Antiphospholipid Syndrome (APS) in Pregnancy

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It is an autoimmune disease characterized by the presence in maternal circulation of one or more  auto  antibodies  against  membrane  phospholipids.  It  is  an  acquired  condition.  Antiphospholipid  syndrome  (APS)  is  characterized  by  venous  or  arterial  thrombosis  and/or  an  adverse  pregnancy  outcome. APS occurs either as a primary condition or in the setting of an underlying disease, usually  systemic lupus erythematosus (SLE). 

Clinical presentation 

  • Recurrent pregnancy adverse outcome e.g. (miscarriages) recurrent miscarriage, intrauterine growth restriction, early severe pre-eclampsia and preterm birth.
  • Unexplained venous thrombosis (DVT) or arterial thrombosis (Stoke) or myocardial infarction
  • thrombocytopenia (common finding but among the clinical classification criteria)

Classification with APS requires one clinical and one laboratory manifestation: 
Clinical 

  • A documented episode of arterial, venous, or small vessel thrombosis
  • 1 or more unexplained deaths of a morphologically normal fetus ≥ 10-week GA
  • 3 or more unexplained consecutive spontaneous abortions before the 10th weeks of GA with anatomic, hormonal or chromosomal causes excluded
  • Eclampsia  or  severe  pre-eclampsia  according  to  standard  definitions,  or  recognized features of placental insufficiency

Laboratory: 

  • Anti-cardiolipin IgG and/or IgM measured on 2 or more occasions, not less than 12 weeks apart;
  • Anti-β2 glycoprotein I IgG and/or IgM measured on 2 or more occasions, not less than 12 weeks apart
  • Lupus anticoagulant detected on 2 occasions not less than 12 weeks apart.

Pharmacological Treatment 

A: acetyl salicylic acid (PO) 75-120mg 24hourly beginning as soon as the pregnancy is  confirmed throughout pregnancy 

AND 

C: unfractionated heparin (SC) 5000–10000 

OR 

S: low molecular weight heparin (SC) 30–40mg 24hourly 

Patients  with  Thrombosis  such  as  stroke  or  pulmonary  embolism  need  therapeutic  anticoagulation.  

C:  unfractionated  heparin  (SC)  5,000  bolus  and  subsequent  15,000–20,000  doses  at  12hourly intervals 

OR   

S: low molecular weight heparin (SC) 1mg/kg 12hourly 

Note: 

  • Warfarin should be avoided in pregnancy due the risk of teratogenicity
  • The aPTT needs to be checked and is best done midway between the 12hourly doses, 24hourly.
  • A target of 1.5–2.5 times the control should be aimed

Referral: Refer immediately to a level where expertise and monitoring for treatment through laboratory testing  is available.