Management of a cohort of Sri Lankan women with antiphospholipid syndrome (APLS) and recurrent pregnancy loss

Abstract

BACKGROUND: APLS is an autoimmune disease leading to recurrent pregnancy loss, the laboratory diagnosis being limited in Sri Lanka. OBJECTIVE: We report the management outcomes of a series of affected women from a single tertiary care unit. DESIGN: Observational case study DIAGNOSTIC CRITERIA: International consensus guidelines for APLS (1999). OUTCOME MEASURES: Outcome of the last pregnancy managed with subcutaneous heparin and aspirin (international practice guidelines) versus previous obstetric outcome of pregnancies that did not receive treatment. RESULTS: 70 with APLS; 38(54 percent) pregnant when recruited. Mean age 31.4ñ5.7 years, duration since marriage 6.1ñ3.5 years. Number of children: 0.44ñ0.67 per woman, 46(66 percent) childless, 17(24 percent) one child, none with 2or>. Total gestations 316, mean gestations 4.5ñ2.1 per patient (range 1-13). Previous pregnancy outcomes: 33(10.4 percent) live births, 18(5.7 percent) stillbirths, 227(71.8 percent) abortions - 87 late (>10 weeks), 140 early (<10 weeks); 21 had 3 or > early miscarriages. Lupus anticoagulant/DRWT positive 25, KCT positive 14, Anticardiolipin antibodies positive 8, ANF positive 4, dsDNA positive 2. Of 15 tested in a reference laboratory AnnexinV IgG+ 2,IgM+ 3 ; anti-_2-Glycoprotein 1 IgG+ 4 ;IgM+ 2 ; Phosphatidyliositol + 12, Phosphatidylethanlamine + 5, Phosphatidylserine +12. Co-morbidities: pregnancy hypertension 11(15.7 percent), gestational diabetes 13(18.5 percent), cerebrovascular disease 3(4.2 percent), deep vein thrombosis 4(5.7 percent). Family history: 25(35 percent) hypertension; 29(41 percent) diabetes, 10(15 percent) recurrent abortions, 1 recurrent stillbriths. 49 pregnancies received heparin and aspirin. Outcomes specific treatment (49) versus no previous treatment (267): early miscarriage 2(4 percent) vs. 138(51.6 percent) (p=0.0001), late abortion 10(20 percent) vs. 77(28.8 percent) (p=0.08), still birth 0 vs. 18(6.7 percent) (p=0.001), live birth 25(53 percent) vs. 9(3 percent) (p=0.0001). In treatment group 14(56 percent) normal delivery; 9(36 percent) elective LSCS; 2(8 percent) emergency LSCS, average birth weight of 2.6 ñ 0.56 kg (range 1.25-3.96) with a mean period of gestation of 36.2ñ2.6 weeks. 12(24 percent) gestations on treatment are currently pregnant with no fetal growth restriction after 28 weeks. CONCLUSIONS AND RECOMMENDATIONS: APLS presenting with recurrent fetal losses requires a high degree of suspicion and management by a multidisciplinary team, which considerably improves the chances of a live birth.