THE MANAGEMENT AND HANDLING

LABOR OF ANTIPHOSPHOLIPID
SYNDROME IN PREGNANCY

Adviser :
Prof. Dr. H. I. O. Marsis, spOG
Compiled by:
Nadya Noviani
(1161050230)
OBSTETRI AND GYNECOLOGY
HOSPITAL CHRISTIAN UNIVERSITY OF INDONESIA
PERIOD

INTRODUCTION

IS AN AUTOIMMUNE CONDITION
CHARACTERIZED BY THE LOSS OF
THE FETUS, THROMBOSIS, OR
AUTOIMMUNE
THROMBOCYTOPENIA. APS
INCREASES THE RISK OF
MATERNAL AND FETAL MORBIDITY
AND FETAL DEATH IN PREGNANCY.

FETAL LOSS RATE CAN EXCEED

90% IN UNTREATED PATIENTS
WHO HAVE APS.

1. Cowchock FS, Reece EA, Balaban D, et al: Repeated fetal losses associated with antiphospholipid antibodies: a
collaborative randomized trial comparing prednisone with low-dose heparin treatment. Am J Obstet Gynecol 2012

THE PREVALENCE OF APS IN GENERAL IS NOT KNOWN, BUT

IT WAS TO BE EXPECTED IN EUROPE IN 2009 REACHED
0.5%.

WOMEN WHO EXPERIENCE FETAL DEATH AFTER 20 WEEKS

OF PREGNANCY REACHES 30%. TRIMESTER FETAL DEATH AT
THE BEGINNING AND THE END OF THE TRIMESTER WAS
35.4% AND 16.9%, WHERE THE PREVALENCE OF LIVE
BIRTHS IN WOMEN WHO DO THERAPY NEARLY 80% AND
20% UNTREATED.

2. J Alijotas Reig. Treatment of refractory obstetric antiphospholipid syndrome: the state of the art an
new trends in the therapeutic management. Systemic Autoimmune Diseases Unit, Department of
Internal Medicine. Spain. 2012.

BASED HEALTH RESEARCH IN 2007, IN INDONESIA

HAS NOT BEEN REPORTED EXACT FIGURES FOR
THE INCIDENCE OF APS IN PREGNANCY, BECAUSE
IN DAILY PRACTICE STILL FOUND A DISCREPANCY
EVEN MISTAKES IN DIAGNOSING APS.

BUT IT HAS BEEN KNOWN APS IN PREGNANCY IS A

RISK FACTOR FOR STROKE, ESPECIALLY AT A
YOUNG AGE (<40 YEARS) AND FOUND ABOUT
18%.

3. Lockwood CJ, Schur PH. Obstetrical Manifestation of Antiphospolipid Syndrome. Up to Date

Literature Review Version. 19.3: Januari 2012.

THE PURPOSE OF THIS LITERATURE REVIEW WAS TO

DETERMINE THE BEST MANAGEMENT AND HANDLING LABOR
OF THE APS IN PREGNANCY, SO THAT THE OCCURRENCE OF
PREGNANCY IN WOMEN WITH APS CAN BE ENHANCED AND
MORTILITAS TO THE MOTHER AND THE FETUS CAN BE
DERIVED.

THE BEST TREATMENT FOR IMPROVING PREGNANCY

OUTCOME WITH APS STILL UNKNOWN. BUT APPROXIMATELY
70% OF PREGNANT WOMEN WITH APS WILL HAVE A
HEALTHY BABY AND OVERALL LIVE BIRTH IN WOMEN WITH
APL HAVE PREVIOUSLY BEEN REPORTED AS HIGH AS 79%

MANAGEMENT OF APS IN
PREGNANCY
Classification criteria laboratory
found lupus anticoagulant (LAC) and / or
anticardiolipin antibodies (aCL) of IgG and / or
presence of IgM isotype in medium to high
titer levels [> 40 IgG phospholipid (GPL) or
IgM phospholipids (MPL)> 99 ] and / or
IgG antibodies anti-b2-glycoprotein I (anti-b2GPI) and / or
presence of IgM isotype in titer> 99 .

THE LUPUS AND ARTHRITIS RESEARCH UNIT, RAYNE

INSTITUTE LONDON (2015), THE CURRENT
RECOMMENDATION FOR APS IS: (I) LOW-DOSE
ASPIRIN (LDA) 75-100MG AND PROPHYLACTIC DOSE
HEPARIN 5000 UNITS PER DAY FOR PATIENTS
FULFILLING THE UPDATED SAPPORO APS
CLASSIFICATION CRITERIA BASED
ON began
PREGNANCY
Therapy
detected
pregnancy by using
MORBIDITY ONLY;
ultrasound at week 6.
Then the cessation of
therapy at week 35.
Treatment was resumed
until 4-6 weeks after birth.

Erkan D, Patel S, Et al. Management of the Controversial Aspects of the Antophospholipid Syndrome
Pregnancies; A Guide For Clinicians and Researchers. Rheumatology 2013; 47; 23-27.

DEPARTMENT OF PUBLIC HEALTH MEDICINE,

UNITED KINGDOM (2015), ANTITHROMBOTIC
THERAPY HAS BEEN USED. IN PATIENTS GIVEN
HIGH-INTENSITY WARFARIN THERAPY WITH OR
WITHOUT ASPIRIN, THE POSSIBILITY ARISES OF
A NEW THROMBOSIS IN 5 YEARS IS
APPROXIMATELY 90%. WHEREAS THOSE GIVEN A
LOW-DOSE ASPIRIN OR WITH LOW-INTENSITY
WARFARIN WAS NO DIFFERENCE BETWEEN THE
TWO.

INDUCTION OF LABOR IS
RECOMMENDED AT 38-40 WEEKS'
GESTATION EVEN IN COMPLICATED
CASES, CLOSE MONITORING OF THE
PREGNANCY WILL DO. SECTIO
CAESARIA (SC) IS DONE FOR THE
CASE OF APS.

Stone S, Hunt B.J, Et Al. Primary Antiphospholipid Syndrome in Pregnancy: an Analysis of Outcome in a
Cohort of 33 Women Treated with a Rigorous Protocol.

DISCUSSION

BY STUDY D.K DOROTA ET AL, DEPARTEMENT OF OBSTETRICS AND

PERINATOLOGY MEDICAL UNIVERSITY OF LUBIN (2012),
IN THE FIRST GROUP WAS GIVEN A LOW-DOSE ASPIRIN, WHILE
THE SECOND GROUP WAS GIVEN ASPIRIN (75-100MG) BEFORE
CONCEPTION, DURING PREGNANCY AND THE FIRST 4 WEEKS
AFTER GIVING BIRTH GIVEN LOW MOLECULAR WEIGHT HEPARIN
(LMWH) 5000 UNITS PER DAY. IF TREATMENT FAILS, TREATMENT
PLANS FOR FUTURE PREGNANCIES SHOULD BE ADDED LMWH.

MANY PATIENTS PREFER TO START

WITH THE SECOND PLAN
D.K Dorota, W Anita, Et. Al. The Management of Obstetric
Antiphospholipid Syndrome. Archives of Perinatal, Departement
of Obstetrics and Perinatology 18(1); 53-58, 2012.

MAR NATALIYA ET ALL, DEPARTEMEN OF

HEMATOLOGY UNIVERSITY OF CONNECTICUT
HEALTH CENTER FARMINGTON (2014)

Mar Nataliya, Rebecca K, Hook K. Recurrent Thrombosis Prevention with Intravenous Immunoglobulin and
Hydrochloroquine During Pregnancy in a Patient with History of Catastrophic Antiphospholipid Syndrome and

S. ERRARHAY, DEPARTEMENT OF GYNECOLOGY AND

OBSTETRICS UNIVERSITY HOSPITAL OF FEZ
MORROCO (2013)
32 YEARS OLD NULLIPAROUS WOMEN
WITH GESTATIONAL 4TH AND
PREVIOUS CONDUCT SPONTANEOUS
LABOR 3X. NO ABNORMALITY WAS
FOUNDED. BUT ANTIBODY
ANTICARDIOLIPIN (IMMUNOGLOBULIN
G) POSITIF.

GIVEN ASPIRIN 100 MG / DAY AND HLMW

AND CORTICOSTEROIDS (PREDNISONE 40
MG / DAY). ASPIRIN WAS STOPPED AT
WEEK 35 OF PREGNANCY. SC FOR LABOR
PERFORMED AT 39 WEEKS GESTATION
AND BIRTH OF HEALTHY BABIES WEIGHING
3700 GRAMS.

N. HMIDANI, DEPARTEMENT OF GYNECOLOGY AND

OBSTETRICS UNIVERSITY HOSPITAL OF FEZ
MORROCO (2013)

R. FISCHER-BETZ, DEPARTEMENT OF DIABETOLOGY

AND RHEUMATOLOGY UNIVERSITY OF HEINRICH
HEINE GERMANY (2012)
PROSPECTIVELY OBSERVE THE 23
PREGNANT WOMEN WITH 20 WOMEN
(AVERAGE AGE 31 YEARS). FOUND 8
PATIENTS HAD TRANSIENT ISCHEMIC
ATTACKS (TIA) AND 12 HAD A STROKE
BEFORE PREGNANCY. ALL PATIENTS
WERE GIVEN ASPIRIN 100 MG AND
LMWH THERAPY DURING PREGNANCY.
THE LIVE BIRTH RATE WAS FOUND 91.3%

STONE S ET ALL, DEPARTEMENT OF HEMATOLOGY

LONDON (2015)
THE SUCCESS RATE IS HIGH ENOUGH APS SC
AT 59%. SC PRIMARY INDICATIONS IN PATIENTS
WITH APS IS FETAL DISTRESS DURING LABOR,
SECONDARY DISTURBANCE AT THE
UTEROPLACENTAL FETUS, AND FAILED
INDUCTION OF LABOR.

CONCLUSION
1.

The optimal management of pregnant women with APS is a

combination therapy with low molecular weight heparin
(5000 units subcutaneously every day) and aspirin 75-100
mg daily with a live birth rate of 91.3%.

2.

Treatment started when detected the pregnancy with

ultrasound is the 6th week of pregnancy. At week 35 of
therapy is stopped and resumed 4-6 minngu after
childbirth.

3.

Sectio Caesaria (SC) is performed in patients with APS. The

success rate is high enough APS SC at 59%. The live birth
rate can occur as much as 91% of pregnant women with a
history of primary APS who have a history of abortion with
or without thrombosis using SC technique.

REFERENCE
1.

Cowchock FS, Reece EA, Balaban D, et al: Repeated fetal losses associated with
antiphospholipid antibodies: a collaborative randomized trial comparing prednisone
with low-dose heparin treatment. Am J Obstet Gynecol 2012 May; 166(5): 1318-23.

2.

J Alijotas Reig. Treatment of refractory obstetric antiphospholipid syndrome: the

state of the art and new trends in the therapeutic management. Systemic
Autoimmune Diseases Unit, Department of Internal Medicine. Spain. 2012.

3.

Lockwood CJ, Schur PH. Obstetrical Manifestation of Antiphospolipid Syndrome. Up

to Date Literature Review Version. 19.3: Januari 2012.

4.

Erkan D, Patel S, Et al. Management of the Controversial Aspects of the

Antophospholipid Syndrome Pregnancies; A Guide For Clinicians and Researchers.
Rheumatology 2013; 47; 23-27.

5.

Del Ross, Et al. Treatment of 139 in Antiphospholipid Positive Women Not Fulfilling
Criteria for Antiphospholipid Syndrome: A Retrospective Study. The Journal of
Rheumatology. 2013; 40; 425.

6.

A Munther, Et al. The Management of Thrombosis in The Antiphospholipid-Antibody

Syndrome. The New England Journal of Medicine Vol. 332, No. 15, April 2015.

7.

Stone S, Hunt B.J, Et Al. Primary Antiphospholipid Syndrome in Pregnancy: an

Analysis of Outcome in a Cohort of 33 Women Treated with a Rigorous Protocol.

8.

Sciascia S, Hunt B.J, Et. Al. The Impact of Hydrochloroquine Treatment on

Pregnancy Outcome in Women with Antiphospholipid Antibodies. Obstetrics,
American Journal of Obstetrics & Ginecology. Februari 2016.

9.

D.K Dorota, W Anita, Et. Al. The Management of Obstetric Antiphospholipid

Syndrome. Archives of Perinatal, Departement of Obstetrics and Perinatology
18(1); 53-58, 2012.

10.

Mar Nataliya, Rebecca K, Hook K. Recurrent Thrombosis Prevention with

Intravenous Immunoglobulin and Hydrochloroquine During Pregnancy in a
Patient with History of Catastrophic Antiphospholipid Syndrome and
Pregnancy Loss. J Thromb Thrombolysis, 38; 196-200, 2014.

11.

Errarhay S, Et Al. Antiphospholipid Antibody Syndrome and Pregnancy. Journal

of Obstetric and Ginekology, 3; 383-385, 2013.

12.

C Scott, Et Al. Apixaban for the Secondary Prevention of Thrombosis Among

Patients With Antiphospholipid Syndrome: Study Rationale and Design
(ASTRO-APS). Intermountain Medical Center, University of Utah. 2015.

13.

R. Fischer-Betz, Et Al. Pregnancy outcome in patients with antiphospholipid

syndrome after cerebral ischaemic events: an observational study.
Departement of Diabetology and Rheumatology University of Heinrich Heine.
Germany. 2012.