Abstract
There is a significantly increased risk of pregnancy complications in women with anti-phospholipid syndrome (APS). The risk is further heightened in those with previous arterial or venous thromboembolism and so-called ‘triple positivity’ for anti-phospholipid antibodies (i.e., when lupus anticoagulant, and anti-cardiolipin (aCL) and anti-β2 glycoprotein-I (anti-β2Gp-I) antibodies are all detected). Management of these cases is extremely difficult and little is available in the medical literature to guide therapy. This report describes the use of regular plasma exchanges (PEx) to bring about a successful pregnancy outcome in a woman with secondary APS and previous recurrent miscarriages. The patient was also anticoagulated with enoxaparin and administered aspirin, prednisolone, azathioprine and hydroxychloroquine. Through regular PEx and immunomodulation therapy, levels of aCL and anti-β2Gp-I antibodies were monitored and documented to fall as pregnancy progressed. Although the outcome in this case was successful, further experience is required before this regimen can be accepted as the standard of care for these patients at very high risk of pregnancy loss.
References
Keeling D, Mackie I, Moore GW, Greer IA, Greaves M (2012) British Committee for Standards in Haematology: guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol 157:47–58
Ruffatti A, Tonello M, Del Ross T, Cavazzana A, Grava C, Noventa F, Tona F, Iliceto S, Pengo V (2006) Antibody profile and clinical course in primary antiphospholipid syndrome with pregnancy morbidity. Thromb Haemost 96:337–341
Lateef A, Petri M (2013) Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol 27:435–447
Pengo V (2011) APS—controversies in diagnosis and management, critical overview of current guidelines. Thromb Res 127(Suppl 3):S51–S52
Alijotas-Reig J (2013) Treatment of refractory obstetric antiphospholipid syndrome: the state of the art and new trends in the therapeutic management. Lupus 22:6–17
Ruiz-Irastorza G, Crowther M, Branch W, Khamashta MA (2010) Antiphospholipid syndrome. Lancet 376:1498–1509
Ruffatti A, Marson P, Pengo V, Favaro M, Tonello M, Bortolati M, Minucci D, De Silvestro G (2007) Plasma exchange in the management of high risk pregnant patients with primary antiphospholipid syndrome. A report of 9 cases and a review of the literature. Autoimmun Rev 6:196–202
Garcia DA, Baglin TP, Weitz JI, Samama MM (2012) Parenteral anticoagulants. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guideline. Chest 141(Suppl 2):24S–43S
Petri M (2011) Use of hydroxychloroquine to prevent thrombosis in systemic lupus erythematosus and in antiphospholipid antibody-positive patients. Curr Rheumatol Rep 13:77–80
Tincani A, Bazzani C, Zingarelli S, Lojacono A (2008) Lupus and the antiphospholipid syndrome in pregnancy and obstetrics: clinical characteristics, diagnosis, pathogenesis, and treatment. Semin Thromb Hemost 34:267–273
Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA (2010) Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review. Ann Rheum Dis 69:20–28
Jung H, Bobba R, Su J, Shariati-Sarabi Z, Gladman DD, Urowitz M, Lou W, Fortin PR (2010) The protective effect of antimalarial drugs on thrombovascular events in systemic lupus erythematosus. Arthritis Rheum 62:863–868
Reverberi R, Reverberi L (2007) Removal kinetics of therapeutic apheresis. Blood Transfus 5:164–174
Zar T, Kaplan AA (2008) Predictable removal of anticardiolipin antibody by therapeutic plasma exchange (TPE) in catastrophic antiphospholipid antibody syndrome (CAPS). Clin Nephrol 70:77–81
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Rose, H.L., Ho, W.K. Management of very high risk pregnancy with secondary anti-phospholipid syndrome and triple positivity to the anti-phospholipid antibodies. J Thromb Thrombolysis 38, 453–456 (2014). https://doi.org/10.1007/s11239-014-1080-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11239-014-1080-7