Intravenous immunoglobulin therapy (NIG) is controversial and has usually been reserved for women with overt diseaseincluding CAPS or heparin-induced thrombocytopenia or both (Alijotas-Reig, 2013). It is used when other first-line therapies have failed, especially in the setting of preeclampsia and fetalgrowth restriction. IlG is administered by some in doses of 0.4 g/kgl d for 5 days-total dose of 2 g/kg. This is repeated monthly, or it is given as a single dose of 1 g/kg each month. Treatment is expensive, as one course costs more than $10,000. A recent literature review found no beneits from adding IlG to low-dose aspirin and low-molecular-weight heparin (Tenti, 2016). And, a Cochrane review found no improvement in the live birth rate for immunotherapy given to women with recurrent pregnancy loss (Wong, 2014). Trials are needed before application of this expensive and cumbersome therapy becomes widespread.
Immunosuppression with hydroxychloroquine may be beneficial with APS by reducing the risk of thrombosis and improving pregnancy outcomes in women with APS (Mekinian, 2015; Sciascia, 2016). Hydroxychloroquine is commonly used with low-dose aspirin in the treatment of women with antiphospholipid antibodies and SLE.
Statins have been examined due to their protective efects on endothelium. In a small trial in 21 women with APS who developed fetal-growth restriction or preeclampsia, the addition of pravastatin to low-dose aspirin and low-molecular-weight heparin improved placental blood flow, preeclampsia features, and pregnancy outcomes (Lekou, 2016). Larger trials are needed.
Fetal loss is common in women with APS if untreated (Rai, 1995). Even with treatment, recurrent fetal loss rates remain at 20 to 30 percent (Branch, 2003; Empson, 2005; Ernest, 2011). Shown in Table 59-6 are pregnancy outcomes from 750 treated women with primary APS-the PREGNANTS study (Saccone, 2017). Participants were treated with low-dose aspirin and prophylactic low-molecular-weight heparin starting in the irst trimester. Importantly, some women with SLE and antiphospholipid antibodies have normal pregnancy outcomes without treatment. Also, it is emphasized that women with LAC and prior bad pregnancy outcomes have had liveborn neonates without treatment.
In a manner similar to neonatal lupus syndrome (p. 1142), up to 30 percent of newborns demonstrate passively acquired antiphospholipid antibodies, and thus there is concern for their adverse neonatal efects (N alii, 2017). One group found higher rates of learning disabilities in these children (Tincani, 2009). Simchen and colleagues (2009) reported a fourfold greater risk for perinatal strokes. Of 141 newborns followed in a European registry, the rate of preterm birth was 16 percent; low birthweight, 17 percent; and later behavioral abnormalities in 4 percent of the children. here were no cases of neonatal thrombosis (Motta, 2012). A 7-year study of 26 women who had APS with 36 pregnancies reported three cases of autism spectrum disorder, all associated with persistent neonatal anti �2_g1ycoprotein-1 IgG antibodies (Abisror, 2013).