Antiphospholipid Antibody Syndrome and Pregnancy

8/7/2019 Antiphospholipid Antibody Syndrome and Pregnancy

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Antiphospholipid Antibody Syndrome andPregnancy

Last Updated: October 3, 2002

Synonyms and related keywords: lupus, lupus anticoagulant, LAC, antiphospholipid syndrome,APS, systemic lupus erythematosus, SLE, autoimmune disease, lupus erythematosus, LE, fetalloss, thrombosis, autoimmune thrombocytopenia, infertility, pregnancy complications, fetalmortality, fetal morbidity, maternal morbidity, spontaneous abortion, prematurity, stillbirth, fetalgrowth restriction, FGR, fetal growth retardation

Author: Stella Nowicki, DDS, Head of Infectious Diseases Laboratory, AssistantProfessor, Departments of Obstetrics and Gynecology, Microbiology andImmunology, University of Texas Medical Branch at GalvestonBackground:Antiphospholipid syndrome (APS) is a recently recognized autoimmune conditionthat may manifest with fetal loss, thrombosis, or autoimmune thrombocytopenia.Women with these clinical features should be tested for lupus anticoagulant

(LAC) and anticardiolipin (aCL) antibodies; most patients with APS have bothLAC and aCL immunoglobulin G (IgG) antibodies. The diagnosis of APS requiresthe presence of both clinical and biological features.

Systemic lupus erythematosus (SLE) is a chronic systemic disease with diverseclinical and laboratory manifestations. LAC (and aCL) predisposes to clotting invivo, predominantly by interfering with the antithrombotic role of phospholipids(PLs); therefore, it is associated with clinical thrombosis, not bleeding. Theantiphospholipid (aPL) autoantibodies bind moieties on negatively charged PLsor moieties formed by the interaction of negatively charged PLs with other lipids,PLs, or proteins.

aPL antibodies belong to the large family of antibodies that react with negativelycharged PLs, including cardiolipin, phosphatidylglycerol, phosphatidylinositol,phosphatidylserine, phosphatidylcholine, and phosphatidic acid.

Pathophysiology: The biologic effects mediated by the human aPL antibodiesinclude (1) reactivity with endothelial structures, which disturbs the balance ofprostaglandin E2/thromboxane production; (2) interaction with platelet PLs, withconsequent up-regulation of platelet aggregation; (3) dysregulation ofcomplement activation; and (4) interaction of aPL with phosphatidylserineexposed during trophoblast syncytium formation, which raises the possibility of a

more direct effect of these autoantibodies on placental structures.

In patients with primary APS, the presence of the 3 aCL isotypes plus LAC hasbeen associated with a higher number of recurrent spontaneous abortionscompared to other possible combinations of aCL isotypes.

The association between aPL antibodies and particular human leukocyte antigen(HLA) alleles and HLA-linked epitopes has been reported in studies of patients
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with lupus erythematous (eg, HLA-DR7, HLA-DR4). The HLA-DR3 phenotypesseem to predispose to the formation of aCL antibodies and antinuclear antibodies(ANAs), but this has not been confirmed in patients. However, particular HLAalleles associated with recurrent miscarriage have not been reported.

Animals immunized with aCL or with the cofactor beta-2 glycoprotein I (b2GPI)develop clinical manifestations of APS, including fetal loss, thrombocytopenia,and neurological and behavioral dysfunction, along with elevated levels of aPLantibodies.

aCL antibodies bind to b2GPI, or a complex formed by this b2GPI is a plateletadhesin glycoprotein and cardiolipin. Exposure of endothelial cells to anti-b2GPIantibodies and their corresponding peptides leads to the inhibition of endothelialcell activation, as shown by decreased expression of adhesion molecules E-selectin, intercellular adhesion molecule, and vascular cell adhesion moleculeand of monocyte adhesion.

In vivo infusion of each of the anti-b2GPI antibodies into BALB/c mice followedby administration of the corresponding specific peptides prevents the peptide-treated mice from developing experimental APS. These fascinating resultssuggest that the use of synthetic peptides that focus on neutralization ofpathogenic anti-b2GPI antibodies represents a possible new therapeuticapproach to APS.

Passive transfer into naive mice of inherently heterogeneous aPL antibodypopulations, either affinity-purified or as part of whole immunoglobulin fractions,from humans with APS or autoimmune mice has been shown to induce growth

retardation and fetal loss.

Frequency:

In the US: SLE occurs in approximately 120 cases per 100,000 populationand causes pregnancy complications in approximately 45 cases per100,000 pregnant population. The aPL antibodies account for 65-70% ofcases of venous thrombosis. In women with venous thrombosis in unusualsites (eg, cerebral portal, splenic, subclavian mesenteric veins), aPLantibodies are detected in approximately 2% of patients with nontraumaticvenous thrombosis. This is a rate similar to that of several inherited

conditions of hypercoagulability such as antithrombin III deficiency andprotein C deficiency. Approximately 22% of women with APS have hadvenous thrombosis and 6.9% have had a cerebrovascular incident (over amedian follow-up period of 60 mo); 24% of thrombotic events occurredduring pregnancy or the postpartum period. The rate for thrombosis orstroke is 5-12%. These observations suggest that women withdocumented APS should not take estrogen-progestin combination oralcontraceptives.


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Mortality/Morbidity:

APS increases the risk for maternal and fetal morbidity and fetal mortalityin pregnancy. The rate of fetal loss may exceed 90% in untreated patientswho have APS. Therapy (including aspirin and heparin) can reduce the

rate of fetal loss to 25%, as described by Cowchock et al.

APS is one of the major causes of thrombosis and its complications inwomen. SLE, transient serologic abnormalities, skin lesions, andcongenital heart block are affected by APS. The true neonatal lupusdermatitis, a variety of systemic and hematologic abnormalities, andisolated congenital heart block are associated with APS.

APS is also associated with infertility and pregnancy complications suchas spontaneous abortions, prematurity, and stillbirths. Fetal deaths at orbeyond 20 weeks gestation may be attributed to APS involvement, and

aPL antibodies are found in 10-15% of women at high risk for fetal growthrestriction.

Sex: The female-to-male ratio is 9:1.

Age: Newborns of women with SLE may develop lupus syndrome. Thispredominantly affects reproductive-aged women (ie, 15-55 y).

Clinical

Physical:

Obstetric complications related to APS include the following:

o Sporadic miscarriage

o Recurrent pregnancy loss: Positive test results for IgG or

immunoglobulin M (IgM) aCL antibodies may be found in up to 20%of women with the antibodies, but many positive results are of lowlevel or only the IgM isotype and therefore are not diagnostic ofAPS.

o

Recurrent embryonic pregnancy loss or death of the fetus at orbeyond 10 weeks of gestation

o Pregnancy-induced hypertension (PIH) with high risk for preterm

delivery

o Preterm birth


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o Uteroplacental insufficiency

o LAC and medium-to-high positive levels of aCL antibodies (IgG or

IgM): These may be found in 2-4% of otherwise healthy individuals.

Clinical evidence of glomerulonephritis is found in more than 50% ofcases. However, if biopsies are performed on all patients, the incidence ofsome nephritis may be as high as 90%. SLE is associated withencephalopathy and seizures, to a lesser degree with ischemic stroke,and, rarely, with subarachnoid hemorrhage.

Clinical criteria for the diagnosis of APS are as follows:

o Fetal loss: This criterion is defined as 3 or more spontaneousabortions with no more than one live birth or unexplained second orthird trimester fetal death.

o Thrombosis or stroke: This is unexplained venous or arterial

thrombosis, including stroke and arterial insufficiency due to arterialthrombosis.

o Autoimmune thrombocytopenia: Other causes of thrombocytopeniamust be excluded.

o Cutaneous manifestations

These may include digital cyanosis, livedo reticularis, digitalgangrene, and leg ulcers. The cause of these features

remains otherwise unexplained. Other features related to cutaneous manifestations, with a

cause that remains unexplained, include transient ischemicattacks or amaurosis fugax, positive result from the Coombstest, hemolytic anemia, chorea, and chorea gravidarum.

Discoid rash (ie, erythematous raised patch with keratoticscaling and follicular plugging) is a criterion. Older lesionsmay be atrophic. Again, the cause remains unexplained.

Photosensitivity with an unexplained cause is anothercriterion.

o Arthritis: Patients may have nonerosive arthritis involving 2 or moreperipheral joints, and the cause cannot otherwise be determined.

o Serositis: This may be (1) pleuritis or pleural effusion or (2)

pericarditis or pericardial effusion, the cause of which cannot beexplained.


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o Renal disorder: Proteinuria of 0.5 g/d or the presence of cellular

casts, without another cause, is a criterion for APS.

o Neurologic disorder: Criteria include seizures in the absence of

other causes or psychosis in the absence of other causes.

o Hematologic disorder: Features, without an otherwise explainablecause, include (1) hemolytic anemia with reticulocytosis, (2)leukopenia of less than 4000 cells/mm3 on at least 2 occasions, (3)lymphopenia of less than 1500 cells/mm3, or (4) thrombocytopeniaof less than 100,000 cells/mm3.

o Immunologic disorder: Again, the cause remains unexplained.

The clinical manifestations of SLE include the following:

o Skin lesions - 84-71%

o Arthritis - 63-95%

o Nephritis - 46-77%o Raynaud phenomenon - 10-58%

o Neuropsychiatric features - 0-59%

o Lymphadenopathy - 0-58%

o Pleurisy - 37-56%

o Mucous membrane ulceration - 7-54%

o Pericarditis - 29-45%

o Splenomegaly - 9-18%

o Aseptic necrosis - 0-10%

Causes: Passive transfer of maternal antibodies mediate autoimmune disorders

in the fetus and newborn. The mechanism of excess autoantibody productionand immune complex formation is not well understood, although currentinvestigation is focused on abnormal regulator functions and the possibility of aslow virus infection. In addition, certain genetic factors may be important, asindicated by a number of family and twin studies for SLE and the demonstrationof an increased frequency of HLA-DR2, HLA-DR3, and HLA-DR4 null alleles inpatients with SLE.

Significant controversy still exists regarding the role of oral contraceptives ininducing SLE. ANA associated with LP were reverted to negative when the drugwas discontinued. Some patients using the intrauterine device complain of

dysmenorrhea and recurrent infections, especially those taking prednisone andcytotoxic drugs. Although the incidence of SLE in families was initially believed tobe no greater than in the general population, this is no longer thought to be true.

PL molecules are ubiquitous in nature and are present in the inner surface of thecell (ie, on the inner or outer surface of the cell membrane or intracellularorganelles) and in microorganisms. Therefore, during infectious diseaseprocesses, including viral (eg, HIV, Epstein-Barr virus [EBV], cytomegalovirus


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[CMV], adenoviruses), bacterial (eg, bacterial endocarditis, tuberculosis,Mycoplasma pneumonia), spirochetal (eg, syphilis, leptospirosis, Lyme disease),and parasitic (eg, malaria infection), the disruption of cellular membranes mayoccur during cell damage. PLs release and stimulate aPL antibodies.

The SWISS PROT protein database revealed high homology between thehexapeptides that bind to ILA-1, ILA-3, and H-3 mAbs and the membraneparticles of different bacteria and viruses. The sequence LKTPRV showedhomology to 8 different bacteria (eg, Pseudomonas aeruginosa) and homologiesto 5 types of viruses (ie, polyoma virus, human CMV, adenovirus). The sequenceTL-RVYK shows homology to 8 different bacteria, including Haemophilusinfluenzae, Neisseria gonorrhoeae, and Shigella dysenteriae, and to viruses suchas EBV and HIV. Therefore, data might support the theory predicting that epitopemimicry is involved in the propagation of the autoimmune status.

Autoantibodies include the following:

o Antiphospholipid

o Anticardiolipin

o Antiphosphatidylinositol

o Antiphosphatidylserine

o Antiphosphatidylcholine

o Antibeta-2 glycoprotein I

o Antinuclear antibody

o Anti-DNA (double- or single-stranded)

o Anti-Sjgren syndrome A antibody (Ro)

o Anti-Sjgren syndrome B antibody (Ia)

Antibodies against microorganism(s) associated with infection or

vaccination include the following:

o Antibacterial PL

o Antibacterial protein

o Antiviral glycoprotein


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o Anti-Sjgren syndrome A antibody (Ro) and anti-Sjgren syndrome

B antibody (Ia): These are associated with neonatal lupuserythematosus, including congenital complete heart block. Theseantibodies are usually present in patients with Sjgren syndrome.

DifferentialPreeclampsiaThymic tumor

Other Problems to be Considered:

Other causes of thrombocytopenia (eg, HIV infection, drug-inducedthrombocytopenia, thrombotic thrombocytopenia, gestational thrombocytopenia,PIH, other autoimmune disease)

Workup

Lab Studies:

APS is diagnosed when the patient has LAC IgG or IgM aCL in medium-to-high levels, or both, on 2 occasions at least several weeks apart.

o APL antibodies are detected by conventional and specific solid-

phase or enzyme-linked immunoassays. Results are measured asGPL (IgG aCL), MPL (IgM aCL), or aPL (immunoglobulin A [IgA]aCL) units and reported in semiquantitative terms such as negative,low-positive, medium-positive, or high-positive.

o Isolated IgA aCL results are also of uncertain clinical significanceand are not diagnostic of APS. An easy and reliable test wouldsignificantly help detection and follow-up of affected patients.

o Autoantibodies include ANA, aCL antibodies, anti-DNA antibodies

(single- or double-stranded), and anti-b2GPI.

SLE is associated with lower serum complement levels measured eitheras total hemolytic complement activity CH50 or as levels of the third andfourth components of complement C3 and C4, respectively. Decreased

levels of these are indicative of consumption by immune complexes.However, preeclampsia is associated with an increased serumcomplement level.

Indications for testing for aPL antibodies include the following:

o Obstetric indications are as follows: Unexplained fetal death or stillbirth


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Recurrent pregnancy loss (3 or more spontaneousabortions)

Unexplained second or third trimester fetal death Severe preeclampsia at less than 34 weeks of gestation Severe fetal growth restriction

o Nonobstetric indications are as follows: Nontraumatic thrombosis or thromboembolism (venous or

arterial) Stroke, especially in individuals aged 24-50 years Autoimmune thrombocytopenia Transient ischemic attacks Livedo reticularis Hemolytic anemia Systemic lupus erythematosus False-positive serologic test result for syphilis

Laboratory criteria for the diagnosis of APS are as follows:

o LAC is detected by PL-dependent clotting assays, without

correction with normal plasma. Results are confirmed bydemonstrating PL dependency. The activated partial thromboplastintime is prolonged. Sera are screened for anticoagulant activity bymixing them with platelet-pool normal sera and assaying theactivated partial thromboplastin time. Several laboratorymeasurements are available for the assessment of LAC.

o

For aCL or anti-b2GPI antibodies, an IgG isotype greater than 12-20 GPL units (medium- to high-positive) detected in a standardizedassay using standard serum calibrators is indicative.

Hematologic and serologic manifestations of APS are as follows:

o For antinuclear factor, the range is 0-94.9.

o For lupus erythematosus cells, the range is 75.7-82.

o For leukopenia with 5000 cells/mm3, the range is 0-66.9. For

leukopenia with 4000 cells/mm3

, the range is 0-45.7

o For gamma globulin at 1.6 g/dL, the range is 0-77.

o For rheumatoid arthritis latex, the range is 0-57.

o For thrombocytopenia, the range is 7-26.


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o For a positive result from the Coombs test, the range is 0-23.9.

o Patients may have positive results for autoimmune hemolytic

anemia.o The range for false-positive results from the VDRL test is 8.3-24.

Imaging Studies:

Appropriate neurologic or imaging studies should be performed based onclinical findings (ie, in the presence of CNS symptoms, a CT scan or MRI).

Histologic Findings: Histologically, 6 classes of lupus glomerulonephritis havebeen recognized by the World Health Organization.

Class I - Normal glomeruli observed with light microscopy; may showdeposits with immunofluorescence or electron microscopy

Class II - Mesangial lesions Class III - Focal proliferative glomerulonephritis Class IV - Diffuse proliferative glomerulonephritis Class V - Membranous glomerulonephritis Class VI - Diffuse glomerular sclerosis

Human aCL antibodies cause placental necrosis in BALB/c mice.

Treatment

Medical Care: Pregnant women with APS are considered high-risk obstetric

patients, and medical care is instituted with this in mind. If a chromosomalabnormality is found, genetic counseling is recommended.

Intravenous immunoglobulin (IVIG): Infused immunoglobulins maymodulate aCL antibodies levels by 3 mechanisms.

o Antiidiotypic antibodies may be present in the IVIG preparation.

These antiidiotypic antibodies may bind autoantibodies to formidiotype-antiidiotype dimers, resulting in neutralization ofautoantibody effects.

o Antiidiotype antibodies may bind and down-regulate B-cellreceptors, resulting in a decrease in autoantibody production.

o Antiidiotype antibodies might bind receptors of regulatory T cells,resulting in suppression of lymphokine production and decreasedactivation of autoantibody-producing B cells.

Landry-Guillain-Barr-Strohl syndrome (LGBSS) of acute inflammatorydemyelinating polyradiculoneuropathy

o Patients usually present with progressive bilateral and symmetrical

muscle weakness accompanied by mild sensory symptoms,


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including paresthesia, numbness, and tingling. The disease canprogress to involve the respiratory muscles, resulting in respiratoryfailure. Two thirds of the patients have a history of virallikeinfections 1-3 weeks prior to the onset of symptoms.

o Recently, CMV infection has been incriminated as a potential

etiologic agent in some pregnant patients presenting with LGBSS.o Acute inflammatory demyelinating polyradiculoneuropathy is a rare

disease with an incidence of approximately 1-1.5 cases per100,000 LGBSS cases per year. LGBSS is exceedingly rare inpregnancy.

Obstetric careo Patients should be counseled in all cases regarding symptoms of

thrombosis and thromboembolism and should be educatedregarding and examined frequently for the signs or symptoms ofthrombosis or thromboembolism, severe PIH, or decreased fetal

movement.o In patients with poor obstetric histories, evidence of PIH, or

evidence of fetal growth restriction, ultrasonography isrecommended every 3-4 weeks starting at 18-20 weeks ofgestation.

o Human chorionic gonadotropin (hCG) values may suggest early

prognosis of the pregnancy outcome in the first trimester. If hCGlevels are increasing normally (ie, doubling every 2 d) in the firstmonth of pregnancy, a successful outcome is predicted in 80-90%of cases. However, when the increases are abnormal (ie, slower), apoor outcome is predicted in 70-80% of cases.

o In patients with uncomplicated APS, ultrasonography isrecommended at 30-32 weeks of gestation (ie, to evaluateuteroplacental sufficiency).

o Low molecular weight heparin (LMWH) may be used in APS and

pregnancy (replacement of unfractionated sodium heparin).o Importantly, counsel the patient regarding potential adverse effects

of heparin. Heparin-induced osteoporosis occurs in 1-2% of cases.o Drugs such as chloroquine and cytotoxic agents are not

recommended during pregnancy, and patients should stop takingthese drugs several months prior to becoming pregnant.

o Warfarin may be substituted for heparin during the postpartum

period to limit further risk of heparin-induced osteoporosis and bonefracture.

o Splenectomy during the early second trimester or at the time of

cesarean delivery may be considered in patients refractory toglucocorticoid therapy.

Nonobstetric care


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o Immunosuppressive agents are recommended for patients with

SLE with secondary APS.o Thromboprophylaxis is recommended.

o Patients should be evaluated for renal disease, (glomerulonephritis,N-stage disease), anemia, and thrombocytopenia.

Proposed Management for Women with aPL Antibodies

Feature

Management

Pregnant Nonpregnant

APS with priorfetal death orrecurrentpregnancy loss

Heparin in prophylacticdoses (15,000-20,000 Uof unfractionatedheparin or equivalent

per d) administeredsubcutaneously individed doses with low-dose aspirin dailyCalcium and vitamin Dsupplementation

Optimalmanagementuncertain; optionsinclude no

treatment or dailytreatment with low-dose aspirin

APS with priorthrombosis orstroke

Heparin to achieve fullanticoagulation (doesnot cross the placenta)

Warfarinadministered dailyin doses tomaintain

InternationalNormalized Ratioof 3 or greater

APS without priorpregnancy lossor thrombosis

No treatment or dailytreatment with low-doseaspirin or dailytreatment withprophylactic doses ofheparin plus low-doseaspirin

Optimal managementuncertain

No treatment ordaily treatment withlow-dose aspirinOptimalmanagementuncertain

Preeclampsia IVIG at 400 mg/kg/d for5 days monthlyAdditional therapy isheparin plus low-dose

Not applicable


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aspirin

LGBSS High-dose IVIG at 400-1500 mg/kg/d forseveral days

IVIG at 400-1500mg/kg/d for severaldays

aPL antibodies without APS

LAC or medium-to-high level ofaCL IgG

No treatment No treatment

Low levels ofaCL IgG, onlyaCL IgM, or onlyaCL IgA Without

LA, aPL, or aCL

No treatment No treatment

Note the following:

o The medications shown should not be used in the presence of

contraindications.o Close obstetric monitoring of the mother and fetus is necessary in

all cases.o The patient should be counseled in all cases regarding symptoms

of thrombosis and thromboembolism.

Surgical Care:

Cardiac valvular surgery is recommended in patients with severe aorticregurgitation as a result of APS.

Splenectomy is recommended in patients with the chronic form ofidiopathic thrombocytopenic purpura and is associated with remission inapproximately 75% cases.

Thromboprophylaxis is recommended for any abdominal or orthopedic

surgery.

Manage thrombotic or hemorrhagic complications. Be aware of associatedthrombocytopenia, and employ laboratory methods of perioperativeanticoagulation monitoring in the setting of prolonged clotting times.

Consultations:


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The patient should be informed about potential maternal and obstetricproblems, including fetal loss, thrombosis or stroke, PIH, fetal growthrestriction, and preterm delivery.

In women with APS and one or more prior thrombotic events, lifelong

anticoagulation with warfarin may be advisable to avoid recurrentthrombosis.

Medication

In women with well-recognized obstetric APS, anticoagulant prophylaxis isrecommended during pregnancy and the postpartum period. Pregnant womenwith APS are considered at risk of thrombosis and pregnancy loss. Data suggestlow-dose aspirin and heparin (either unfractionated heparin or LMWH) are thetreatments of choice for prevention of pregnancy loss in pregnant women withAPS and previous pregnancy losses. Pregnant women with APS and a history of

thrombosis but no pregnancy loss only require treatment with heparin. Treatmentis optional for patients with no history of pregnancy loss or thrombosis.

Drug Category: Heparin compounds-- Unfractionated IV heparin andfractionated 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 intravascularthrombosis. Special precaution should be exercised in obstetrical emergencies ormassive liver failure.

LMWHs may also be used. Similar to unfractionated heparin, LMWHs are a classof anticoagulants termed glycosaminoglycans. LMWHs are derived fromunfractionated heparin but have smaller, more standard average masses thanheterogeneous unfractionated heparin.

Unlike standard heparin, LMWHs have higher specificity for factor Xa and havefewer effects on platelet activity. As a result, LMWH may cause bleeding lessoften, while still retaining anticoagulant effects. LMWHs may be associated withless risk of heparin-induced osteoporosis.

Drug Name Heparin, unfractionated (Hep-Lock) --

Indicated to decrease risk of thrombosisand pregnancy loss in pregnant womenwith APS.Augments activity of antithrombin III andprevents conversion of fibrinogen tofibrin. Does not actively lyse but is able toinhibit further thrombogenesis. Preventsreaccumulation of clot after spontaneous


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fibrinolysis.

Adult Dose

APS with prior fetal death/recurrentpregnancy loss: 15,000-20,000 U/d SCdivided q12h plus low-dose aspirinAPS with prior thrombosis or stroke:

Adjusted dose heparin SC q12h tomaintain aPTT within target rangeAPS without prior pregnancy loss orthrombosis: 15,000-20,000 U/d SCdivided q12h (treatment optional)

Pediatric Dose Adolescents: Administer as in adults

Contraindications

Documented hypersensitivity; subacutebacterial endocarditis, active bleeding,history of heparin-inducedthrombocytopenia

Interactions

Digoxin, nicotine, tetracycline, andantihistamines may decrease effects;NSAIDs, aspirin, dextran, dipyridamole,and hydroxychloroquine may increasetoxicity

PregnancyC - Safety for use during pregnancy hasnot been established.

Precautions

Hemorrhage, monitor aPTT, adjust doseaccordingly; caution in severehypotension and shock; heparin-induced

osteoporosis

Drug Name

Enoxaparin (Lovenox) -- Indicated todecrease risk of thrombosis andpregnancy loss in pregnant women withAPS.Prevents DVT, which may lead topulmonary embolism in patientsundergoing surgery who are at risk forthromboembolic complications. Enhancesinhibition of factor Xa and thrombin byincreasing antithrombin III activity. In

addition, preferentially increasesinhibition of factor Xa.

Adult Dose APS with prior fetal death/recurrentpregnancy loss: 40 mg/d SC plus low-dose aspirinAPS with prior thrombosis or stroke: 1mg/kg SC q12h


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APS without prior pregnancy loss orthrombosis: 40 mg/d SC (treatmentoptional)


ContraindicationsDocumented hypersensitivity; majorbleeding, thrombocytopenia

Interactions

Platelet inhibitors or oral anticoagulantssuch as dipyridamole, salicylates, aspirin,NSAIDs, sulfinpyrazone, and ticlopidinemay increase risk of bleeding

PregnancyB - Usually safe but benefits mustoutweigh the risks.

Precautions

If thromboembolic event occurs despiteLMWH prophylaxis, discontinue drug andinitiate alternate therapy; elevation ofhepatic transaminases may occur but isreversible; heparin-associatedthrombocytopenia may occur withfractionated or LMWH; 1 mg of protaminesulfate reverses effect of approximately 1mg of enoxaparin if significant bleedingcomplications develop; heparin-inducedosteoporosis; monitor target anti-Xalevels, adjust dose accordingly

Drug Category: Antiplatelet agents-- Randomized controlled trialsdemonstrate improved fetal survival when pregnant women with APS and priorpregnancy losses are treated with low-dose aspirin plus heparin compared tolow-dose aspirin alone.

Drug Name

Aspirin (Anacin, Ascriptin, Bayer Aspirin,Bayer Buffered Aspirin) -- Antiplateleteffect indicated to decrease risk ofthrombosis and pregnancy loss inpregnant women with APS. Inhibitsprostaglandin synthesis, preventing

formation of platelet-aggregatingthromboxane A2. Used in low dose toinhibit platelet aggregation and improvecomplications of venous stasis andthrombosis.

Adult Dose1-2 mg/d PO for antiplatelet effect; not toexceed 325 mg/d (low-dose aspirin)


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Contraindications

Documented hypersensitivity; liverdamage, hypoprothrombinemia, vitamin Kdeficiency, bleeding disorders, asthma;due to association of aspirin with Reye

syndrome, do not use in children (2 g/dmay potentiate glucose-lowering effect ofsulfonylurea drugs

PregnancyC - Safety for use during pregnancy hasnot been established.

Precautions

Pregnancy category D in third trimesterwith full-dose aspirin; may causetransient decrease in renal function andaggravate chronic kidney disease; avoiduse in patients with severe anemia, withhistory of blood coagulation defects, or

taking anticoagulants

Follow up

Further Inpatient Care:

Institute inpatient care as appropriate for the clinical findings.

Further Outpatient Care:

Institute outpatient care as appropriate for clinical findings.

Grief support may be indicated for families who experience perinatallosses.

Special Concerns:


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Regarding corticosteroid therapy, administer supplementation to cover thelabor or cesarean delivery in patients currently receiving steroids or thoserecently treated with these drugs.

No evidence indicates adverse effects related to breastfeeding, although

breastfeeding is not recommended if high doses of cytotoxic orimmunosuppressive agents are required.

Pregnancy in itself is not harmful to the mother or the baby unless theadded work related to the newborn and the emotional stress in the familyprove to be too much for a particular patient. Therapeutic abortions aregenerally not indicated in pregnant women with autoimmune disease.

Epidural anesthetic is not recommended if the mother has a marked dropin the maternal platelet count.

The use of forceps or the vacuum extractor should be individualized.

Documents

Antiphospholipid Antibody Syndrome and Pregnancy