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Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Shavit R, Ellis MH, Agmon-Levin N. Long Term Follow up of Patients With Primary Obstetric Antiphospholipid Syndrome. Front Pharmacol 2022; 13:824775. [PMID: 35529433 PMCID: PMC9068935 DOI: 10.3389/fphar.2022.824775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Primary obstetric antiphospholipid syndrome (OAPS) is defined by specific morbidities and/or losses of pregnancy in the presence of persistent antiphospholipid antibodies (aPL). This variant of APS is usually treated during pregnancy and the post-partum period. Data on occurrence of thrombotic event during long term follow-up of OAPS patients is limited. Methods: A multi-centre retrospectively cohort of female patients with primary APS (pAPS) was assembled during 2004–2019. Patients were grouped according to disease presentation as pure OAPS or thrombotic APS (tAPS) for those presenting with thrombosis. Clinical and serological data were compared between groups. Results: Of 219 pAPS female patients 67 (30.6%) were diagnosed with OAPS and 152 (69.4%) with tAPS. During >10 years of follow-up 24/67 (35.8%) OAPS and 71/152 (50%) tAPS suffered a new thrombotic event (p = 0.06), while obstetric morbidity was more likely in the OAPS group (31.3 vs. 10.5%, p < 0.001) respectively. Among patients with OAPS at presentation heart valve disease and the presence of ANA were related to thrombosis following diagnosis (25 vs. 4.7%, p = 0.02; and 45.8 vs. 20.8%, p = 0.04 respectively). Conclusion: Thrombotic event following diagnosis were common among female patients with pAPS regardless of disease presentation. Heart valve disease and ANA positivity may be risk factors for thrombosis during follow-up of patients presenting with pure OAPS.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Micha J. Rapoport
- Department of Internal Medicine “C”, Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Martin H. Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Nancy Agmon-Levin,
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Tonello M, Calligaro A, Favaro M, Del Ross T, Veronese P, Salvan E, Gervasi MT, Ruffatti A. The first thrombotic event in purely obstetric antiphospholipid syndrome patients and in antiphospholipid antibody carriers: comparison of incidence and characteristics. Arch Gynecol Obstet 2021; 303:455-461. [PMID: 32880711 DOI: 10.1007/s00404-020-05766-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The long-term risk of thrombosis after pregnancy in women with purely obstetric antiphospholipid syndrome (OAPS) is not well defined. The current study's primary outcome was to evaluate the incidence and characteristics of the first thrombotic event in OAPS, identifying the risk factors for thrombosis in OAPS was its secondary one. METHODS Patients with purely OAPS were consecutively enrolled between September 1999 and September 2019. Subjects without a history of pregnancy morbidity or thrombosis but with persistent positivity for one or more antiphospholipid antibodies (aPL carriers) made up the control group. The study groups included 94 OAPS patients and 124 aPL carriers who were matched for clinical and laboratory parameters. RESULTS An event rate of 0.49/100 patient years was registered in OAPS patients during a mean follow-up of 8.7 years ± 5.5 SD. Kaplan-Meier survival analysis revealed that the cumulative incidence of thromboembolic events was not significantly different in OAPS patients vs aPL carriers. Arterial thrombosis and cerebrovascular events were the more frequent types of vascular involvement in the two groups. As far as risk factors for thrombosis were concerned, the presence of lupus anticoagulant significantly prevailed in both thrombotic OAPS patients and thrombotic aPL carriers with respect to purely OAPS patients and aPL carriers who did not develop thrombosis (p = 0.01 and p = 0.00, respectively). CONCLUSION Just as for aPL carriers, closer monitoring and possibly, a pharmacological prophylaxis should be reserved for OAPS patients at highest risk of developing the first thrombotic event.
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Affiliation(s)
- Marta Tonello
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Paola Veronese
- Obstetrics and Gynecology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Elisa Salvan
- General Department, University of Padua, Padua, Italy
| | - Maria Teresa Gervasi
- Obstetrics and Gynecology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy.
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Bettiol A, Emmi G, Finocchi M, Silvestri E, Urban ML, Mattioli I, Scalera A, Lupoli R, Vannacci A, Di Minno MND, Prisco D. Obstetric antiphospholipid syndrome is not associated with an increased risk of subclinical atherosclerosis. Rheumatology (Oxford) 2020; 59:3709-3716. [PMID: 32388557 DOI: 10.1093/rheumatology/keaa116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/18/2020] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVES The persistent positivity of aPLs, either isolated or associated with thrombotic and/or obstetric events (APS), has been associated with the increase of intima-media thickness (IMT) and carotid plaques. Despite the fact that aPLs can promote both thrombotic and obstetric complications, some pathogenic differences have been documented between the two entities. This study aimed to evaluate whether the atherosclerotic risk differs between subjects with obstetric and thrombotic APS. METHODS A total of 167 APS women (36 obstetric and 131 thrombotic) were compared with 250 aPLs negative controls. IMT of the common carotid artery (CCA) and of the bulb and the prevalence of carotid plaques were assessed. RESULTS CCA- and bulb-IMT were significantly higher in women with thrombotic APS, while being similar between the obstetric APS and the controls [CCA-IMT: mean (s.d.) 0.97 (0.49), 0.78 (0.22) and 0.81 (0.12) mm for the thrombotic, obstetric and control groups, respectively, P < 0.001 between thrombotic and controls, P = 0.002 between thrombotic and obstetric; bulb-IMT: mean (s.d.) 1.38 (0.79), 0.96 (0.27) and 0.96 (0.51) mm for the thrombotic, obstetric and control groups, P < 0.001]. Women with thrombotic APS had significantly increased risk of presenting carotid plaques. This risk was significantly lower in obstetric APS. CONCLUSION Unlike thrombotic APS, obstetric APS is not associated with an increase of markers of subclinical atherosclerosis. If confirmed on wider populations, these results could suggest different pathogenetic role of aPLs in promoting atherosclerosis in vascular and obstetric APS, and raise questions on the risk-benefit profile of thromboprophylaxis in obstetric APS outside pregnancy periods.
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Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Martina Finocchi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Irene Mattioli
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Antonella Scalera
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Roberta Lupoli
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
| | | | - Domenico Prisco
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
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Antiphospholipid syndrome: Diagnosis and management in the obstetric patient. Best Pract Res Clin Obstet Gynaecol 2020; 64:31-40. [DOI: 10.1016/j.bpobgyn.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
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Schreiber K, Hunt BJ. Managing antiphospholipid syndrome in pregnancy. Thromb Res 2020; 181 Suppl 1:S41-S46. [PMID: 31477227 DOI: 10.1016/s0049-3848(19)30366-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid antibodies (aPL). The antibodies currently included in the classification criteria include lupus anticoagulant (LA), anticardiolipin antibodies (aCL) and anti-^2-glycoprotein 1 antibodies (^2GPI). APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature and obstetrical complications. Pregnancy complications in obstetric APS (OAPS) include unexplained recurrent early pregnancy loss, fetal death, or premature birth due to severe preeclampsia, eclampsia, intrauterine growth restriction or other consequences of placental insufficiency. Careful, well monitored obstetric care with the use of aspirin and heparin has likely improved the pregnancy outcome in obstetric APS and currently approximately 70-80% of pregnant women with APS have a successful pregnancy outcome. However, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. Other treatments options are currently being explored and retrospective studies suggest that trials with hydroxychloroquine and possibly pravastatin are warranted in pregnant women with aPL. In this review will focus on the current treatment of OAPS.
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Affiliation(s)
- Karen Schreiber
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK; Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Beverley J Hunt
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK.
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaria Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Ortells LC, Pérez ECC, Rego GDC, Corral SG, Varela CF, López MM, Nishishinya B, Navarro MN, Testa CP, Pérez HS, Silva-Fernández L, Taboada VMM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations. REUMATOLOGIA CLINICA 2020; 16:133-148. [PMID: 30686569 DOI: 10.1016/j.reuma.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS Forty-six recommendations were drawn up, addressing 5main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clinic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaria Ortiz
- Unidad de Hemostasia y Trombosis, Servicio de Hematología. Hospital Vall d́Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología. Facultad de Medicina. Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología. Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte. Medicina del Deporte. Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología. Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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7
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Sobhani NC, Shulman R, Tran EE, Gonzalez JM. Early Onset Severe Hypertensive Disease in Pregnancy and Screening for Antiphospholipid Syndrome. AJP Rep 2020; 10:e32-e36. [PMID: 32140289 PMCID: PMC7056392 DOI: 10.1055/s-0040-1702926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022] Open
Abstract
Objective Although preterm delivery (PTD) before 34 weeks for severe hypertensive disease is a diagnostic criterion for antiphospholipid syndrome (APS), there is no consensus regarding testing for antiphospholipid antibodies (aPL) in this setting. We aim to describe the frequency of and the characteristics associated with inpatient aPL testing in this population. Study Design In this retrospective study of PTD before 34 weeks for severe hypertensive disease, charts were reviewed for aPL testing, gestational age at delivery, fetal complications, and severity of maternal disease. Wilcoxon rank-sum test, Fisher's exact, and chi-squared tests were used for analyses of continuous and categorical variables, and multivariate logistic regression for adjusted odds ratios. Results Among 133 cases, 14.3% had APS screening via aPL testing. Screened patients delivered earlier than unscreened patients (28.9 vs. 31.7 weeks, p <0.001). Each additional week of gestation was associated with a 39% decrease in the odds of screening (95% confidence interval: 0.43-0.85). There were no other differences between the groups. Conclusion APS screening after PTD for severe hypertensive disease is uncommon but more likely with earlier PTD. Despite conflicting recommendations from professional organizations, prior studies demonstrate contraceptive, obstetrical, and long-term risks associated with APS, suggesting that we should increase our screening efforts.
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Affiliation(s)
- Nasim C. Sobhani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | | | - Erin E. Tran
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois
| | - Juan M. Gonzalez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
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Tektonidou MG, Andreoli L, Limper M, Tincani A, Ward MM. Management of thrombotic and obstetric antiphospholipid syndrome: a systematic literature review informing the EULAR recommendations for the management of antiphospholipid syndrome in adults. RMD Open 2019; 5:e000924. [PMID: 31168416 PMCID: PMC6525610 DOI: 10.1136/rmdopen-2019-000924] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/31/2023] Open
Abstract
Objective To perform a systematic literature review (SLR) informing the European Lmmendations for the management of antiphospholipid syndrome (APS) in adults. Methods A SLR through January 2018 was performed. Research questions were constructed using the Patient, Intervention, Comparator, Outcome (PICO) format. We included data from articles that reported on each relevant intervention. Summary effect estimates were calculated for direct comparison studies that matched the PICO question exactly, and for studies with the relevant intervention and comparator. When meta-analyses were available, we used these estimates. Results From 7534 retrieved articles (+15 from hand searches), 188 articles were included in the review. In individuals with high-risk antiphospholipid antibody (aPL) profile without prior thrombotic or obstetric APS, two meta-analyses showed a protective effect of low-dose aspirin (LDA) against thrombosis. Two randomised controlled trials (RCTs) and three cohort studies showed no additional benefit of treatment with vitamin K antagonists at target international normalised ratio (INR) 3–4 versus INR 2–3 in patients with venous thrombosis. In patients with arterial thrombosis, two RCTs and two cohort studies showed no difference in risk of recurrent thrombosis between the two target INR groups. One open-label trial showed higher rates of thrombosis recurrences in triple aPL-positive patients treated with rivaroxaban than those treated with warfarin. RCTs and cohort studies showed that combination treatment with LDA and heparin was more effective than LDA alone in several types of obstetric APS. SLR results were limited by the indirect evidence and the heterogeneity of patient groups for some treatments, and only a few high-quality RCTs. Conclusion Well-designed studies of homogeneous APS patient populations are needed.
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Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, NIAMS/NIH, Bethesda, Maryland, USA
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de Jesús GR, Sciascia S, Andrade D, Barbhaiya M, Tektonidou M, Banzato A, Pengo V, Ji L, Meroni PL, Ugarte A, Cohen H, Branch DW, Andreoli L, Belmont HM, Fortin PR, Petri M, Rodriguez E, Cervera R, Knight JS, Atsumi T, Willis R, Nascimento IS, Rosa R, Erkan D, Levy RA. Factors associated with first thrombosis in patients presenting with obstetric antiphospholipid syndrome (APS) in the APS Alliance for Clinical Trials and International Networking Clinical Database and Repository: a retrospective study. BJOG 2018; 126:656-661. [PMID: 30222236 DOI: 10.1111/1471-0528.15469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients. DESIGN Retrospective study. SETTING The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository. POPULATION Women with Ob-APS. METHODS Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM). MAIN OUTCOME MEASURES Risk factors for thrombosis and aGAPSS. RESULTS Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089]. CONCLUSION Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women. TWEETABLE ABSTRACT More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity.
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Affiliation(s)
- G R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - S Sciascia
- Department of Clinical and Biological Sciences, Centre of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - D Andrade
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - M Barbhaiya
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - M Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - A Banzato
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - V Pengo
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - L Ji
- Rheumatology and Immunology Department, Peking University, First Hospital, Beijing, China
| | - P L Meroni
- Department of Rheumatology, University of Milan, Milan, Italy
| | - A Ugarte
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital Universitario Cruces, Barakaldo, Spain
| | - H Cohen
- Department of Haematology, University College London, London, UK
| | - D W Branch
- Department of Obstetrics and Gynecology, University of Utah Health Sciences and Intermountain Healthcare, Salt Lake City, UT, USA
| | - L Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - H M Belmont
- Division of Rheumatology, NYU School of Medicine, New York, NY, USA
| | - P R Fortin
- Division of Rheumatology, Centre Hospitalier de l'Université Laval, Québec, QC, Canada
| | - M Petri
- Division of Rheumatology, John Hopkins University, Baltimore, MD, USA
| | - E Rodriguez
- Rheumatology Department, Hospital 12 de Octubre, Madrid, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - J S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - T Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - R Willis
- Antiphospholipid Standardization Laboratory, Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - I S Nascimento
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - R Rosa
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - D Erkan
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - R A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,GlaxoSmithKline Immunology and Inflammation, Upper Providence, PA, USA
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Antovic A, Sennström M, Bremme K, Svenungsson E. Obstetric antiphospholipid syndrome. Lupus Sci Med 2018; 5:e000197. [PMID: 30364418 PMCID: PMC6195166 DOI: 10.1136/lupus-2016-000197] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Abstract
The present clinical and laboratory classification criteria for antiphospholipid syndrome (APS) were established in Sydney, Australia, in 2006. In this review, we focus on the obstetric subset of APS (OAPS), defined by persistent positivity for antiphospholipid antibodies together with either early recurrent pregnancy loss, early fetal death, stillbirth or premature birth <34 gestational weeks due to pre-eclampsia, eclampsia and placental insufficiency. It is important to diagnose these cases since most women suffering from OAPS can, when given appropriate treatment, have successful pregnancies. Furthermore, patients with OAPS may, depending on the antibody profile, be at enhanced risk of thrombotic events later in life. We present an update on the present knowledge of possible underlying pathogenesis, risk factors and risk estimations for adverse pregnancy outcomes before and during pregnancy, current treatment concepts, and long-term outcomes for women with OAPS and their children.
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Affiliation(s)
- Aleksandra Antovic
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Maria Sennström
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Bremme
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Zuo Y, Barbhaiya M, Erkan D. Primary Thrombosis Prophylaxis in Persistently Antiphospholipid Antibody-Positive Individuals: Where Do We Stand in 2018? Curr Rheumatol Rep 2018; 20:66. [DOI: 10.1007/s11926-018-0775-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is defined as the association of thrombotic events and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies (aPL). In this review, we will highlight the most important clinical presentations of APS with a focus on the obstetric morbidity, the current management strategies and the outlook for the future. RECENT FINDINGS The use of aspirin and heparin has improved the pregnancy outcome in obstetric APS and approximately 70% of pregnant women with APS have a successful pregnancy outcome. Unfortunately, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. This therefore highlights the need for alternative treatments to improve obstetrical outcome. Other treatment options are currently explored and retrospective studies show that pravastatin for example is beneficial in women with aPL-related early preeclampsia. Moreover, the immunmodulator hydroxychloroquine may play a beneficial role in the prevention of aPL-related pregnancy complications. SUMMARY APS is among the most frequent acquired risk factors for a treatable cause of recurrent pregnancy loss and increases the risk of conditions associated with ischaemic placental dysfunction, such as fetal growth restriction, preeclampsia, premature birth and intrauterine death. Current treatment is mainly based on aspirin and heparin. Studies to inform on alternative treatment options are urgently needed.
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Antiphospholipid antibody profile-based outcome of purely vascular and purely obstetric antiphospholipid syndrome. J Thromb Thrombolysis 2018; 46:166-173. [DOI: 10.1007/s11239-018-1672-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Khamashta M, Taraborelli M, Sciascia S, Tincani A. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2016; 30:133-48. [DOI: 10.1016/j.berh.2016.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mekinian A, Costedoat-Chalumeau N, Masseau A, Tincani A, De Caroli S, Alijotas-Reig J, Ruffatti A, Ambrozic A, Botta A, Le Guern V, Fritsch-Stork R, Nicaise-Roland P, Carbonne B, Carbillon L, Fain O. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2014; 14:23-9. [PMID: 25179813 DOI: 10.1016/j.autrev.2014.08.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 01/12/2023]
Abstract
The use of the conventional APS treatment (the combination of low-dose aspirin and LMWH) dramatically improved the obstetrical prognosis in primary obstetrical APS (OAPS). The persistence of adverse pregnancy outcome raises the need to find other drugs to improve obstetrical outcome. Hydroxychloroquine is widely used in patients with various autoimmune diseases, particularly SLE. Antimalarials have many anti-inflammatory, anti-aggregant and immune-regulatory properties: they inhibit phospholipase activity, stabilize lysosomal membranes, block the production of several pro-inflammatory cytokines and, in addition, impair complement-dependent antigen-antibody reactions. There is ample evidence of protective effects of hydroxychloroquine in OAPS similar to the situation in SLE arising from in vitro studies of pathophysiological working mechanism of hydroxychloroquine. However, the clinical data on the use of hydroxychloroquine in primary APS are lacking and prospective studies are necessary.
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Affiliation(s)
- Arsene Mekinian
- AP-HP, Hôpital Saint-Antoine, Service de médecine interne, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, F-75012 Paris, France.
| | - Nathalie Costedoat-Chalumeau
- Université René Descartes, Paris, France; APHP, Centre de reference malades auto-immunes et systemiques rares, Service de médecine interne, Hopital Cochin, Paris, France
| | - Agathe Masseau
- Université Nantes, Nantes, France; Service de médecine interne, Hopital Nantes, Nantes, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara De Caroli
- Department of Obstetrics, Gynaecology, and Pediatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Internal Medicine I, Vall d'Hebrón University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ales Ambrozic
- Department of Rheumatology, University Medical Centre Ljubljana, Slovenia
| | - Angela Botta
- Department of Obstetrics, Gynaecology, and Pediatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Véronique Le Guern
- Université René Descartes, Paris, France; APHP, Centre de reference malades auto-immunes et systemiques rares, Service de médecine interne, Hopital Cochin, Paris, France
| | - Ruth Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, Netherlands
| | - Pascale Nicaise-Roland
- Université Paris 7, Paris, France; AP-HP, Unité Fonctionnelles d'Immunologie «Auto-immunité et Hypersensibilités», Hôpital Bichat-Claude Bernard, Paris, France
| | - Bruno Carbonne
- Université Paris 7, Paris, France; AP-HP, Service de gynécologie obstétrique, Hôpital Trousseau Paris, France
| | - Lionel Carbillon
- Université Paris 13, Bondy, France; AP-HP, Service de gynécologie-obstétrique, Hôpital Jean Verdier, 93140 Bondy, France
| | - Olivier Fain
- AP-HP, Hôpital Saint-Antoine, Service de médecine interne, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, F-75012 Paris, France
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Danowski A, Rego J, Kakehasi AM, Funke A, de Carvalho JF, Lima IV, Silva de Souza AW, Levy RA. Diretrizes para o tratamento da síndrome do anticorpo antifosfolipídeo. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000200005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Abstract
The discovery of antiphospholipid antibodies (aPL) positivity in individuals who have never experienced thrombosis or pregnancy complications is not a rare event, and is one of the unresolved issues in the field of antiphospholipid syndrome (APS). This paper focuses on primary prophylaxis for thrombotic events in aPL carriers. In our view, patients with high risk aPL profiles and/or other cardiovascular risk factors, concomitant diagnosis of systemic lupus erythematosus (SLE) and patients with an history of obstetric APS (OAPS) should be offered thromboprophylaxis. Chronic thromboprophylaxis with low-dose aspirin and hydroxychloroquine in aPL positive SLE patients should be prescribed both to prevent thrombosis and to avoid early organ damage.
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Affiliation(s)
- M T Bertero
- Clinical Immunology, AO Ordine Muriziano, Torino, Italy.
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