When otherwise unexplained fetal deaths are examined, the data are mixed. One study measured ACA levels in 309 pregnancies with fetal death and found no diferences in their frequency compared with levels in 618 normal pregnancies (Haddow, 1991). In another of women with recurrent pregnancy loss, those with antiphospholipid antibodies had a higher rate of preterm delivery (Clark, 2007). In a case-control study of 582 stillbirths and 1547 live births, a three-to fivefold higher risk for stillbirth was found in women with elevated ACA and anti-3rglycoprotein I levels (Silver, 2013). In women with antiphospholipid antibodies, adverse outcomes are more common in the presence of: (1) all three classic anti phospholipid antibody types, (2) comorbid SLE or systemic autoimmune diseases, and (3) prior thrombosis and pregnancy morbidity. Logistic regression found the probability of pregnancy failure was 93 percent with two or more antiphospholipid antibody types but was 63 percent for those with only one (Rufatti, 2011).
Because of study heterogeneity, current treatment recommendations for women with antiphospholipid antibodies can be confusing. Therapy is directed at thrombosis prevention. As discussed, antiphospholipid antibodies are immunoglobulins that may be of G, M, or A classes. Those directed against the phospholipids (PL) are termed GPL, MPL, and APL, respectively. During testing, these are reported as semiquantified phospholipid binding-unit levels and expressed as negative, low-positive, medium-positive, or high-positive (American College of Obstetricians and Gynecologists, 2017). Of the three, higher titers for GPL and MPL anticardiolipin antibodies are clinically important, whereas low-positive titers are of questionable clinical signiicance.
As discussed in Chapter 52 (p. 1008), women with prior thromboembolic events who have antiphospholipid antibodies are at risk for recurrence in subsequent pregnancies. For these women, prophylactic anticoagulation with heparin throughout pregnancy and then for 6 weeks postpartum with either heparin or warfarin is recommended (American College of Obstetricians and Gynecologists, 2017). For those without prior thromboembolic events, recommendations for management from the American College of Obstetricians and Gynecologists (2017) and the American College of Chest Physicians (Bates, 2012) vary and are listed in Table 52-6 (p. 1020). Some acceptable schemes include close antepartum maternal observation with or without prophylactic or intermediate-dose heparin, and some form of postpartum anticoagulation for 4 to 6 weeks. Scias results with treatment with hydroxychloroquine.
Several trials have questioned the need for heparin for women with antibodies but no history of thrombosis (Branch, 2010). lthough this is less clear, some recommend that fetal death not attributable to other causes (Dizon-Townson, 1998; Lockshin, 1995). Some report that women with recur rent early pregnancy loss and medium-or high-positive titers of antibodies may beneit from therapy (Robertson, 2006).
Described earlier (p. 1143), catastrophic antiphospholipid syndrome is treated aggressively with full anticoagulation, high-dose corticosteroids, plasma exchange, and/or intravenous immunoglobulins (Cervera, 2010; Tenti, 2016). If needed, rituximab may be added (Sukara, 2015).