1. Antiphospholipid Syndrome

2. Prof. Dr. Suchitra N. Pandit
MD, DNBE, DFP, FRCOG, FICOG, B.Pharm
Consultant Obstetrician & Gynaecologist
Kokilaben Dhirubhai Hospital, Mumbai ,India
Clinical secretary –MOGS, Vice President - FOGSI ( )
Chairperson -Young Talent promotion committee FOGSI ( )

3. Antiphospholipid ( APLA ) syndrome
Antiphospholipid syndrome (Hughes syndrome) is a
disorder of immune system ,characterised by excessive clotting of blood ,thrombocytopenia & /or adverse pregnancy outcomes
Body recognizes negatively charged phospholipids on cell membrane as foreign & produces antibodies against them leading to an acquired autoimmune thrombophilia
Patients have laboratory evidence for antibodies ( IgG, IgM or IgA ) against phospholipids or phospholipid-binding protein cofactors in their blood

4. How many types of APLA syndromes are there
A.) One
B.) two
C.) Three
D.) Four

5. Antiphospholipid antibody syndrome (APLA)
Primary antiphospholipid syndrome (PAPS) - when APS occurs in the absence of any other related disease (LA, ACL antibodies in patient’s serum).
Secondary antiphospholipid syndrome - when APS coexists with other diseases such as SLE I
In catastrophic APLA (rare ), APS leads to rapid organ failure due to generalised thrombosis & a high risk of death
Other rare antibodies to phosphotidyl ethanolamine & phosphotidylserine are also associated with it

6. either acquired or inherited
Thrombophilic defects
either acquired or inherited

7. Thrombophilia - tendency to thrombosis
Lupus anticoagulant
antibodies
Acquired
APLA
Anticardiolipin antibodies
Myeloprolipherative diseases
Malignancy
Paroxysmal nocturnal Haemoglobinuria
Nephrotic syndrome

8. Inherited Hyperhomocysteinemia (C677T) mutation
Factor V Leiden mutation (A506G) mutation
Mutation in prothrombin ( G A)
Prothrombin II (PTII) mutation
Protein S deficiency
Protein C deficiency

9. All these conditions should be investigated for APLA except :
A.) Early onset severe preeclampsia
B.) Arterial or venous thrombosis
C.) Unexplained fetal growth restriction
D.) Gestational Diabetes

10. Primary antiphospholipid antibody syndrome
Presentation may be totally asymptomatic or in a classical manner :
Various clinical presentations :
Recurrent pregnancy loss
Unexplained second or third trimester loss
Early onset severe preeclampsia
Arterial or venous thrombosis
Unexplained fetal growth restriction
Prolonged coagulation studies
Autoimmune diseases
Cardiac valvular diseases
Neurological disorders
Thrombocytopenia

11. Diagnosis of APLA Challenging !!!
Due to fluctuating titers of the antibodies,
Lack of agreement between laboratories concerning standardization of the assays
Debates among researchers & clinicians concerning which antibodies to measure.

12. Which is not an APLA antibody ?
A.) Anti Ro
B.) Lupus Anticoagulant (LAC)
C.) Anticardiolipin Antibodies (ACL)
D.) Anti insulin antibodies

13. Which are the Antibodies
Lupus Anticoagulant (LAC)
Anticardiolipin Antibodies (ACL)
Anti Beta 2 glycoprotein antibodies
Other antibodies

15. Lupus anticoagulant ( LAC)
LAC is characterized by a prolonged partial thromboplastin time & paradoxically the so-called ‘anticoagulant’ is a powerful thrombotic agent in vivo
Higher thrombotic potential than ACL when present alone
LAC interferes with platelet function, causing aggregation & thrombosis & also interferes with endothelial function, causing procoagulant activation & thrombosis
Prevalence of LAC in low risk population is < 1% Bad obstetric history % Early pre eclampsia %, Abruption - 33% Systemic lupus erythematosus - 34%

16. Patient typically has a prolonged APTT that does not correct in 80:20 mixture with normal human plasma
Prolonged Dilute Russel viper venom time (DRVVT), Kaolin clotting test (KCT),(TDT/DTT) or prothombin time
Due to heterogeneous nature of LA ,minimum of 2 tests required, 6 weeks apart & should be positive each time showing persistent positivity to confirm diagnosis of APLA Caution : patients with transient positive tests (due to infection etc) can be diagnosed as positive.

17. Lupus anticoagulant (LAC)
Prolongation of which of these tests is most sensitive for LAC ?
A.) Activated partial thromboplastin
B.) Dilute Russel Viper venom
C.) Kaolin clotting time
D.) Partial Thrombin time

18. Anticardiolipin Antibodies
Were thought to react against cardiolipin but it is now thought to interact with B2GP1
85% of APS pts have both LA & aCL
These can be detected using an (ELISA)
Screens for the presence of β2 glycoprotein 1 dependent anticardiolipin antibodies (ACA)
A low platelet count & positivity for antibodies against β2-glycoprotein 1 or phosphatidylserine may also be observed in a positive diagnosis

19. Anti Beta 2 GP1 Discovered after LA & ACL
Found without other two in 11% of APS pts & commonly with others.
Binds to B2GP1 disrupting f(x)
B2GP1 has anticoagulant activity through the inhibition of the conversion of prothrombin-thrombin, regulation of protein S, & /or activation of platelets.

20. Sapporo criteria
International Consensus Conference held in Sapporo (’98)
Clinical criteria of ( APAS )
Thrombosis, one or more confirmed episodes
of venous, arterial, or small vessels disease
‘ Coexisting inherited or acquired thrombotic
risk factors are not reasons for excluding
patients from a diagnosis of APS trials.’

21. Sapporo Criteria (updated)
Pregnancy criteria :
One or more unexplained fetal deaths > 10 wks of pregnancy
One or more preeclampsia / eclampsia or placental
insufficiencies occurring before 34 weeks .
Three or more unexplained consecutive spontaneous
abortions < 10 weeks
Laboratory criteria
LAC defined by a functional, clot-based assay (ISTH
guidelines)
ACL (IgG or IgM) antibody
Anti-b2 glycoprotein I ,IgG or IgM antibody
Miyakis, et al., J. Thromb. Haemost.,2006; 4:

22. The International Consensus Statement
Definite CAPS diagnosis requires:
Vascular thrombosis in three or more organs or tissues & development of manifestations simultaneously or in < a week & small vessel thrombosis in at least one organ or tissue
Lab. confirmation of presence of aPL
Some serological tests for syphilis may be positive in aPL- positive patients if it is positive) although more specific tests for syphilis that use recombinant antigens are negative
Transient elevations common. Elevations common in autoimmune disease & infections ex. HIV, Hep C, syphilis

23. Principal pathogenic mechanisms mediated by APL
Reduction of proliferation & differentiation; Gonadotrophin secretion impairment
a.) Trophoblast cells:
Interference with :
Induction of a pro-adhesive, pro-inflammatory & pro-coagulant endothelial  phenotype ; induction of a procoagulant phenotype in monocytes
b.) Coagulation cells:
  Protein C/S pathway   inhibition;   fibrinolysis inhibition
a.) Soluble coagulation
factors
Interference with

24. Pregnancy losses classified as :
Occult (preclinical or chemical) pregnancy loss prior to missed menses. (40% of implantation embryos)
Early pregnancy loss before 12 wk. (13%)
Late pregnancy loss after 12 wk. (1%)

25. Causes of pregnancy loss
Chromosomal
55% of occult & early losses
5% of recurrent losses.
Environmental
hormonal
anatomical
Immunological
45% of early losses
95% of late losses

26. Aneuploidy 1/200 1/80 Aneuploid fetus risk in women > 35yr. age
Inherent risk of fetal loss after
amniocentesis
1/200
Standard of care is to offer genetic amniocentesis
for all pregnant women older than 35 years

27. What is Recurrent pregnancy loss ?
What actually causes it ?

28. Definition
A recurrent pregnancy loss (RPL) is 3 or more consecutive, spontaneous pregnancy losses, under week gestation from the last menstrual period by the same partner.
Primary recurrent pregnancy loss" refers to couples that have never had a live birth
“Secondary RPL" refers to those who have had repetitive losses following a successful pregnancy

29. Pregnancy loss in the APLA syndrome - A possible thrombogenic mechanism
Levels of annexin V, a phospholipid-binding protein with potent anticoagulant activity, are markedly reduced on placental villi from women with APLA
APL antibodies reduce the levels of annexin V & accelerate the coagulation of plasma on cultured trophoblasts & endothelial cells.
Reduced annexin V levels on vascular cells may be an important mechanism of thrombosis & pregnancy loss in APLA syndrome.
Jacob Rand, Xiao-Xuan Wu, H. Andree, CJ. Lockwood, Seth Guller, J Scher, Peter Harpel, -N Engl J Med ; 337: , 1997

30. Pregnancy loss in autoimmune connective tissue disorders (CTDs)
Adverse outcomes like IUGR, prematurity, recurrent pregnancy loss & stillbirth are common
Systemic lupus erythematosus (SLE) is prototype , others are rheumatoid arthritis, scleroderma, Behcet’s disease & Sjogren’s syndrome
Recent studies show anti-Ro/SSA antibody as a possible factor for unexplained pregnancy loss in SLE.
Antibody is directed against cellular ribonucleoprotein complexes which is present in serum of > 10% pts of CTDs.
It is associated with neonatal lupus & congenital heart block showing passively acquired autoimmunity

31. How do you proceed ? Interview the couple together
History of the case is very important
Clinical examination
Investigations as per the history
Reassurance & counselling
Treatment plan : Drugs, maternal & fetal surveillance , dealing with complications
Timely referral to a tertiary centre

32. Special Investigations
LAC tested by prolonged coagulation time (inhibition of phospholipids)
APTT , KCT , TTIT
Most accurate - Dilute russel viper venom test (DRVVT)
ACL - ELISA IgG (GPL) IgM (MPL)
IgG/ IgM isotypes of anticardiolipin & antiphosphotidyl
serine antibodies
In c/o low titres-repeat after 6-8wks (can revert to normal)
Transient low titres can be found in viral fever
If autoimmune disorders are suspected ANA, anti –nDNA, antiSm, anti-Ro/SSA antibody, anti La (SSP)

33. So how does one manage the drug treatment in pregnancy ?
General guidelines for anticoagulation in Pregnancy with APS leading to recurrent pregnancy loss
Very controversial issue !

34. Commonly used Drugs Steroids : Reduces ACA, normalises prolongation of
invitro coagulation
Complications : ? perinatal outcome preterm labour,
preeclampsia
Low dose Aspirin (LDA) : Selective inhibition of
Thromboxane A2
No effect on PGI2
Azathioprine
Warfarin

35. Which is the commonly used drug for APLA ?
A.) Progesterone
B.) Folic acid
C.) Low dose Aspirin
D.) RU- 486

36. Unfractionated Heparin (UFH)
Potentiates complex formation with AT III + factor VII A  XII A & thrombin
Complications : Reduces platelet bleeding &
B.M.D.
Low molecular weight Heparin (LMWH)
Once daily dose, less monitoring
Lesser osteopenia, does not cross placenta
Cost factor !!

37. Trials Heparin vs Aspirin + prednisolone Live birth 75%
Pre-eclampsia, preterm delivery more in latter group
L.S. + LDA Vs Heparin + LDA (n=20)
No placebo
Large multicentric trials needed
Cowchock et al .1994

38. Randomised controlled trial of LDA versus LDA plus heparin in pregnant women with APS
90 women with APS were randomized into two groups with 1st group receiving 75mg of LDA & 2nd group LDA & Heparin 5000u subcut, every 12 hourly
Outcomes measured were number of live births & miscarriages
LDA group had 19 live births & 26 miscarriages
LDA + heparin group had 32 live births & 13 miscarriages
Significant (p=0.01) improvement in outcomes with heparin
R. Rai, H.Cohen et al..,BMJ. (1997 )

39. Antiphospolipid antibodies
Presence of Antiphosholipid antibodies may cause recurrent pregnancy loss
Are antibodies directly responsible ?
Should all women with APA be treated ?
How do you treat a women with positive APLA ?

40. Controversies surrounding treatment for pregnancy loss
Evidence-based medicine (EBM) has not succeeded in giving patients & physicians the data they need to choose (or not choose) a therapy in the field of pregnancy loss

41. Women with APLA are advised to take LDA & to start LMWH Rx after pregnancy is diagnosed (80% success)
In case of H/o thrombotic symptoms, Warfarin is used as anticoagulant .Maintain INR between
Patients with APLA have minor elevations of PT & are difficult to manage with warfarin.
During pregnancy, LMWH & LDA are preferred to Warfarin (teratogenic effects )
If previous H/o thrombosis use LMWH in therapeutic doses throughout pregnancy :dose 1mg/kg subcut.
If UFH is used dose is 10,000 u 12 hourly

42. Since APLA reacts with phospholipids both aPTT & PT can be affected
Since APLA reacts with phospholipids both aPTT & PT can be affected. If UFH used to anticoagulate patients with APLA monitor heparin levels ( anti-Xa units 6 hours post injectiont ).
With LMWH , monitoring is easier : predictable dosing & anticoagulant effect . Measure LMW heparin levels in these patients for long term Rx ( anti-Xa units)
Perform prothrombin & proconvertin times ("P&P") to follow anticoagulation. Being less dependent on phospholipids & one can monitor therapy.
If miscarriage occurs with heparin & aspirin & there is a pregnancy again IVIG can be tried (RCT did not show benefit)
In refractory cases plasmapheresis may be used

43. ACCP Guidelines : Pregnancy & APL
Manifestation
Recommendation
Grade
Antiphospholipid antibody; no prior VTE or pregnancy loss
Surveillance, or mini-dose heparin, or prophylactic LMWH, & /or aspirin 2C
Antiphospholipid antibody; prior thrombotic event
Adjusted dose UFH or LMWH, plus low-dose aspirin. 1C
- Bates, et al., Chest, 2004; 126: 627S - 644S

44. Can pregnancy outcome be improved ?

45. Management of pregnant women
Surveillance depends on past obstetric history
LDA preconception & LDA + LMWH has 80% success rate for treatment of APLA ( Feinberg et al,’ 97 ).
Refer preferably to a tertiary centre with a neonatal backup
Team effort including an obstetrician , hematologist, physician, & neonatologist
Vigilant monitoring
B.P, platelets, complement levels , renal function test (to asses target organ damage )

46. Care of the fetus Surveillance depends on past obstetric history
1st trim U.S.G : viability & dating , nuchal & nasal bone
U.S.G at 19 weeks & serial scans with doppler for early diagnosis of IUGR & waveform abnormalites
Inj Betamethasone 2 doses for enhancing lung maturity
Timely delivery in a centre with a good neonatal backup

47. Future Possibilities PAPRE warfarin intensity
PRECLUDE primary prevention
More frequent use of LMWH, IVIG

48. What to do with the patient with APLA but no thrombotic manifestations ?
Although some of these patients are at risk, especially those with SLE, many will never develop thrombosis
The current recommendation would be to do very careful search for thrombosis. Brain MRI in patients with SLE & in patients with any neurological symptom
If this work-up is negative follow the patient very closely
Does immunosuppression work ?
APLA seems like an autoimmune disease, but immunosuppression does not prevent recurrent thrombosis, fetal loss, or neurological syndromes & so no role in the Rx of thrombotic APLA

49. In"catastrophic APLA" plasmapheresis may play a crucial role.
Low intensity anticoagulation with warfarin appears to be mostly effective in APLA (except patients with venous thrombosis)
Many patients will fail low intensity warfarin & need more aggressive anticoagulation.
Heparin anticoagulation appears more effective. Arterial Thrombosis: Warfarin to an INR of Venous Thrombosis: Warfarin to an INR of Patients who "break through" warfarin should receive heparin.

50. Inherited Thrombophilia

51. Inherited Thrombophilia
Three important inherited thrombophilias :
Mutation in factor V Leiden causing resistance to
activated protein C (responsible of 20–30% of venous
thromboembolism events.)
Mutation in prothrombin (guanine adenine )
Mutation in methylene tetrahydrofolate reductase
(MTHFR) (cytosine 677 thymine (C677T) ) This
is responsible for reduced MTHFR activity & is most
frequent cause of mild hyperhomocysteinemia &
is found in 5–15% of the population.

52. Factor V Leiden (A506G) mutation
Present in 3-8% of the general population , (heterozygotes) have a seven fold increased risk for thrombosis whereas homozygotes have an eighty fold increase.
It has been linked with an increased risk for venous thromboembolism due to resistance to activated protein C & is responsible of 20–30% of venous thromboembolism events

53. Protein S deficiency
Protein S deficiency (PSD), present in up to 2% of general population.
Found in approximately 15% of individuals with a DVT or PE .
Found in 6% of women with obstetrical complications including a relatively high risk for stillbirth.

54. MTHFR (C677T) mutation
A homozygous (MTHFR) mutation, present in 1-4% of the general population, is associated with a three fold increased risk for DVT or PE, as well as preeclampsia & placental abruption.

55. MTHFR (C677T) mutation
Responsible for reduced MTHFR activity results in decreased synthesis of 5-methyltetrahydrofolate, the primary methyl donor in the conversion of homocysteine to methionine & the resulting increase in plasma homocysteine concentrations ( Hyperhomocysteinemia ) is a risk factor for thrombosis
Dietary restriction of folate & vitamin B12 remains the most common cause.

56. Prothrombin (G20210A) mutation
A change of G to A at position in prothrombin (prothrombin 20210A) elevates baseline prothrombin levels & thrombin formation.

57. Unexplained recurrent miscarriage
In about half the women in the research studies, no cause could be found, so no specific treatment could be given.
However, this group responded very well to a programme which removed as many stress factors as possible from their lives, resulting in an 80% success rate with the subsequent pregnancy
Psychological support can improve outcome between the higher areas of the mind & the delicately balanced hormonal system

58. Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy assessment unit.
After all these investigations 50% of recurrent aborters will have no abnormalities & these should be attributed to chromosomal defect in the conceptus.

59. Conclusion
In cases of adverse pregnancy outcomes APLA should be kept in mind
Detailed history & tailor investigations
Couple should be counselled together .
The only intervention to have demonstrated benefit is serial ultrasound scans in early months of pregnancy.
Referral to a tertiary unit as multidisciplinary management is needed for patients with APLA / Thrombophillia
Psychological support
Education & reassurance has an important role to play

60. Thromboprophylaxis for previous thromboembolic episode
Risk categoryp
Risk factors
Prophylaxis
High risk
TED (thromboembolic
disease)
-Prev. TED
-Prev TED+APLA
-Prev TED+ family history of TED
-Recurrent TED
-TED in current preg.
ANC:s/c UH or
LMWH
Intrapartum:s/c UH
or LMWH
Post partum:s/c UH
or LMWH for 3-7 days f/b UH or LMWH or warfarin for 3-7 days
Low risk
One prev TED (No other risk factors)
ANC: g odd
Intrapartum or post partum:as above

61. Diagnosis of APLA can be challenging, due to fluctuating titers of the antibodies, a lack of agreement between laboratories concerning standardization of the assays, and debates among researchers and clinicians concerning which antibodies to measure. Although multiple APLAs might eventually be considered pathologic to pregnancies, anti-cardiolipin, anti-phosphotidylserine, and the 'lupus anticoagulant' are generally believed to be culprits when identified in women with pregnancy losses.

62. Rx APLA syndrome generally requires daily baby aspirin prior to conception & the use of baby aspirin & heparin as soon as pregnancy is diagnosed
One recently published study demonstrated an 80% success rate for treatment of APLA by this approach. The 20% failure rate is likely accounted for in large part by genetically-abnormal losses.
More aggressive treatment of APLA occasionally involves the use of human intravenous immunoglobulin. This is an expensive therapy that has less clear-cut efficacy demonstrated. The use of empiric intravenous immunoglobulin should generally be discouraged, and is not endorsed by the American College of Obstetricans and Gynecologists.