Infertility and spontaneous abortion - Spontaneous abortion, habitual abortion - Miscarriage : Guidelines, reviews
Treatment of antiphospholipid syndrome in pregnancy
Royal College of Obstetricians and Gynaecologists. The investigation and treatment of recurrent miscarriage [Internet]. Guideline No 17. London: RCOG Press; 2003 May [cited 2009 Feb 8]. 13 p. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/investigation-and-treatment-couples-recurrent-miscarriage-green-top-
- To diagnose antiphospholipid syndrome (APS) it is mandatory that the patient should have two positive tests at least six weeks apart for either lupus anticoagulant or anticardiolipin (aCL) antibodies of IgG and/or IgM class present in medium or high titre. (C)
- Currently there is no reliable evidence to show that steroids improve the live birth rate of women with recurrent miscarriage associated with aPL when compared with other treatment modalities; their use may provoke significant maternal and fetal morbidity. (A)
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In women
with a history of recurrent miscarriage and antiphospholipid antibodies
(aPL), future live birth rate is significantly improved when a combination
therapy of aspirin plus heparin is prescribed. (A)
- A randomised controlled trial showed that the live birth rate of women with recurrent miscarriage associated with aPL treated with low-dose aspirin only is 40% and this is significantly improved to 70% when they are treated with low-dose aspirin in combination with low-dose heparin.
- A meta-analysis of two controlled trials concluded that, in women with a history of recurrent miscarriage associated with aPL, treatment with low-dose heparin plus low-dose aspirin significantly reduced the pregnancy losses by 54% when compared with aspirin alone. However, these trials do not exclude the possibility of placebo effect from heparin treatment.
- The same meta-analysis examined the role of aspirin alone compared with placebo or supportive care and found no significant benefit (three trials).
- A recent randomised controlled trial reported a high success rate with aspirin alone and no significant benefit in live birth rate with the addition of heparin. However, this study included women with low titres of aPL, some of whom were randomised at up to 12 weeks of gestation, by which time most of aPL-related pregnancy losses would have already occurred.
- Pregnancies associated with aPL treated with aspirin and heparin remain at high risk of complications during all three trimesters. (B)
Grades of recommendations
| A | Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. |
| B | Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. |
| C | Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. |
Aspirin, 75 mg/d, should be commenced as soon as the
urine pregnancy test becomes positive.
Low-dose heparin, by self-administered subcutaneous injection, should be
commenced when fetal heart activity is seen on ultrasonography: unfractionated
heparin (5000 IU) twice daily subcutaneously or low molecular weight heparin
in once-daily subcutaneous doses.
The ideal duration of heparin therapy has not been determined, but should
not be unnecessarily extended because of the potential risk of heparin-induced
osteopenia. Discontinuation at 34 weeks gestation is a reasonable compromise
in women with no history of thrombosis in whom early pregnancy loss has
been a feature. When late pregnancy complications have occurred previously,
continuation of antithrombotic therapy to delivery is reasonable and postpartum
thromboprophylaxis will usually also be indicated in those women with a
history of thrombosis. Delivery by Caesarean section carries an additional
thrombotic risk and perioperative thromboprophylaxis is indicated.
After commencement of heparin, the platelet count should be monitored. A
weekly platelet count for the first 3 weeks and every 4-6 weeks thereafter
is generally practicable. Regular obstetric assessment, including Doppler
ultrasound fetal scanning, allows early detection of complications.
In APS, our original dosing protocol of dalteparin yielded significant differences (P <.05) in drug exposure throughout pregnancy. Based on these results, we recommend a prophylactic dalteparin dosing regimen of 2500 U every 24 hours pre-pregnancy (and for 6 weeks postpartum), and 5000 U every 24 hours during the first, second, and third trimesters.
OBJECTIVE: To compare low molecular weight heparin
(LMWH), specifically dalteparin, to unfractionated heparin (UFH) for the
treatment of antiphospholipid antibody syndrome (APS) in pregnancy.
METHODS: The women were randomized to receive either prophylactic dosing
of dalteparin or UFH starting either preconceptionally or early in pregnancy.
All women also received low-dose acetylsalicylic acid, started preconceptionally.
The primary outcome was a live birth. The secondary outcomes were maternal
and fetal complications.
RESULTS: Of the 14 women who received the LMWH, dalteparin, and the 14 women
who received UFH, 1 woman in each group did not conceive. Nine of the 13
women (69%) given dalteparin had a successful pregnancy (95% confidence
interval [CI], 39-91%), compared to 4 out of the 13 women (31%) in the UFH
group (95% CI, 9-61%).
CONCLUSION: Dalteparin may be an effective alternative to UFH for treatment
of APS in pregnancy.
METHODS: We examined 40 women with recurrent abortion
(at least 3 occurrences) and repeatedly positive test results for anticardiolipin
or lupus anticoagulant. The subjects were randomly assigned to treatment
with IVIG or LMW heparin plus low-dose aspirin. Both therapies were started
when the women were pregnant as documented by a positive urine test. IVIG
was stopped at the thirty-first week of gestation, aspirin at the thirty-fourth
week, and heparin at the thirty-seventh week. The primary outcome of interest
was the rate of live births with the 2 treatments.
RESULTS: The characteristics of the 2 groups were similar at the time of
randomization. The women treated with LMW heparin plus low-dose aspirin
had a higher rate of live births (84%) than those treated with IVIG (57%).
CONCLUSION: Treatment with LMW heparin plus low-dose aspirin should be considered
as the standard therapy for recurrent pregnancy loss due to aPL.