Peter S. Bernstein, MD, MPH, FACOG; Karen L. Koscica, DO

Disclosures

January 08, 2003

Question

Would you give low-dose aspirin and heparin to a patient 27 years old G4P2A1 in her eighth week of pregnancy and a positive low level of anticardiolipin antibodies? In her first pregnancy she had a preterm birth after premature rupture of membranes at 30 weeks. In her second pregnancy she had severe preeclampsia at 35 weeks. In her third pregnancy she had a first-trimester abortion.

Response from Peter S. Bernstein, MD, MPH, FACOG and Karen L. Koscica, DO

Karen L. Koscica, DO
Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York

Peter Bernstein, MD, MPH
Associate Professor of Clinical Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, and Medical Director, Obstetrics and Gynecology, Comprehensive Family Care Center of Montefiore Medical Group, Bronx, New York

 

In order for the diagnosis to be made, individuals should meet at least 1 clinical and 1 laboratory criterion. Clinical characteristics include the following: recurrent spontaneous abortion (defined as at least 3 or more recurrences), unexplained fetal death, venous or arterial thrombosis, autoimmune thrombocytopenia, autoimmune hemolytic anemia, transient ischemic attacks, amaurosis fugax, chorea gravidarum, and livedo reticularis. As far as laboratory tests, there are 2 antibodies associated with this syndrome that can be analyzed. These are the lupus anticoagulant and the anticardiolipin antibody. Lupus anticoagulant is simply reported as present or absent. Anticardiolipin antibodies can be quantified. It is the medium-high levels of immunoglobulin (IgG) that are considered sufficient for diagnosis. Low levels of IgG and IgM of anticardiolipin antibodies can be detected in healthy individuals and can be caused by infection. Levels that are considered positive can be transient and should be repeated in several weeks for confirmation.[1]

Patients who should undergo serologic testing for this syndrome should be limited to those having disorders related to this entity, including recurrent spontaneous abortion, unexplained second- or third-trimester fetal death, severe preeclampsia prior to 34 weeks, unexplained venous or arterial thrombosis, unexplained stroke, SLE, autoimmune thrombocytopenia or anemia, livedo reticularis, chorea gravidarum, false-positive test for syphilis, unexplained prolonged clotting assay, or unexplained severe fetal growth restriction.[1]

Management of women with antiphospholipid syndrome still remains controversial. Because of the proposed etiology of this disorder, treatment has been directed at suppression of the immune system with prednisone and intravenous immunoglobulin and preventing thrombosis with heparin and low-dose aspirin.[1,2] There have been several studies as well as case series that have explored the potential best management of these patients. A randomized, controlled trial of aspirin and aspirin plus heparin showed that there was a significantly higher rate of live births in the patients who received both aspirin and heparin.[2]

Corticosteroids have been associated with increased maternal and fetal morbidity, such as preterm premature rupture of membranes, preterm delivery, and preeclampsia.[1,2] Therefore, the combination of heparin plus aspirin has been recommended as primary therapy in pregnancy because of the less severe side effects.[1] What is not clear is whether the same therapy is appropriate for the patient whose syndrome is characterized by recurrent pregnancy loss or for the patient with history of venous thrombosis or severe fetal growth restriction.

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