1. Pregnancy outcome and Thrombophilia
Dr Chandrashekara S
Chanre RICR and ChanRe Diagnostic
Bangalore

2. Thrombophilia
A state of increased tendency to clot denovo without a precipitating cause
Acquired or hereditary defect
Blood is prevented actively from it’s clotting tendency
Both cellular element- platelet, protein and non-protein factors are responsible for the clot formation

3. Why thrombophilia a problem in pregnancy
During pregnancy the haemostatic balance with a trend towards thrombophilia in order to be prompt for the haemostatic challenge of delivery [1,2].
Thus, pregnancy is a condition associated to thrombophilia per se, and for this reason it is associated with the increase of several clotting factors (i.e. factor VIII, vWF, fibrinogen, factor VII) [7]. other markers of a hypercoagulable state are also increased during pregnancy, such as D-dimer and/or prothrombin fragment
The placental surface also a pro thrombotic property
1.Abbate R, Lenti M, Fatini C, Gazzini A, Lapini I, Fedi S. L’ipercoagulabilità gravidica e puerperale. Haematologica 2003; 88 (Suppl.7): 1-2 [Italian].
2.Hathaway WE, Goodnight SH Jr. Thrombosis in pregnancy. In: Disorders of hemostasis and thrombosis. A clinical guide (Eds.) Hathaway WE, Goodnight HS Jr. New York: McGraw-Hill 1993;

4. Kupferminc et al N Eng J Med 1999
110 healthy women who had during pregnancy severe preeclampsia, IUGR , severe abruptio placentae and stillbirth were enrolled in the study. The control group comprised 110 healthy matched women with normal pregnancies. All 220 patients were tested for all known thrombophilias at least 2 months after delivery.
The total prevalence of all thrombophilias detected in the 110 women with complications was 65% compared to 18% in controls.
Kupferminc et al N Eng J Med 1999

5. A high rate of protein S deficiency, APCR, hyperhomocysteinemia and aCL IgG or IgM was found in women with severe preeclampsia .
Dekker et al Am J Obstet Gynecol 1995

6. % Obstetric manifestations 9 Pre-eclampsia/eclampsia 3 Toxemia 0.6
OBSTETRICAL AND FETAL MANIFESTATIONS IN THE COHORT OF 1,000 APS PATIENTS ENROLLED BY THE EUROPEAN APL FORUM %
Obstetric manifestations 9
Pre-eclampsia/eclampsia 3
Toxemia
0.6
Abruptio placentae
0.3
Post-partum cardio-pulmonary syndrome
Fetal manifestations 36
Early fetal losses 17
Late fetal losses

7. DIFFERENT AREA OF THROMBOSIS
SITE OF THROMBOSIS IN-PATIENTS SCREENED IN OUR STUDY: Chandrashekara et al JAPI 2003
DIFFERENT AREA OF THROMBOSIS
NO. PATIENTS (TN – 148)
Coronary Artery
CNS Vasculature
Arterial Thrombosis
Peripheral Venous Thrombosis
Pregnancy Wastage
Associated With CTD 19 16 4 33 15 11

8. CAUSE OF THROMBOSIS* Chandrashekara et al JAPI 2003
APLA
Protein C Def
Protein S Def
Protein At III Def
58/ %
1/ %
4/ %
2/ %

9. APLA syndrome was recognized as a distinct entity from the work of pioneers in the field - Harris, Gharavi & his colleagues in 1983

10. THE CHANGING CRITERIA Has undergone revision twice within a decade.
There are 4 existing criteria

11. Main Clinical manifestations reported in association with antiphospholipid antibodies.1.
Thrombosis Venous
Arterial
Other
Mainly deep veins but also axillary, retinal, renal, hepatic, superior and interior vena cava
Cerebrovascular accidents, peripheral arterial gangrene, coronary, retinal, mesenteric, renal
Thromboembolic pulmonary hypertension
Hypoadrenalism and Addison’s disease 2.
Obstetric complications
Recurrent intrauterine death, growth retardation, preeclampsia. 3.
Thrombocytopenia
Intermittent, acute or chronic

12. Main Clinical manifestations reported in association with antiphospholipid antibodies. (Contd.)4.
Other clinical features
Coombs positivity (with or without haemolytic anaemia)
Livedo reticularis
Sneddon’s syndrome
Migraine
Chorea
Epilepsy
Transverse myelitis
Guillain – Barre syndrome
Chronic leg ulcers
Heart valve lesions
Avascualr necrosis of bone
Progressive dementia due to repeated cerebrovacular thrombosis
Behavioural disorders
Nonthromboembolic pulmonary hypertension
Nail-splinter haemorrhages.

14. Types Of APLA syndrome 1. Type I
syndrome includes deep vein thrombosis of the upper and lower extremities, inferior vena cava, hepatic, portal, and renal veins and pulmonary embolus 2.
Type II
syndrome includes patients with arterial thrombosis, including the coronary arteries, peripheral (extremity) arteries, and aorta. 3.
Type III
syndrome includes patients with retinal or cerebral vascular thrombosis. Several neurologic syndromes may be manifested, including transient cerebral ischemic attacks, migraine headaches, and optic neuritis 4.
Type IV
syndrome includes patients with combinations of the aforementioned types of thrombosis. Similar to anticardiolipin antibodies, the lupus anticoagulant has been associated with a recurrent fetal wastage syndrome. Abortion occurs frequently in the first, second, or third trimester. Placental vasculitis and vascular thrombosis may be apparent, and there may be an associated maternal thrombocytopenia

15. APLA ANTIBODY A heterogenous group of antibodies
Primarily directed against a phospholipid moiety.
Seen in 5% of normal population, several drug induced diseases and diseases without clinical features of APLA syndrome.

16. APLA ANTIBODY (CLASSIFICATIONS)
Types of antibodies Galli & Bevers:
Lupus Anticoagulant Antibodies (Pt – P1 Compx)
APLA (2GPI antigen)
Anti free 2GPI ab
Anti Protein S & activated Protein C
True APLA requiring no cofactor
Other APLA ab
Galli, Lupus 1994:4;223-8

17. CLASSIFICATION OF APLA ANTIBODY
True APLA
IgM Antiphosphotidyl choline
Etc
Pseudo APLA
Acl In human AIDS
Some LA
Anti co – factor antibodies
Anti 2 glycoprotein
Anti prothrombin
Alarcon – Segovia, J Rheumatol 1996:23;223-8

18. PATHOGENECITY Pathogenesis of a clot
Presence of associated antibody against
Protein C & S
Heparin sulphate
Protien C & S pathways
Anti Prothrombin activity
Anti 2 GPI ab
Phospholipase A2
Activation of platelet and endothelium

19. IMPORTANCE OF APLA ANTIBODY IN DIAGNOSIS
Pathogenic vs Non pathogenic
C/f consistent with syndrome borderline positivity.
The confounding variables in the test procedures.

20. EPIDEMIOLOGY naturally occuring APLA
Prevalence of APLA in normal individuals in various age group with-out an episode of thrombosis.
Study indicate that more than 3-8% of normal have this ab.
Our study indicate
LiJayalakshmi, Chandrashekara S., H.B.Veeranna
Occurrence of rheumatoid factor, anticardiolipin antibody and antinu-clear antibody in healthy Indian adults (greater than expected in young adults) Biomedical Research 2011; 22 (3):

21. TO BE OR NOT TO BE

22. Management dicision Risk and type of APLA Other associated condition
Compliance and other factors

23. factor V Leiden (A506G) mutation
adenine 506 guanine (A506G) mutation in factor V (factor V Leiden) (a substitution of glutamine for arginine at amino acid 506 of factor V) Factor V Leiden (FVL) is a mutation in the factor V molecule, rendering it resistant to cleavage by activated protein C. Factor V remains a procoagulant and thus predisposes the carrier to clot formation.
It has been linked with an increased risk for venous thromboembolism due to Resistance to activated protein C and is responsible of 20–30% of venous thromboembolism events

24. factor V Leiden (A506G) mutation
The Factor V Leiden (FVL) mutation, present in 3-8% of the general population, leads to less than normal anticoagulant response to activated protein C resulting in an increased risk for venous thrombosis.
Individuals with one copy of the FVL gene mutation (heterozygotes) have a seven fold increased risk for thrombosis compared to the general population whereas homozygotes have an eighty fold increase.

25. MTHFR (C677T) mutation
cytosine 677 thymine (C677T) mutation (a C to T change at position 677 of MTHFR) is responsible for reduced MTHFR activity results in decreased synthesis of 5-methyltetrahydrofolate, the primary methyl donor in the conversion of homocysteine to methionine and the resulting increase in plasma homocysteine concentrations
( Hyper homocysteinemia ) is a risk factor for thrombosis
Dietary restriction of folate and vitamin B12 remains the most common cause.

26. MTHFR (C677T) mutation
A homozygous methylenetetrahydrofolate reductase (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 and placental abruption.
But literature and systematic analysis has mixed message- with an exception of 1 study all were inconclusive

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

28. Protein C deficiency
Protein C deficiency (PCD), present in about 1.5% of the general population, is associated with a lower risk for obstetrical complications than PSD and is found in 3-5% of individuals with a DVT or PE.
Furthermore, PCD combined with a FVL mutation is a relatively common cause of DVTs and show a higher risk for thrombosis compared to FVL alone.

29. Antithrombin III deficiency
Antithrombin III deficiency (ATIII), present in less than 0.5 % of the general population, as with PSD and PCD, may rarely result from mutational events
Because of its relative rarity, actual risks for thrombotic events are difficult to estimate, but without question this entity contributes to thrombotic risks during pregnancy.

30. Christiansen Recurrent pregnancy loss Current Opinion in Obstetrics and Gynecology 2006, 18:304–312

31. Recently, the Cochrane Collaboration reported a 15% reduction in the risk of preeclampsia (32 trials with 29,331 women) and a 14% reduction in fetal and/or neonatal death (30 trials with 30,093 women). This reduction in death was the greatest amongst high-risk women (4134 women).
The combination of aspirin and heparin or low molecular weight (LMW) heparin is effective in recurrent fetal loss in APS syndrome and could be considered for women with inherited thrombophilias and history of severe preeclampsia, IUGR, abruptio placentae or fetal loss, although no controlled studies on the subject are currently available
Antiplatelet drugs for prevention of pre-eclampsia and its consequences: Systematic review. BMJ 2001

32. Fetal death or severe early pre-eclampsia or severe placental insufficiency, without history of thrombotic events
1) Standard heparin: 7, ,000 U every 12 hours in the first trimester; 10,000 U every 12 hours in the second and third trimesters.
2) Low molecular weight heparin:
1) Enoxaparin 40 mg/day daily or dalteparin 5,000 U/day, or
2) Enoxaparin 30 mg every 12 hours or dalteparin 5,000 U every 12 hours

33. Anticoagulation treatment in women with previous thrombotic events
1) Standard heparin: 7,500 U every 8-12 hours adjusted to maintain the mid-interval heparin levels in the therapeutic range.
2) Low molecular weight heparin:
1) Weight-adjusted (e.g., enoxaparin 1 mg/kg every 12 hours or dalteparin 200 U/kg every 12 hours), or
2) Intermediate dosage (e.g., enoxaparin 40 mg/day or dalteparin 5,000 U/day until 16 weeks' gestation and every 12 hours from 16 weeks' gestation onwards)

34. Treatment should be prolonged for life if aPL positivity persists .
Whether or not APS patients can be safely treated with intermediate-intensity warfarin treatment (INR range from 2.0 to 2.9) or with a high-intensity treatment (INR =3.0), is still a matter for debate due to the report of severe hemorrhagic complications associated with high-intensity anticoagulation therapy .