Elsevier

Obstetrics & Gynecology

Volume 101, Issue 6, June 2003, Pages 1333-1344
Obstetrics & Gynecology

High-risk pregnancy series: an expert’s view
Antiphospholipid syndrome: obstetric diagnosis, management, and controversies

https://doi.org/10.1016/S0029-7844(03)00363-6Get rights and content

Abstract

Antiphospholipid syndrome, a condition characterized by one or more thrombotic or pregnancy-related clinical features in association with medium to high levels of antiphospholipid antibodies, has emerged as an important diagnostic consideration in several medical fields. Antiphospholipid syndrome is one of the few treatable causes of pregnancy loss, and successful pregnancy rates of 70% or more can be achieved with appropriate treatment. Heparin, usually combined with low-dose aspirin, is used in patients at risk for thrombosis. Pregnancy in these women is associated with increased rates of preeclampsia, placental insufficiency, and preterm delivery, so that attentive clinical care is required for best outcomes. Recent studies indicate that women at low risk for thrombosis may be treated with low-dose aspirin. However, remaining controversies and unanswered questions in the field of antiphospholipid syndrome are a source of clinical confusion. This review highlights the most important controversies, taking into account the results of recent obstetric treatment trials and our own clinical experience.

Section snippets

Pathogenesis of obstetric features of antiphospholipid syndrome

Whether antiphospholipid antibodies per se are the cause of adverse obstetric outcomes associated with the antibodies remains a subject of debate. Working with mice, some investigators found administration of human antiphospholipid antibodies results in clinical manifestations of antiphospholipid syndrome, including fetal loss.7, 8 The induction of fetal loss in this model is, however, variable. One group has used a mouse venous thrombosis model to show that circulating human and mouse

Diagnostic approach to antiphospholipid syndrome

The diagnosis of antiphospholipid syndrome is first and foremost clinical—the patient must have one or more thrombotic or obstetric features of the condition. Laboratory testing for antiphospholipid antibodies is used to confirm or refute the diagnosis. The 1999 international consensus statement on preliminary classification criteria for definite antiphospholipid syndrome1 provides simplified criteria for the classification of antiphospholipid syndrome (Table 1). A patient with antiphospholipid

Therapeutic approach to antiphospholipid syndrome in pregnancy

The ideal treatment for antiphospholipid syndrome during pregnancy would 1) improve maternal and fetal–neonatal outcome by preventing pregnancy loss, preeclampsia, placental insufficiency, and preterm birth and 2) reduce or eliminate the maternal thrombotic risk of antiphospholipid syndrome during pregnancy. Treatment of antiphospholipid syndrome in pregnancy to improve fetal outcome has evolved considerably. Early enthusiasm for glucocorticoids waned when a small, randomized trial found

Complications of antiphospholipid syndrome in pregnancy

The potential complications of pregnancy in women with antiphospholipid syndrome include recurrent pregnancy loss (including fetal death), preeclampsia, placental insufficiency, maternal thrombosis (including stroke), and complications due to treatment. In women with systemic lupus erythematosus, the potential complications also include lupus exacerbation.

In case series of antiphospholipid syndrome pregnancies that included women with systemic lupus erythematosus and prior thrombosis, the

Laboratory testing for antiphospholipid antibodies

Despite international efforts to standardize laboratory testing for antiphospholipid antibodies (reviewed in Levine et al2), significant variation in the performance of antiphospholipid antibody assays (and hence the results) remains a critical problem. Large interlaboratory variation in anticardiolipin antibody testing has been amply documented.29 Agreement among commercially available kits is also poor.30 It is not surprising that the prevalence of antiphospholipid antibodies varies from

Acknowledgements

We thank the following individuals who, in addition to members of our Editorial Board, will serve as referees for this series: Dwight P. Cruikshank, MD, Ronald S. Gibbs, MD, Gary D. V. Hankins, MD, Philip B. Mead, MD, Kenneth L. Noller, MD, Catherine Y. Spong, MD, and Edward E. Wallach, MD.

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  • Cited by (0)

    DWB is supported by the H. A. and Edna Benning Presidential Endowed Chair at the University of Utah. MAK is supported by Lupus UK and The St. Thomas’ Lupus Trust.

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