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Antiphospholipid Syndrome and Pregnancy Treatment & Management

  • Author: Teresa G Berg, MD, FACOG; Chief Editor: Thomas Chih Cheng Peng, MD  more...
 
Updated: Apr 15, 2015
 

Approach Considerations

Pregnant women with APS are considered high-risk obstetric patients, and medical care is instituted with this in mind.

In patients receiving or recently treated with corticosteroid therapy, administer supplementation to cover the labor or cesarean delivery.

Pregnancy in itself is not harmful to the mother or the baby unless added work related to the newborn, as well as emotional stress in the family, proves to be too much for a particular patient. Therapeutic abortions are generally not indicated in pregnant women with autoimmune disease.

Epidural anesthetic is not recommended if the mother has a marked drop in the maternal platelet count. The use of forceps or the vacuum extractor should be individualized.

No evidence indicates adverse effects related to breastfeeding, although breastfeeding is not recommended if high doses of cytotoxic or immunosuppressive agents are required.

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Obstetric Care

Patients should be counseled in all cases regarding symptoms of thrombosis and thromboembolism and should be educated regarding, and examined frequently for, the signs or symptoms of thrombosis or thromboembolism, severe preeclampsia, or decreased fetal movement.

Ultrasonography is recommended every 3-4 weeks starting at 18-20 weeks’ gestation, in patients with a poor obstetric history, evidence of preeclampsia, or evidence of fetal growth restriction.

Human chorionic gonadotropin (hCG) values in the first trimester can be followed to evaluate the viability of the pregnancy. If hCG levels are increasing normally (ie, doubling every 2 days) in the first month of pregnancy, a successful outcome is predicted in 80-90% of cases. However, when the increases are abnormal (ie, slower), a poor outcome is predicted in 70-80% of cases.

In patients with uncomplicated APS, ultrasonography is recommended at 30-32 weeks’ gestation to assess fetal growth. Lagging fetal growth may reflect uteroplacental insufficiency in patients with APS.

Drugs such as chloroquine and cytotoxic agents are not recommended during pregnancy; patients should stop taking these drugs several months prior to becoming pregnant.

Splenectomy during the early second trimester or at the time of cesarean delivery may be considered in patients with thrombocytopenia refractory to glucocorticoid therapy.

Anticoagulation therapy

Anticoagulation with heparin is recommended in APS and pregnancy with a history of a thromboembolic event. Low-molecular-weight heparin (LMWH) may be used in these patients.

Importantly, counsel the patient regarding potential adverse effects of heparin. Heparin-induced osteoporosis occurs in 1-2% of cases. Initiation of heparin in the face of a failing pregnancy should be undertaken with caution due to bleeding risks.

Bone density studies should be considered in patients receiving anticoagulation therapy with heparin or LMWH due to the risks of osteopenia. This may be most important in women who have been treated in a previous pregnancy or are planning pregnancy.

Warfarin may be substituted for heparin during the postpartum period to limit further risk of heparin-induced osteoporosis and bone fracture.

In women without a history of a thromboembolic event, optimal therapy is not as clear. Anticoagulation may decrease recurrent pregnancy loss in this group of women. Low-dose aspirin combined with prophylactic doses of heparin or LMWH appears to be superior to aspirin therapy alone or maternal steroids.

Intravenous immunoglobulin

Infused immunoglobulins may modulate aCL antibodies levels by the following 3 mechanisms:

  • Antiidiotypic antibodies may be present in the intravenous immunoglobulin (IVIG) preparation; these antiidiotypic antibodies may bind autoantibodies to form idiotype-antiidiotype dimers, resulting in neutralization of autoantibody effects.
  • Antiidiotype antibodies may bind and downregulate B-cell receptors, resulting in a decrease in autoantibody production
  • Antiidiotype antibodies might bind receptors of regulatory T cells, resulting in suppression of lymphokine production and decreased activation of autoantibody-producing B cells
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Nonobstetric Care

Immunosuppressive agents are recommended for patients with SLE with secondary APS. Thromboprophylaxis is also recommended. In addition, patients should be evaluated for renal disease, (glomerulonephritis, end-stage renal disease), anemia, and thrombocytopenia. (See the Table below.)

Table. Proposed Management for Women With aPL Antibodies (Open Table in a new window)

Feature Management
Pregnant Nonpregnant
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

Note the following:

  • The medications shown should not be used in the presence of contraindications
  • Close obstetric monitoring of the mother and fetus is necessary in all cases
  • The patient should be counseled in all cases regarding symptoms of thrombosis and thromboembolism
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Cardiac Valvular Surgery and Splenectomy

Patients with APS, especially secondary APS, may require surgical interventions for long-standing complications of their autoimmune disorder.

Cardiac valvular surgery is recommended in patients with severe aortic regurgitation due to the noninfectious vegetations that are seen as a result of APS.

Splenectomy is recommended in patients with the chronic form of idiopathic thrombocytopenic purpura and is associated with remission in approximately 75% cases.

Thromboprophylaxis is recommended for any abdominal or orthopedic surgery. Manage thrombotic or hemorrhagic complications. Be aware of associated thrombocytopenia, and use laboratory methods of perioperative anticoagulation monitoring in the setting of prolonged clotting times.

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Consultations and Follow-up

The patient should be informed about potential maternal and obstetric problems, including fetal loss, thrombosis or stroke, PIH, fetal growth restriction, and preterm delivery. Consultation with specialists in Maternal-Fetal Medicine and Rheumatology should be considered.

In women with APS and 1 or more prior thrombotic events, lifelong anticoagulation with warfarin may be advisable to avoid recurrent thrombosis. An assessment by a rheumatologist or hematologist may also be helpful.

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Contributor Information and Disclosures
Author

Teresa G Berg, MD, FACOG Associate Professor, Program Director, Director of the Perinatal Diagnostic Center, Department of Obstetrics and Gynecology, University of Nebraska Medical Center

Teresa G Berg, MD, FACOG is a member of the following medical societies: American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Thomas Chih Cheng Peng, MD Professor (Collateral), Department Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, VCU Health System

Thomas Chih Cheng Peng, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Gregory Locksmith, MD Associate Director, Division of Gynecology, Department of Medical Education, Orlando Regional Health System

Disclosure: Nothing to disclose.

Bruce A Meyer, MD, MBA Executive Vice President for Health System Affairs, Executive Director, Faculty Practice Plan, Interim CEO, University Hospitals; Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School

Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Bogdan Nowicki, MD, PhD Head of Infectious Disease Laboratory, Associate Professor, Departments of Microbiology and Immunology, Obstetrics and Gynecology, University of Texas Medical Branch at Galveston

Disclosure: Nothing to disclose.

Stella Nowicki, DDS Head of Infectious Diseases Laboratory, Associate Professor, Departments of Obstetrics and Gynecology, Microbiology and Immunology, University of Texas Medical Branch at Galveston

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Fischer-Betz R, Specker C, Brinks R, Schneider M. Pregnancy outcome in patients with antiphospholipid syndrome after cerebral ischaemic events: an observational study. Lupus. 2012 Oct. 21(11):1183-9. [Medline].

  2. Alijotas-Reig J, Ferrer-Oliveras R, Ruffatti A, et al. The European Registry on Obstetric Antiphospholipid Syndrome (EUROAPS): A survey of 247 consecutive cases. Autoimmun Rev. 2015 May. 14(5):387-395. [Medline].

  3. Bouvier S, Cochery-Nouvellon E, Lavigne-Lissalde G, et al. Comparative incidence of pregnancy outcomes in treated obstetric antiphospholipid syndrome: the NOH-APS observational study. Blood. 2014 Jan 16. 123(3):404-13. [Medline].

  4. Asherson RA, Khamashta MA, Ordi-Ros J, et al. The "primary" antiphospholipid syndrome: major clinical and serological features. Medicine (Baltimore). 1989 Nov. 68(6):366-74. [Medline].

  5. Kochenour NK, Branch DW, Rote NS, Scott JR. A new postpartum syndrome associated with antiphospholipid antibodies. Obstet Gynecol. 1987 Mar. 69(3 Pt 2):460-8. [Medline].

  6. Cowchock FS, Reece EA, Balaban D, Branch DW, Plouffe L. Repeated fetal losses associated with antiphospholipid antibodies: a collaborative randomized trial comparing prednisone with low-dose heparin treatment. Am J Obstet Gynecol. 1992 May. 166(5):1318-23. [Medline].

  7. Wilson WA, Gharavi AE, Koike T, et al. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop. Arthritis Rheum. 1999 Jul. 42(7):1309-11. [Medline].

  8. [Guideline] Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006 Feb. 4(2):295-306. [Medline].

  9. [Guideline] The American College of Obstetricians and Gynecologists. Antiphospholipid Syndrome. ACOG Practice Bulletin. January/2011. 118:1-8. [Full Text].

  10. Sciascia S, Murru V, Sanna G, Roccatello D, Khamashta MA, Bertolaccini ML. Clinical accuracy for diagnosis of antiphospholipid syndrome in systemic lupus erythematosus: evaluation of 23 possible combinations of antiphospholipid antibody specificities. J Thromb Haemost. 2012 Dec. 10(12):2512-8. [Medline].

 
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Table. Proposed Management for Women With aPL Antibodies
Feature Management
Pregnant Nonpregnant
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
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