Management of pregnant women with antiphospholipid antibodies

ABSTRACT

Introduction: Important advancements in pregnancy outcome have been reported in women with antiphospholipid antibodies (aPL), despite the fact that the treatment of aPL related pregnancy morbidity is not guided by consistent findings from well-designed trials.

Areas covered: The current study draws a picture of the studies in the literature by performing a Medline search of relevant English language articles and reports our experience in managing different subsets of obstetric antiphospholipid syndrome (APS), defined on the basis of their clinical and laboratory characteristics. The management of pregnant women with non-criteria APS manifestations and that of aPL carriers during their first pregnancy is also examined.

Expert commentary: A heparin/aspirin combination constitutes conventional treatment for APS affected pregnant women. As this strategy fails in approximately 20–30% of cases, uncovering other options for women refractory to conventional treatment or at high risk of pregnancy complications has become an urgent undertaking. Some attempts have been made to prescribe additional treatments in the effort to improve live birth rates and/or reduce pregnancy complications, which often occur even in patients treated conventionally. The evidence from some studies and an individual risk/benefit assessment should instead guide treatment decisions for pregnant patients with non-criteria APS manifestations and aPL carriers.

KEYWORDS:

• Antiphospholipid antibodies
• management
• obstetric antiphospholipid syndrome
• pregnancy
• risk factors

Article Highlights

• All women who are aPL-positive do not have the same obstetric risk. Stratifying patients according to their aPL profiles and clinical features is a crucial step in quantifying their risk of poor pregnancy outcome and in enabling clinicians to choose the best therapy for each patient.

• Patients with primary APS who are exclusively affected by previous uncomplicated pregnancy loss, and especially early miscarriage, generally have successful pregnancies when they are treated with prophylactic heparin + LDA.

• Therapeutic heparin + LDA constitutes the most frequently applied treatment protocol in APS patients with previous thrombosis ± pregnancy morbidity, but it is considered a treatment not sufficiently effective in this type of patients because it is frequently associated with maternal and/or fetal complications.

• Up to 40% of APS women with triple or double/single aPL positivity, always including the presence of LAC and a history of severe maternal-fetal complications, receiving conventional therapy develop pregnancy failure/complications. Other treatments in addition to heparin/LDA combination might be useful during the pregnancies of these high risk patients.

• Some additional treatments have been found to be safe and efficacious in high risk APS pregnant women. HCQ therapy begun before pregnancy seems to be a good option especially for APS patients with a previous pregnancy refractory to conventional therapy leading to a fetal death not associated to severe pregnancy complications. IVIG combined to plasma exchange or alone could be used in very high risk pregnant APS women and particularly in those with high risk aPL profile and a history of thrombosis and/or refractory to previous HCQ treatment.

• For the time being, decisions on the use of prophylactic heparin + LDA during pregnancy in women with non-criteria clinical or laboratory manifestations of obstetric APS and in aPL carriers should be based on the evidence from some studies and an individual risk/benefit assessment.

• Pregnancies in APS women should be planned and preceded by counselling during which the future parents are informed about the benefits and risks of the treatment. Clinical, laboratory, and instrumental monitoring must be strict during pregnancy so that a more intensive treatment can be prescribed as soon as the first sign of pregnancy complication presents.

• Puerperium is a critical thrombophilic period, thus, heparin thromboprophylaxis should be extended for at least 6 weeks after delivery. Life-long LDA treatment could be prescribed after puerperium to purely obstetric APS women with one or more risk factors for thrombosis.

Acknowledgments

The authors would like to thank the following investigators involved in the study: Hoxha A, Mattia E, Tonello M and and Inverso Moretti L for editing the English version.

Declaration of interest

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.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.