Antiphosholipid antibody syndrome

1. ANTIPHOSPHOLIPID ANTIBODY SYNDROME
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Antiphospholipid Antibody
syndrome
Venous thromboembolism during pregnancy
DEFINITION:
It is a condition in which antibodies (lupus anticoagulant and anti cardiolipins antibodies) are formed
against vascular endothelium and plattlets leading to vasoconstriction, thrombosis, placental
infarctions and fetal loss
PATHOGENESIS:
Antiphosholipid antibodies
(lupus anticoagulant and anti cardiolipins antibodies)
relative excess of
thromboxane E2
(vasodilator and prevent
plattlets aggregation)
reduces the release of
hCG
(vasoconstrictor substance)
blocks the action of
prostacyclin
inhibits
trophoplastic invasion
vasculopathy of
Spiral Arterioles
Thrombosis
uteroplacental
insufficiency
Oligohydraminos
Fetal Hypoxia
IUGR
Fetal loss
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2. ANTIPHOSPHOLIPID ANTIBODY SYNDROME
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EFFECT OF ANTIPHOSPHOLIPID ANTIBODIES ON PREGNANCY:
1.
2.
3.
4.
5.
6.
7.
Recurrent pregnancy loss (typically at or beyond 10 weeks)
IUGR
IUFD
Early onset pre-eclampsia (before 20 weeks)
Placental abruption
Preterm labour
Occasionally infertility
DIAGNOSIS:
Criteria for diagnosis should include at least one clinical data + one laboratory data
 Clinical criteria:
I. Pregnancy morbidity:
i.Any unexplained fetal death of a morphologically normal fetus at or beyond 10 weeks
(normality is determined by direct examination or ultrasound)
ii.Any birth of a morphologically normal neonate before 34 weeks due to SPET or severe
placental insufficiency
iii.At least 3 consecutive spontaneous abortions before 10 weeks after exclusion of
maternal, anatomical, hormonal and chromosomal causes (of both parents)
II. Vascular thrombosis: past or current history of:
i.Recurrent DVT
ii.Peripheral arterial gangrene
iii.Cerebro-vascular stroke
iv.Coronary thrombosis
v.Pulmonary hypertension
III. Associated immune and connective tissue disease:
i.SLE
ii. Thrombocytopenia
IV. Persistent false positive Wasserman’s test
V. Infertility
 Laboratory criteria:
I. Positive titres of moderate to high dilution of anti-cardiolipin antibody at least 12 weeks apart
(IgG, IgM)
II. Anti-β2 glycoprotein antibody
III. Lupus anti-coagulant antibody (Russell’s Viber Venom test)
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3. ANTIPHOSPHOLIPID ANTIBODY SYNDROME
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MANAGEMENT:
 Lines of management:
I.
II.
III.
IV.
V.
VI.
Pre-conception counselling
Throboprophylaxis
Corticosteroid therapy
Immunologic therapy
Prevention of complications
Post-partum care
I. PRE-CONCEPTION COUNSELLING:
 Counselling the patient about the possible risk and pregnancy outcome
 Patients with antiphospholoipid antibody syndrome secondary to renal disease, SLE,
thrombocytopenia, and hemolytic anemia need a specialized care
 Pre-conceptional correction of anemia, thrombocytopenia ….etc
II. THROBOPROPHYLAXIS:
 Low dose Aspirin: Aspirin (60 – 80 mg) tablet once daily
 Heparin:
Onset
I. Unfractionated heparin → UFH “Cal-heparin”
II. Low molecular weight heparin → LMWH “Clexan”
Within 10 minutes
Half-life
6 hours
Types
Doses
I.




II.
Monitoring
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

1.
2.
3.
Unfractionated heparin
Normal body weight → 5000 IU/day
Body weight ˂ 50 kg → 2500 IU/day
Body weight ˃ 90 kg → 5000 IU/12 h
High prophylactic dose→ 100 IU/kg/12h
Low molecular weight heparin
Normal body weight → 40 mg/day
Body weight ˂ 50 kg → 20 mg /day
Body weight ˃ 90 kg → 40 mg / 12h
High prophylactic dose→ I mg/kg/12h
Activated partial thromboplastin aPPT twice weekly
Plattlets concentration monthly
Bone mineral density every 3 months
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4. ANTIPHOSPHOLIPID ANTIBODY SYNDROME
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Advantages
Drawbacks
Anti-dot
1. No effect on the fetus ( does not cross placental blood
barrier )
2. Not secreted on milk ( no effect on lactation )
N.B : advantages of LMWH over UFH
o Fewer side effect
o Prolonged half-life
o Greater inhibitory effect on factor X
o Prophylactic dose once daily
o No need for continuous laboratory monitoring
 Increase bleeding tendency
 Osteoporosis ( improved by adding calcium , hence name “
Cal-heparin “
 Fat necrosis at site of injection
 Alopecia
Protamine sulphate 1mg/100IU
N.B:
Epidural anesthesia should be avoided in patients under heparin therapy
III. CORTICOSTEROID THERAPY:
 Prednisone ( ˃40 mg/day) in combination with low dose aspirin
 Complications include: cushenoid manifestation, induced DM, predisposition to
infections
IV. IMMUNOLOGIC THERAPY:
 Indications :
a. Failure of 1st line therapy
b. Associated hypertensive disorders
c. Associated IUGR
 Immunoglobulins IV 0.4 gm/kg/daily for 5 days and repeated monthly
 Immunosuppressive drugs; azathioprine, cyclosporins do not improve success rate
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5. ANTIPHOSPHOLIPID ANTIBODY SYNDROME
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V. PREVENTION OF COMPLICATIONS:
 Continuous monitoring by:
a. ANC weekly
b. NST and ultrasound every 2 weeks
c. Doppler ultrasound for early detection of uteroplacental insufficiency and IUGR
 Corticosteroid therapy may be used for lung maturity but it is better to be avoided in
heparinized patients
 High risk patients should be fully anticoagulated with LMWH throughout the whole
pregnancy
 Low-dose aspirin alone is enough if no complications
VI. POST-PARTUM CARE:
 Thromboprophylaxis should be continued for first 6 weeks postpartum
 Warfarin can be used to achieve INR values between 2.0 and 3.0 even in breast feeding
woman
 Estrogen-containing pills are contraindicated
N.B: Postpartum examination of placenta is important
In complicated cases the placenta appears of low weight, massive infarctions
and intravascular thrombosis
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