Update on the current recommendations and outcomes in pregnant women with antiphospholipid syndrome

Abstract

Pregnancy morbidity is part of the clinical spectrum of the antiphospholipid syndrome (APS), a chronic autoimmune condition serologically characterized by the persistent positivity of antiphospholipid antibodies (aPL). Antiplatelet and anticoagulant agents are the mainstay of the treatment of obstetric APS. However, there is an ongoing debate about the optimal management of women with most severe aPL-mediated obstetric complications, women not fulfilling APS criteria and those with refractory disease. Unfortunately, the literature cannot provide definite answers to these controversial issues, being flawed by many limitations. The evidence supporting the recommended therapeutic management of different aPL-related obstetrical clinical manifestations is presented, with a critical appraisal of each approach.

Keywords::

• antiphospholipid antibodies
• antiphospholipid syndrome
• outcomes
• pregnancy morbidity
• treatment

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The revised criteria for obstetric morbidity comprise otherwise unexplained pregnancy loss and/or premature birth due to eclampsia, preeclampsia or placental insufficiency, associated with the persistent positivity at medium-high titers for antiphospholipid antibodies (aPL).

• The evidence in support of the association with aPL is not solid for the whole array of related obstetric manifestations.

• Mechanisms other than thrombotic are increasingly recognized to play a role in the pathogenesis of obstetric antiphospholipid syndrome: placental inflammation and the effects on the functionality of both trophoblast and decidual cells.

• The association of low-dose aspirin and prophylactic doses of heparin is currently regarded as the standard of care for women with obstetric manifestations.

• Literature is flawed by several limitations, preventing the drawing of meaningful conclusions.

• There is no evidence-based recommendation about the management of refractory cases; additional therapeutic tools comprise therapeutic doses of heparin, IVIg, low-dose prednisone and plasma exchange.

• It is still debated whether women with low-titer aPL or one or two pregnancy losses deserve a pharmacological treatment.

• There is an unmet need of better defining treatment options upon to the aPL profile and the subset of pregnancy complication.

• Future therapeutic approaches envisage hydroxychloroquine, inhibition of complement cascade and of anti-β2GPI antibody binding.

Notes