Obstetric Antiphospholipid Syndrome: Current Trends in Managing Refractory Cases - Abstract
Antiphospholipid syndrome is an autoimmune disease characterized by the occurrence of vascular thrombosis and/or pregnancy morbidity (three or more miscarriages, fetal loss at ? 10 gestational weeks, stillbirth, or preterm delivery due to preeclampsia, fetal growth restriction or placental insufficiency) in the presence of antiphospholipid antibodies (lupus anticoagulant antibody, anticardiolipin antibodies or anti ?2glycoprotein-1 antibodies). Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most frequent treatable cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. The current standard of care for obstetric APS based on aspirin and low molecular weight heparin improves pregnancy outcomes up to 70-80 %. However, 20-30% of these women still have pregnancy complications despite treatment referred as refractory OAPS. New understanding of OAPS pathogenesis involves inflammatory and thrombotic mechanisms. In refractory cases, the addition of Hydroxychloroquine (HCQ), low dose steroids and intravenous immunoglobulins improved pregnancy outcomes. New therapeutic agents (statins and biologic therapies) have been tried for high-risk and recurrent refractory cases with preliminary good results. Currently, focus is put on HCQ, due to its anti-inflammatory, immunomodulatory and antithrombotic mechanisms. Data from retrospective studies shows that the addition of 400mg HCQ started at least 2 months before conception was associated with increased live birth and less pregnancy complications. Hydroxychloroquine seems to be a very promising approach for refractory OAPS. Results from the ongoing randomized controlled trials are expected before any evidence-based recommendations can be given.