Prevalencia de aPL en poblacin obsttrica

en gral: 2%
Riesgo de trombosis aumenta x estado
hipercoagulable en embarazo
Riesgo d perdidas fetales esta directamente
relacionado a tiutlos IgG aCL

Management (Cont)
Antenatal
Care of pregnant women with APS should be
multidisciplinary and in centres with expertise of
caring for these high-risk pregnancies.
Aspirin inhibits thromboxane and may reduce the
risk of vascular thrombosis. There are many nonrandomized studies suggesting that low-dose
aspirin is effective and it can prevent pregnancy
loss in experimental APS mice.
Aspirin is a logical treatment in those with aPLs but
no clinical features of APS.

Management (Cont)
Antenatal
. Most centres now advocate treatment with lowdoses aspirin for all women with APS, prior to
conception, in the belief that the placental damage
occurs early in gestation, and that aspirin may
prevent failure of placentation.

Antenatal (Cont)
Women with APS and previous thromboembolism are at
extremely high risk of further thromboembolism in pregnancy
and the puerperium and should receive antenatal
thromboprophylaxis with a high prophylactic dose of low
molecular-weight heparin (LMWH) (e.g. Enoxaparin 40 mg
b.d.) . Many of these women are on life-long anticoagulation
therapy with warfarin. The change from warfarin to heparin
should be achieved prior to 6 weeks' gestation to avoid warfarin
embryopathy.
A few women with cerebral arterial thrombosis due to APS on
long-term warfarin may experience transient ischemic symptoms
when LMWH is substituted for warfarin. If these do not improve
on higher (full anticoagulant) doses of LMWH, the reintroduction
of warfarin is justified to prevent maternal stroke.

Antenatal (Cont)
Opinion is divided about the best therapy for those with
recurrent pregnancy loss, but without a history of
thromboembolism.
Treatment with high-dose steroids (in the absence of
active lupus) to suppress LA and aCL, in combination
with aspirin, is no longer recommended because of the
maternal side effects from such prolonged high doses
of steroids. This strategy has been abandoned in
favour of anticoagulant treatment with aspirin and/or
s.c. LMWH. Such regimens give equivalent fetal
outcome with fewer maternal side effects than
combinations of aspirin and steroids.

Table 3 - Therapeutic management

of APS pregnancies
Clinical History

Anticoagulant therapy

No thrombosis, no miscarriage,
no
adverse
pregnancy
outcome

Aspirin 75 mg o.d. from pre-conception

Previous thrombosis

On maintenance warfarin: transfer to

aspirin and LMWH (enoxaparin 40 mg
b.d.) as soon as pregnancy confirmed
Not on warfarin: aspirin 75 mg o.d. from
preconception and commence LMWH
(enoxaparin 40 mg o.d.) once
pregnancy confirmed.
Increase LMWH to bd at 16-20 weeks
No prior

Table 4 - Therapeutic management

of APS pregnancies
Clinical History
Recurrent
weeks

miscarriage

Anticoagulant therapy
<10

No prior anticoagulant therapy: Aspirin

75 mg o.d. from pre-conception Prior
miscarriage with aspirin alone: Aspirin
75 mg o.d. from pre-conception and
LMWH (enoxaparin 40 mg o.d.) once
pregnancy
confirmed.
Consider
discontinuation of LWWH at 20 weeks'
gestation if uterine artery waveform is
normal

Late fetal loss, neonatal death

or adverse outcome due to
pre-eclampsia,
IUGR
or
abruption

Aspirin 75 mg o.d. from pre-conception

and LMWH (enoxaparin 40 mg o.d.)
once pregnancy confirmed

Antenatal (Cont)
Any additional benefit of heparin must be balanced
against the risk of heparin-induced osteoporosis (0.04%
with LMWHs), and the cost and inconvenience of daily
injections.
In women with recurrent miscarriage, but without a
history of thrombosis, there is evidence to support the
use of no therapy, aspirin alone, and aspirin and LMWH.
A pragmatic approach is to offer aspirin alone, particularly
if the history is of less than three miscarriages and then if
miscarriage occurs despite aspirin therapy to offer LMWH
in addition.

Antenatal (Cont)
Antithrombotic strategies vary in different
centres around the world.
LMWH is given in prophylactic doses
(enoxaparin [Clexane] 40 mg o.d.; dalteparin [Fragmin] 5000 units o.d.) when
given for fetal indications, but in women with
previous thrombosis higher doses (e.g.
enoxaparin [Clexane] 40 mg b.d.; dalteparin
[Fragmin] 5000 units b.d.), are indicated.

Antenatal (Cont)
Immunosuppression with azathioprine, i.v.
immunoglobulin (IVIg) and plasmapheresis
have all been tried. The numbers treated do
not allow firm conclusions regarding efficacy,
although there is some evidence available
for IVIg. IVIg is extremely expensive,
precluding its use outside a research setting
in most centres.

Antenatal (Cont)
Close fetal monitoring is essential. Uterine artery
Doppler waveform analysis at 20-24 weeks' gestation
helps predict the higher-risk pregnancies. Monthly
growth scans are performed from 28 weeks if the
uterine artery Doppler wave form at 24 weeks shows
pre-diastolic 'notching'.
High-risk women require closer surveillance with
regular blood pressure checks and urinalysis to detect
early-onset pre-eclampsia.
Such intensive monitoring allows for timely delivery,
which may improve fetal outcome.

Postpartum
Women on long-term warfarin treatment may
recommence this postpartum (starting days 2-3) and
LMWH is discontinued when the international
normalised ratio (INR) is >2.0.
Women with previous thrombosis should receive
postpartum heparin or warfarin for 6 weeks.
Women without previous thrombosis should receive
postpartum heparin for at least 5 days to 6 weeks,
depending on the presence of other risk factors.