Antiphospholipid Syndrome and Pregnancy Medication
- Author: Teresa G Berg, MD, FACOG; Chief Editor: Thomas Chih Cheng Peng, MD more...
In women with well-recognized obstetric APS, anticoagulant prophylaxis is recommended during pregnancy and the postpartum period. Pregnant women with APS are considered at risk for thrombosis and pregnancy loss. Data suggest low-dose aspirin and heparin (either unfractionated heparin or LMWH) to be the treatments of choice for prevention of pregnancy loss in pregnant women with APS and previous pregnancy losses. Pregnant women with APS and a history of thrombosis but no pregnancy loss require only treatment with heparin. Treatment is optional for patients with no history of pregnancy loss or thrombosis.
Unfractionated intravenous (IV) heparin and fractionated subcutaneous (SC) LMWH are the 2 choices for initial anticoagulation therapy. Warfarin therapy may be initiated in the postpartum stage.
These are used in the treatment or prophylaxis of clinically evident intravascular thrombosis. Special precaution should be exercised in obstetrical emergencies or massive liver failure.
Similar to unfractionated heparin, LMWHs are a class of anticoagulants termed glycosaminoglycans. LMWHs are derived from unfractionated heparin but have smaller, more standard average masses than does heterogeneous unfractionated heparin.
Unlike standard heparin, LMWHs have higher specificity for factor Xa and have fewer effects on platelet activity. As a result, LMWH may cause bleeding less often, while still retaining anticoagulant effects. LMWHs may be associated with less risk of heparin-induced osteoporosis.
Heparin is indicated to decrease the risk of thrombosis and pregnancy loss in pregnant women with APS.
It augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin. Heparin does not actively lyse but is able to inhibit further thrombogenesis. The drug prevents reaccumulation of clot after spontaneous fibrinolysis.
Enoxaparin, an LMWH, is indicated to decrease the risk of thrombosis and pregnancy loss in pregnant women with APS. It prevents deep venous thrombosis (DVT), which may lead to pulmonary embolism in patients undergoing surgery who are at risk for thromboembolic complications. Enoxaparin enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, it preferentially increases the inhibition of factor Xa.
Dalteparin is indicated for the prevention of DVT, which may lead to PE. It enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, dalteparin preferentially increases the inhibition of factor Xa. The average duration of treatment is 7-14 days.
Antiplatelet Agents, Hematologic
Randomized, controlled trials demonstrate improved fetal survival when pregnant women with APS and prior pregnancy losses are treated with low-dose aspirin plus heparin, compared with low-dose aspirin alone.
Aspirin's antiplatelet effect is indicated to decrease the risk of thrombosis and pregnancy loss in pregnant women with APS. It inhibits prostaglandin synthesis, preventing the formation of platelet-aggregating thromboxane A2. Aspirin is used in low dose to inhibit platelet aggregation and to improve complications of venous stasis and thrombosis.
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|APS with prior fetal death or recurrent pregnancy loss||Heparin in prophylactic doses (15,000-20,000 U of unfractionated heparin or equivalent per day) administered subcutaneously in divided doses with low-dose aspirin daily
Calcium and vitamin D supplementation
|Optimal management uncertain; options include no treatment or daily treatment with low-dose aspirin|
|APS with prior thrombosis or stroke||Heparin to achieve full anticoagulation (does not cross the placenta)||Warfarin administered daily in doses to maintain international normalized ratio of =3|
|APS without prior pregnancy loss or thrombosis||No treatment or daily treatment with low-dose aspirin or daily treatment with prophylactic doses of heparin plus low-dose aspirin; optimal management uncertain||No treatment or daily treatment with low-dose aspirin; optimal management uncertain|
|LGBSS||High-dose IVIG at 400-1500 mg/kg/day for several days||IVIG at 400-1500 mg/kg/d for several days|
|aPL Antibodies Without APS|
|LAC or medium to high level of aCL IgG||No treatment||No treatment|
|Low levels of aCL IgG, only aCL IgM, or only aCL IgA without LA, aPL, or aCL||No treatment||No treatment|