), anti-beta2 glycoprotein 1 antibodies (β2GP1), and FGR was 1.26 (95%CI 1.12, 1.40), 2.25 (95%CI 1.55, 2.94), and 1.31 (95% CI 1.12, 1.49), respectively. Lupus anticoagulant (LA) did not increase the chance of FGR (OR 0.82, 95%CI 0.54, 1.10).

CONCLUSIONS

Our meta-analysis showed that aPL increased the risk of FGR. The risk of FGR varies with the aPL types. ACA and β2GP1 are strongly associated with FGR. There are currently insufficient data to support a significant relationship between LA and FGR.

Hydroxychloroquine and antiphospholipid antibody-related pregnancy morbidity: a systematic review and meta-analysis

PURPOSE OF REVIEW

Pregnancies in women with antiphospholipid antibodies (aPL) are associated with several pregnancy complications. The current treatment to prevent obstetric aPL-mediated morbidity is largely based on low-dose aspirin (LDA) and low-molecular-weight heparin (LMWH). Alternative treatment regimens to prevent obstetric aPL-related morbidity include the addition of the antimalarial hydroxychloroquine (HCQ). The aim of this systematic review is to identify the currently available evidence on the efficacy of HCQ to prevent aPL-related obstetric morbidity.

RECENT FINDINGS

We identified four retrospective observational studies. No definite signal of harm was identified as none of the studies reported adverse outcomes. When comparing a total of 214 aPL-positive women with a total of 250 HCQ-exposed aPL-positive pregnancies and 521 pregnancies not exposed to HCQ, we found that HCQ exposure was not associated with an increased rate of live births [pooled OR 1.33; 95% confidence interval (CI) 0.62--2.86]). There was considerable heterogeneity in the analysis (I = 59%).

SUMMARY

HCQ seems well tolerated in pregnancy. However, because of the heterogeneity of available studies, the questions whether women with aPL (or some subpopulation of those) might benefit from this agent during pregnancy remains unanswered. Randomized controlled data are needed.

The additional use of hydroxychloroquine can improve the live birth rate in pregnant women with persistent positive antiphospholipid antibodies: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy of additional treatment with hydroxychloroquine (HCQ) for pregnant women with persistent positive antiphospholipid antibodies or antiphospholipid antibody syndrome (APS).

METHOD

We conducted a systematic search of the PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials databases from inception to 31th December 2019. Two authors performed study selection, data collection, and data analysis independently.

RESULT

Five retrospective studies involving 477 pregnancies were selected. The live birth rate was significantly improved in the experimental group (OR, 3.29; 95 % CI, 1.45-7.49; P = 0.004). Additionally, pregnancy loss was associated with the additional use of HCQ (OR, 0.30;95 % CI, 0.13-0.69; P = 0.004). However, HCQ had no significant association with preterm delivery (OR, 0.43; 95 % CI, 0.13-1.37; P = 0.16) and fetal growth restriction showed an OR of 0.22 (95 % CI, 0.13-1.88; P = 0.55).

CONCLUSION

These data suggest that receiving HCQ as an additional treatment can improve the live birth rate in pregnant women with persistent antiphospholipid antibodies.

Clinical features associated with pregnancy outcomes in women with positive antiphospholipid antibodies and previous adverse pregnancy outcomes: a real-world prospective study

OBJECTIVE

This study aims to analyze factors related to pregnancy outcomes in women with positive antiphospholipid antibodies and previous adverse pregnancy outcomes (APOs) prospectively.

METHODS

Patients' characteristics were described. Factors associated with obstetric complications were analyzed using logistic regression analysis.

RESULTS

A total of 128 females with 73.4% non-criteria obstetric antiphospholipid syndrome (NC-OAPS) were included. APOs accounted for 38.3%, of which 65.3% were fetal losses. Live birth rates in criteria OAPS and NC-OAPS were similar (76.5% and 74.5%). For the whole patients, antinuclear antibody (ANA) titer ≥ 1:160 (OR 5.064, 95% CI (1.509, 16.995), P = 0.009) was a risk factor for APOs and low molecular weight heparin (LMWH) use (OR 0.149, 95% CI (0.029, 0.775), P = 0.024)) was a protective factor. Age (OR 1.159, 95% CI (1.011, 1.329), P = 0.034) and previous APOs ≥ 3 times (OR 3.772, 95% CI (1.14, 12.435), P = 0.029) were risk factors for fetal loss, and LMWH use (OR 0.068, 95% CI (0.009, 0.486), P = 0.007) was a protective factor. Regular rheumatology visits was a protective factor for APOs and fetal loss (OR 0.085, 95% CI (0.024, 0.306), P < 0.001; OR 0.019, 95% CI (0.004, 0.104), P < 0.001). The proportion of it decreased in APOs and fetal loss groups (53.1% and 28.1%). Glucocorticoid use was a risk factor for APOs in NC-OAPS and higher serum C3 levels in the first gestational trimester was a protective factor for fetal loss (OR 3.703, 95% CI (1.402, 9.777), P = 0.008; OR 0.041, 95% CI (0.002, 0.947), P = 0.046).

CONCLUSION

Age, APO history, ANA titer, LWMH and glucocorticoid use, serum C3 levels, and regular rheumatology visits were related to obstetric complications. Key Points • This was one of the few prospective studies focused on patients with positive antiphospholipid antibodies and previous adverse pregnancy outcomes. The majority were NC-OAPS patients. • The study first evaluated the impact of rheumatologists' monitoring based on individual disease assessments on pregnancy outcomes. The live birth proportion was similar in patients with criteria OAPS and NC-OAPS when treated. • Age, APO history (≥ 3 times), ANA titer (≥ 1:160), LMWH use, glucocorticoid use, and serum C3 were factors related to obstetric complications.