Guidelines Summary
In 2020, the American College of Rheumatology published guidelines on the in patients with rheumatoid diseases, including patients who are positive for antiphospholipid antibodies (aPL). [12] Recommendations for aPL-positive pregnant patients included the following:
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In pregnant women with positive aPL who do not meet criteria for obstetric or thrombotic APS, the ACR conditionally recommends treating with prophylactic aspirin, 81 or 100 mg daily, during pregnancy as preeclampsia prophylaxis. Treatment should begin early in pregnancy (before 16 weeks) and continue through delivery.
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For patients meeting criteria for obstetric antiphospholipid syndrome (APS), the ACR strongly recommends combined low‐dose aspirin and prophylactic‐dose heparin (usually low molecular weight heparin [LMWH]). The ACR strongly recommends continuing prophylactic‐dose anticoagulation for 6–12 weeks post partum.
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In pregnant women with thrombotic APS, the ACR strongly recommends treating with low‐dose aspirin and therapeutic‐dose heparin (usually LMWH) throughout pregnancy and post partum.
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The ACR conditionally recommends against using the combination of prophylactic‐dose heparin and low‐dose aspirin therapy for patients with positive aPL who do not meet criteria for obstetric APS.
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In refractory obstetric APS, the ACR conditionally recommends against treatment with intravenous immunoglobulin or an increased LMWH dose, as these have not been demonstrably helpful in cases of pregnancy loss despite standard therapy with low‐dose aspirin and prophylactic heparin or LMWH.
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The ACR strongly recommends against adding prednisone to prophylactic‐dose heparin or LMWH and low‐dose aspirin in patients in whom standard therapy has been unsuccessful, since there are no controlled studies demonstrating a benefit.
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The ACR conditionally recommends the addition of hydroxychloroquine (HCQ) to prophylactic‐dose heparin or LMWH and low‐dose aspirin therapy for patients with primary APS.
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In pregnant women with positive aPL who do not meet criteria for APS and do not have another indication for the drug (such as systemic lupus erythematosus), the ACR conditionally recommends against treating with prophylactic HCQ.
Tables
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 |
