Pregnancy Treatment and Labour Management in Antiphospholipid Syndrome

8/14/2019 Pregnancy Treatment and Labour Management in Antiphospholipid Syndrome

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Pregnancy Treatment

and Labour Management

in Antiphospholipid

Syndrome

NUS PURN W N PUTR 0861050031

MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY

FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA


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PRELUDE

Antiphospholipid syndrome (APS) is a syste

autoimmune disease characterized by the

presence of arterial or venous thrombosi

pregnancy morbidity and the presence of a

persistent increase in serum titer positive

antiphospholipid antibodies (aPL).


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PRELUDE

In the United States noted that the

prevalence of APS in the general populati

of the country reached 2-4%.

In Singapore, 134 APS patients treated dur

2004 to 2005, 43.3% had a positive outcomof LA, and 66.4% of aCL.

In Indonesia, there is no research data

regarding the prevalence of women diagno

with antiphospholipid syndrome (APS).


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PRELUDE

Current first-line treatment for APS is lo

dose aspirin(LDA) plus unfractioned hepar

with low molecular weight heparin(LMWH

However, in about 20% of cases of APS, th

expected final destination, include live bircan not be achieved.

Without treatment, the rate of miscarriag

subsequent pregnancies in these condition

90%.


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PRELUDE

The purpose of this paper is to

investigate the pregnancy treatment

and management of labour in

antiphospholipid syndrome, so as to

reduce the morbidity and mortality ofboth mother and fetus by selecting

the appropriate treatment.


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TR

MEN

NPHOSHOLPD

SNOME

Non-medically

Clinical andLaboratorymonitoring duringantenatal care

Management of la

MedicallyAnti coagulant

Anti aggregation

Steroid

HCQ

IVIG

Others


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Follow-upbefore or during pregnancy

after delivery, including fetal viability

confirmed by transvaginal ultrasound

Serial ultrasound examinations to mon

fetal growth and amniotic fluid volum

velocity of blood velocity in the uteri

umbilical arteries were also assessed.


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The examination of platelets to monitor the

occurrence of thrombocytopenia should be

routinely.

Primary assessment is the level of live-bornand the secondary assessment is excessive b

thrombocytopenia, IUGR, pre-eclampsia, IUFD


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Timing of heparin can be initiated in the early

stages of pregnancy, without waiting for th

results of an ultrasound examination.

In another study from the Laboratory ofHormonology, Maternity, and Haemostatis U

Geneva University Hospitals, Switzerland, h

administration begins when the heart starts

activity seen on ultrasound (about 7-8 week


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Aspirin given in APS patients at a dose

of 75 mg daily when the gestational

sac (gestational sac)seen on

ultrasound around 6 weeks gestation

until the end of 35 weeks.


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Large doses of corticosteroids (0.5-1 mg /

day) was associated with an increased risk o

gestational diabetes, infections, hypertens

to pregnancy and preterm delivery. Side effects did not seem to occur when th

of prednisone is used in low doses (10-20 mg

day).


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Hydroxychloroquine (HCQ) annexin A5

protect from disruption by antiphosph

antibodies.

However, clinical evidence is still lim

the successful outcome of them in th


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The effectiveness of rituximab in

combination with chemotherapy inclu

plasmapahresis, has been widely used i

treatment of B cell malignancies, the

clinical manifestations of APS or just

reduce the levels of aPL.


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Department of Obstetrics and Gynecology,

University of Utah Health Sciences Center an

Intermountain Healthcare, USA, said that in th

handling of labor in patients with antiphosph

syndrome, obstetric patients depending on th

of the pregnancy.

Indications for cesarean delivery is poor obs

history, IUGR, pre-eclampsia, failure in the pro

of labor, and breech presentation.


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DISCUSSION

Department of Obstetrics and Gynecology in the Uof Sheffield, UK, explained that Enoxaparin is used

of 20 mg subcutaneously produces 80% live birth

In line with the above result, the Department of In

Medicine, Niguarda Hospital, Milan, Italy, reported

results of a study involving 27 patients APS. The u

subcutaneous heparin at a dose of 5000 IU twice arecommended in this case, as well as oral administ

100 mg aspirin.


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DISCUSSION

Of the 32 pregnancies studied 84.4%

managed to deliver the baby alive and

15.6% had a miscarriage.

This suggests that combination thera

produces slightly better results.


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DISCUSSION

Another study from the Department ofObstetrics and Gynecologic, Academic Me

Center, University of Amsterdam,

Netherlands, involving 364 APS patients w

subsequently received treatment with 80 m

aspirin combined with subcutaneous nadro(at a dose of 2,850 IU, started immediately a

the diagnosis of pregnancy is established)

80 mg aspirin alone, or placebo.


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DISCUSSION

The results also support from previous studcombination therapy better than monotherap

reported by the Department of Obstetrics an

gynaecologic, Liverpool Women's Hospital, U

study involving 176 patients APS.

When analyzed, 53/67 (79%) live-born infants

women who had received aspirin and heparin,

compared with 64/104 (62%) of women with A

who received aspirin alone.


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DISCUSSION

In line with the research before, the study othe Laboratory of Hormonology, Maternity

Haemostatis Unit, Geneva University Hospita

Switzerland, reported the APS patients with

anti-thrombotic therapy (aspirin 75 mg and 4

Enoxaparin inj.).

Of the 60 patients, 56 patients (93%) had a l

birth.


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DISCUSSION

Another study from the Department ofObstetrics and Gynecology, University of

Health Sciences Center and Intermountain

Healthcare, USA, APS involving 42 patient

treated with UFH and aspirin.

In this study, the live birth rate reached 85

in the treatment, and in previously untreat

pregnancies, only reached 4.6%.


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DISCUSSION

Another study by the Departmentof Obstetrics aGynecology, University of Chicago, USA, reporte

therapy with IVIG, of the 22 women in the IVIG gro

only 10 women (45%) who had a live birth at term.

In contrast to these findings, other studies of

the Operative Unit of Gynecology, University of R

Italy,which did HIVIg therapy in 60 patients with th

HIVIg APS (intact immunoglobulin type 20 g daily f

days, total dose 100 g), the live birth rate was 73.

(44 / 60).


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DISCUSSION

Maternal and Fetal Research Unit, King'sCollege London, UK, in the study, 18 wome

with antiphospholipid antibodies who have

recurrent miscarriages therapy is given

prednisolone (10 mg). before low-dose

prednisolone given as treatment, 4 of the pregnancies have resulted in live births (4

Among the 23 pregnancies that comes with

prednisolone, 9 women had 14 live births (6


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DISCUSSION

The European Registry on Obstetricantiphospholipid syndrome (Europas)repo

194 patients with APS have done therapy w

low molecular weight heparin (LMWH), wit

dose prophylaxis, low-dose aspirin combin

well (LDA) and prednisone.

Overall, produce live births obtained in

174/194 (89.69%).


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DISCUSSION

In another study, Department of Gynecology andObstetrics, New York University School of Medic

New York, USA, APS reported on 87 patients trea

with prednisone and aspirin, live birth rate was 83

(73/87) and the rate of miscarriage fetus reache

16.09% (14/87).

Of the 42 patients treated with prednisone and as

plus LMWH and IVIG, live birth rate was 97.62% (4

and fetal miscarriage rate was 2.38% (1/42).


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DISCUSSION

From these studies, therapy in APS patient

with a combination of aspirin, LMWH,prednisone, and IVIG, resulting in the live

birth rate is very high compared with

monotherapy or combination therapy to

another, reaching 97.62%.


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DISCUSSION

But according to the author, IVIG should n

included in the combination of the above duthe relatively high cost and the research a

their effectiveness is still small and

controversy.

By simply using a combination of aspirin, LM

and prednisone was live birth rate can reac

89.69% based research that has been previ

explained above.


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DISCUSSION

Department of Obstetrics and Gynecolog

University of Utah Health Sciences CenterIntermountain Healthcare, USA, reported t

study of labour management in patients wit

A total of 7 (17.5%) of 40 patients in the st

through elective Caesarean section and 3

of 40 patients by emergency Caesarean sec

the remaining 75% using a vaginal delivery.


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DISCUSSION

This is in line with another study of the Department of

Obstetrics and Gynaecology, King's College, St ThomHospital, London, UK, reported the study, from 39 APS

patients, 12 through childbirth by caesarean section

and the rest are normal vaginal birth (69.2 %).

In contrast to the two studies above, Laboratory of

Hormonology, Maternitym and Haemostatis Unit, Gene

University Hospitals, Switzerland, reported that in 56

with APS syndrome, 49 childbirth (87.5%) by caesarean

due to obstetric causes patients. The remaining 7 patie

(12.5%) by vaginal delivery.


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CONCLUSION

1. Best management in patients with antiphospholipid sya combination of LDA (dose 75 mg, once daily beginnin

conception and continuing through 36 weeks of gest

plus LMWH (dose of 5000 IU or 40 mg once daily star

cardiac activity began to look at the ultrasound ( ab

weeks) to gestational age 37 weeks) and prednisolon

dose, starting from a positive pregnancy test until 14gestation), which will reach 89.69% live birth rate.


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CONCLUSION

2. Handling of labor in patients withantiphospholipid syndrome still

prioritizing vaginal delivery for live-birth

that can reached 75%. It is actually not

accompanied with poor obstetric

morbidity.


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Thank YouNusa Purnawan Putra 0861050031MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY

FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA

Pregnancy Treatment and Labour Management in Antiphospholipid Syndrome

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