Recurrent Pregnancy Loss and Antiphospholipid Syndrome

Women are the most affected by APS

APS Can be classified as primary whereby there is no other associated autoimmune disorder such as systemic lupus erythematosus (SLE) or secondary APS, in which case there is another autoimmune disorder such as SLE. 4 out of 10 women with SLE have APS and 60% of the patients with lupus and positive lupus anticoagulant are likely to develop APS on follow up in the future.

The clinical types are:

• • • The thrombotic type with a history of blood clots
    • Obstetric APS with a history of pregnancy-related complication or morbidity.

There is a genetic predisposition which requires environmental factors for APS to manifest clinically. This is the two-hit hypothesis in which case the antiphospholipids (APLs) induce a thrombophilic state-tendency to have blood clotting and the second hit is the environmental exposure that triggers thrombosis or inflammation to occur. This may explain asymptomatic APS.

Environmental risk factors that trigger APS are

• • Pregnancy
  • Immobilization
  • Surgery
  • Cigarette smoking and alcohol use
  • Infection
  • Obesity or Overweight
  • Use of oral contraceptive pills and hormonal replacement therapy in menopause
  • Other inflammatory stimulants for thrombosis
  • Previous history of unexplained pregnancy loss
  • Antiphospholipid antibodies profile
  • History of vascular thrombosis

The clinical manifestations of the disorder will depend on the location of the blood clots.

• Thrombotic Complications: Deep Venous Thrombosis-clots in the deep veins of the legs; Pulmonary Thromboembolism-Clot in the pulmonary arteries leading to difficulty in breathing or breathlessness, chest pain; Transient ischemic attack or ischemic attack/stroke.
• The pregnancy-related complications-unexplained early recurrent pregnancy losses of 3 or more pregnancies less than 10 weeks gestation; One or more pregnancy losses of more than 10 weeks gestation of morphologically normal pregnancies; stillbirths of pregnancy less than 34 weeks gestation due to high blood pressure in pregnancy (severe preeclampsia or eclampsia); placental insufficiency manifesting as preterm births, intra-uterine growth restriction and low birth weight babies; HELLP-Hemolytic _Elevated Liver function tests_ Low Platelet Syndrome
• Unexplained thrombocytopenia (low platelets).
• Catastrophic APS is the severest form of APS. This can occur in 1% of women after delivery-puerperium
• Nervous system manifestations
• Cutaneous manifestations
• Asymptomatic carriers

The presence of antiphospholipid antibodies alone is not enough to make a diagnosis of antiphospholipid syndrome.

History of either a thrombotic event or a pregnancy-related complication combined with the presence of at least one of the laboratory criteria is required for diagnosis of APS.

Laboratory Criteria

Three APLs are tested on two occasions 12 weeks apart;

• • Lupus Anticoagulant-positivity
  • Anticardiolipin antibodies (ACA) for medium to high titers
  • Anti beta 2 Glycoprotein 1 antibodies (IgG and IgM)

Your doctor will take a history from you and examine you before sending you to the laboratory for testing.

Yes. Some non-criteria manifestations of APS have been identified in both the clinical criteria and laboratory criteria. They include having 2 unexplained recurrent miscarriages; a history of three early recurrent miscarriages that are not consecutive; placental abruption and late preterm birth beyond 34 weeks gestation; low titres of anticardilolipin and anti Beta 2 Glycoprotein 1 and detection of APL antibodies 6-12 weeks apart. 

Screening may be offered to those who have had unexplained recurrent miscarriages and unprovoked proximal DVT or other unprovoked thrombotic events like pulmonary embolism or ischemic stroke. Talk to your doctor to explore the possibility of getting a screen.

Preconception counselling will help with the identification of medications that you are on that may be teratogenic to the baby such as warfarin for those who may be on the same for prior thrombotic event. C

Pregnancy with APS is considered a high-risk pregnancy with closer follow-up needed since the risk of suffering from placental insufficiency is high with its attendant complications. For instance, there will be monthly ultrasound scanning to check the fetal well being et cetra

Copper IUD which is a non-hormonal contraceptive method is the recommended contraceptive.

Patients with APS respond to ovulation drugs and In-Vitro-Fertilization (IVF) as the general population with 30% probability of a successful pregnancy.

• I have observed that many patients with little income are not able to afford the costs of laboratory tests which remain prohibitive.
• Treatment with low molecular weight heparin is the recommended treatment modality yet most patients are not able to access the daily or twice daily injections due to cost constraints.
• Some patients with recurrent pregnancy loss are so mentally drained and need a lot of counselling to be in a better place, yet they may not seek help as they may feel that society may frown upon them. More support groups for these patients are needed.
• Some of these patients may not be so keen on follow-up and they could do better by going for checkups with their doctors and gynecologists.