High-risk pregnancy series: an expert’s viewAntiphospholipid syndrome: obstetric diagnosis, management, and controversies☆
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.
References (44)
Autoantibodies to phospholipid-binding plasma proteinsA new view of lupus anticoagulants and other “antiphospholipid” antibodies
Blood
(1994)- et al.
Immunoglobulin G fractions from patients with antiphospholipid antibodies cause fetal death in BALB/c miceA model for autoimmune fetal loss
Am J Obstet Gynecol
(1990) - et al.
Experimental thrombosis and antiphospholipid antibodiesNew insights
J Autoimmun
(2000) - et al.
Repeated fetal losses associated with antiphospholipid antibodiesA collaborative randomized trial comparing prednisone with low-dose heparin treatment
Am J Obstet Gynecol
(1992) Antiphospholipid antibody-associated recurrent pregnancy lossTreatment with heparin and low-dose aspirin is superior to low-dose aspirin alone
Am J Obstet Gynecol
(1996)- et al.
Use of antithrombotic agents during pregnancy
Chest
(2001) - et al.
Pregnancy complicated by the antiphospholipid syndromeOutcomes with intravenous immunoglobulin therapy
Obstet Gynecol
(1999) - et al.
A multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy. The Pregnancy Loss Study Group
Am J Obstet Gynecol
(2000) - et al.
Does aspirin have a role in improving pregnancy outcome for women with the antiphospholipid syndrome? A randomized controlled trial
Am J Obstet Gynecol
(2000) - et al.
Prednisone does not prevent recurrent fetal death in women with antiphospholipid antibody
Am J Obstet Gynecol
(1989)
Antiphospholipid antibodies and preeclampsiaA case-control study
Obstet Gynecol
Heparin-induced thrombocytopenia is rare in pregnancy
Am J Obstet Gynecol
Clinical utility of anticardiolipin antibody assaysHigh inter-laboratory variation and limited consensus by participants of external quality assurance programs signals a cautious approach
Pathology
Antiphospholipid syndrome in pregnancyA randomized, controlled trial of treatment
Obstet Gynecol
Anticardiolipin antibodiesClinical consequences of “low titers”
Obstet Gynecol
Antiphospholipid antibody panels and recurrent pregnancy lossPrevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies
Fertil Steril
Which are the best biological markers of the antiphospholipid syndrome?
J Autoimmun
Comparative trial of prednisone plus aspirin versus aspirin alone in the treatment of anticardiolipin antibody-positive obstetric patients
Am J Obstet Gynecol
International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome. Report of an international workshop
Arthritis Rheum
Anti-phospholipid syndrome
N Engl J Med
The management of thrombosis in the antiphospholipid-antibody syndrome
N Engl J Med
Outcome of treated pregnancies in women with antiphospholipid syndromeAn update of the Utah experience
Obstet Gynecol
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.