aps 7 th aug 2015
TRANSCRIPT
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Antiphospholipid syndrome Dr. Suman Kumari MS OBGY
Graham R.V. Hughes
First discribed by Graham R.V. Hughes in 1983
Introduction
• known as Hughes syndrome.
• Autoimmune disorder associated with acquired
thrombophilia.
• Most common association is SLE.
• Asherson’s syndrome-Catastrophic APS.
• Obstetric complications are “hallmark” of APS.
• Severe FGR,preeclampsia,prematurity imp. Complications.
Introduction conti..
• It is the most common thrombotic defect leading to fetal
wastage.
• Responsible for frequent miscarriages in young female.
• Obstetric care based on medical- obs high risk combined
management.
• Prevalence of antiphospholipid antibodies is 2% in overall
pregnancy.
• 15% of women with recurrent miscarriage.(RCOG)
Introduction conti..
Definition
A patient with definite APS must have
• laboratory criteria.
– persistent high titer antiphospholipid antibodies(APL)
– history of arterial or venous thrombosis or both and
• clinical criteria.
– recurrent pregnancy morbidity.
Talk Plan Sapporo criteria• Diagnostic criteria Sydney criteria primary APS• Classification of APS
• Epidemiology Secondary APS• Pathophysiology• Clinical features• Investigation Preconception
• Management Antenatal• Follow up Postnatal• Recommendation
International consensus conference held in Sapporo(98)
Sapporo criteria
• Helped galvanize research in this disorder .
• High sensitivity and specificity in APS .
• Seen in conjunction with lupus and lupus-like
diseases.
Sapporo criteria conti...
Amendments to the Sapporo criteria –
• more insights into clinical, laboratory, and experimental
criteria.
• No clear cutoffs for “medium to high titers” of IgG and
IgM anticardiolipin(aCL).
• Timing of laboratory testing in relation to the clinical
event was not clarified.
Revised classification criteria for anti-phospholipid syndrome:Sydney criteria
2006Clinical criteria1. Vascular thrombosis• One or more clinical episodes of arterial, venous or small vessel thrombosis
2. Pregnancy morbidity• (a) One or more unexplained deaths of a morphologically normal fetus at or
beyond the 10th week of gestation
• (b) One or more pre-term births of a morphologically normal neonate before the 34th week of gestation because of: (i) eclampsia or
severe pre-eclampsia or (ii) recognized features of placental insufficiency
• (c) Three or more unexplained consecutive spontaneous miscarriages before the 10th week of gestation, (with maternal anatomic or
hormonal abnormalities and chromosomal causes excluded)
Revised classification criteria for anti-phospholipid syndrome:Sydney criteria
2006Laboratory criteria1.Lupus anticoagulant (LA) present in plasma.
2. Anticardiolipin (aCL) antibody of immunoglobulin (Ig)G and/or IgM isotype in serum or plasma, present in medium or high titre (i.e. >40GPL units or MPL units, or > the 99th centile).
3. Anti-β2–glycoprotein I antibody of IgG and/or IgM isotype in serum or plasma (in titre >the 99th centile).
• Antiphospholipid antibody syndrome (APS) is present if at least one of the clinical criteria and one of the laboratory criteria are met
• Presence of aPL on two or more occasion atleast 12 week apart• GPL units, IgG antiphospholipid units; MPL units, IgM antiphospholipid units.
“Non-criteria” APS findings
• Thrombocytopenia and/or hemolytic anemia.
• Transverse myelopathy or myelitis.
• Livido reticularis.
• Cardiac valve disease.
• Nephropathy.
• Non-thrombotic neurologic manifestations, including multiple sclerosis-
like syndrome, chorea, or migraine headaches.
Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306
Advancement in criteria 2006
• Better definition of clinical criteria.
• Stratification of patients as per primary or secondary APS.
• Time interval increased to 12 weeks.
• Transient positivity excluded.
• Categorisation of asymptometic aPL and Catastrophic APS
(CAPS).
• APS with or without associated rheumatic disease.
Classification of APS
A. PRIMARY APS (PAPS) B. SECONDARY APS
(Obstetric APS) PRIMARY APS
• Majority of patients with APS are in PAPS group.
• Small proportion of the PAPS may devlops SLE over the period
of 15-20 years.
• some experts recommend evaluation prolonged period of time.
Classification of APS....
B. SECONDARY APS
1. autoimmune disorder 3. Malignancy SLE 25-50% Ca cervix and ovary Sjogren syndrome-42% Lymphoma Rheumatoid arthritis-33% leukemia
DM Autoimmune thyroid disease. 2 .Drug induced condition 4. infectious disease ocp syphlis, HIV
Epidemiology
• Women : men is 5:1
• Mean age of onset is 31 yrs.
• Risk of thrombosis is 0.5-30 %
• Artheritis,livedo ,migrane more common in female.
• MI,epilepsy arterial thrombosis more common in
male.
Mechanisms by which APS causes pregnancy morbidity
early pregnancy late pregnancy
inhibition to trophoblastic function and differentiation
thrombosis of the Uteroplacentalvasulature
Activation of compliment system at the maternal fetal interface --local inflammatory response.
Pathophysiology
• aPLs –acquired antibodies(IgG,IgM,and/orIgA) -binds to
negatively charged phospholipids.
• Beta2GP-I is major target molecule,present on the surface of
trophoblastic cell membrane.
• Beta 2 GP-1 helps in syncytial trophoblast formation from
cytotrophoblast.
• Inhibit prothrombin to thrombin conversion and activation of
intrensic coagulation pathway and thus inhibits thrombosis.
Pathophysiology
• Anti-β2GP I - most strongly associated with thrombosis (de Laat et al, 2005).
• Anti β2GPI significant association with venous thrombosis.
• strongest association for thrombos is the
combination of LA, anti β2GPI• LA -stronger association with pregnancy loss Opatrny et al, 2006.
Mechanisms for thrombosis in APS
• Increased expression of tissue factor on monocytes and
endothelial cells (Branch & Rodgers, 1993)
• Interference in the protein C anticoagulant pathway
(Malia et al, 1990)
• Inhibition of fibrinolysis (Atsumi et al, 1998b)
• Pregnancy failure may be due to thrombosis in the
placental bed.
Clinical features
• Can affect any organ of the body including the lung,
skin, brain, liver,kidneys, adrenal glands, heart, and
eyes.
• ‘‘classic’’ clinical presentations include peripheral
deep venous thrombosis (DVT), pulmonary embolism
(PE), and/or arterial thrombotic events
Clinical features cont...
• Venous thrombosis in APS is commonly- lower limb deep
vein thrombosis (DVT) and/or pulmonary embolism(PE)
• Any part of the venous system may be involved.
• The most frequent site of arterial thrombosis in APS is in
the cerebral vasculature resulting in transient cerebral
ischaemia/stroke.
Clinical features conti...
• APS -only a minor contribution to the overall burden of
disease fromVTE and stroke.
• Microvascular thrombosis in APS is least common seen
in‘catastrophic antiphospholipid syndrome’
(CAPS)potentially lethal .
• In CAPS -multiorgan failure ,but lungs, brain and kidneys
are spared.
Clinical features conti...
Obstetric features
• Recurrent pregnancy loss
• Unexplained second or third trimester fetal death
• Severe preeclampsia at less than 34 weeks’ gestation
• Unexplained severe fetal growth restriction.
• Chorea gravidarum
• Unexplained primary infertility –only symptom in APS.
Clinical features cont...
Nonobstetric features
• Thrombocytopenia,
• heart valve disease
• chorea,
• stroke
• nephropathy
• SLE or other connective tissue disorder
Clinical features conti...
Nonspecific associations
• Unexplained transient ischemic attack
• Livedo reticularis
• Unexplained prolongation of a clotting assay
• False-positive serologic test result for syphilis
(Miyakis et al, 2006).
Nonspecific associations
Clinical features PAPS APS-SLE notes
thrombocytopenia
20-25% 30-40% Usually mildNo protective effect on thrombotic risk.
Heart valvedefect
12-33% 40% Possibly an additional risk for secondarythromboembolism
Superficial thrombophlebitis
9% Reported in aPL-positive patients but their value stilldebated
nephritis. 35% 39-67% Association with pregnancy complications,
How to diagnose
Who should be tested for aPL???
• recurrent first-trimester miscarriage
• one or more unexplained second-trimester or third-
trimester loss
• Early onset,severe preeclampsia.
• Severe IUGR
Who should be tested for aPL???
• Autoimmune disease or connective tissue disease.
• False positive serological test for syphilis.• Positive autoantibody tests.
RCOG GUIDELINES
Investigation• Antiphospholipid (aPL) antibodies
solid-phase enzyme-linked immunoassays.
• Results -reported in semiquantitative terms such as negative, low positive, medium positive, or high positive.
• Systemic lupus erythematosus (SLE) -lower serum complement levels,
total hemolytic complement activity (CH50) complement C3 and C4, Ds DNA, ANA ,LE cell test are the basic test for SLE.
Investigation plan
If APS suspected-as per the laboratory
diagnostic criteria following aPL are tested.
• Lupus anti coagulant(LA/LAC)
• Anticardiolipin antibody(aCL).
• Anti beta2 GP-1(β2GP- 1)
Investigation conti...
Lupus anticoagulant(LAC)• Misnomer-associated with hypercoagulable state and
frequently found in patient without SLE.• An immunoglobulin (IgG/IgM/Both) –interfere with one or
more phospholipid-dependent test of in vitro coagulation.• Most common test that identify LAC includes aPTT-activated partial thromboplastin time KCT-the kaolin clot time test dRVVT-dilute Russell viper venom time PCT-plasma clot time.
Screening test for lupus anticoagulants(LAC)test In pregnancy advantage disadvantage sensitivityaPTT increased
factor VIII may mask the result.
Readily available,easily automated.
Vary in sensitivity widely
least
KCT Not affected Very sensitive to LAC if on oral anticoagulant
Not readily automated
most
dRVVT Not affected Easy to perform ,readily available
Affected by ocp and heparin
good
PCT Increased factor VII –blunt LAC effect.
Requires no reagents/equipment.
Must be performed on freshly drawn blood.
good
Confirmation of LAC
Prolonged phospholipid-dependent coagulation mixing with normal plasma
Failure to correct the prolong coagulation time . addition of excess phospholipid
Shortening/correction of prolonged coagulation time
Exclusion of other coagulopathy.
Anti cardiolipin antibody(aCL).
• Cardiolipin(phospholipid) –on membrane.
• ELISA –gold standard.
• IgG,IgM,and IgA-Standard sera available.
• Ability to bind 1 ug of cardiolipin and result in titres.
• Value decline in pregnancy as increase in plasma
volume causes dilution of phohpholipid.
Management
• Pre conception• Antepartum• Postpartum• Follow up
Preconception management
• Pregnant women with APS are considered high-risk
obstetric patients.
• Patients should be counselled regarding symptoms of
thrombosis and thromboembolism.
• Therapeutic abortions -not indicated in pregnant
women with autoimmune disease.
Preconception management cont..
• With no treatment-only 20-30% of patient with aPL antibody
has successful delivery.
• Combination of unfractionated heparin with low dose aspirin
–provide the highest success rate in terms of live birth.
• Low dose heparin with low dose aspirin reduces the
pregnancy loss by 54%
Preconception management cont..
• Low dose aspirin 75 mg should be initiated before
conception and discontinued 4 weeks before EDD.
• M.O.A of aspirin-selective inhibition of thromboxane
production-restoration of balance with
prostaglandin.
Antepartum surveillance
• If h/o first trimester losses-do USG weekly till progress beyond
the point of their prior losses.
• If h/o second /third trimester fetal loss-serial antepartum testing
required.
• close fetal survillance needed in form of 30-32 wk onword
nonstress test-twice weekly.
Biophysical profile weekly.
Daily fetal kick count,
ManagementFeature Pregnant Nonpregnant
APS with prior fetal death or recurrent pregnancy loss
Heparin in prophylactic doses with low-dose aspirin.Calcium and vitamin D supplementation
Optimal management ,no treatment or treatment with low-dose aspirin.
APS with prior thrombosis or stroke
Heparin in therapeutic doses.Calcium and vitamin D supplementation
Warfarin administered daily in doses to maintain international normalized ratio of =3
APS without prior pregnancy loss or thrombosis
No treatment /low-dose aspirin / prophylactic doses of heparin plus low-dose aspirin.
No treatment or daily treatment with low-dose aspirin.
Anticoagulation therapy
• Heparin should be continued until the onset of spontaneous
labor.
• Or night before scheduled induction/operative delivery.
• If the patient is fully anticoagulated and delivery is emergent-
1%protamine sulphate ,iv over 10 min.
Anticoagulation therapy (heparin)
• After confirmation of pregnancy.
5000 units every 12 hr.-
• Platelets and PTT –
base line
every week for 2 weeks
Once ineach trimester throughout pregnancy .
Anticoagulation therapy ( heparin)
• With prior h/o thromboembolism –
therapeutic dose required10000-12000 IU sc/day.
• Does not cross the placenta
• Aim to keep aPTT at the upper end of normal range.
Anticoagulation therapy
• Side effect of heparin-
Heparin induced thrombocytopenia (HIT)-
o incidence 1% at dose >15000Iu/day(combined with low platelets in
pregnancy.)
o bleeding risks-If platelets counts decreases significantly ,heparin dosage
should be reduced.
o Splenectomy -- early second trimester or at the time of CS may be considered
in patients with thrombocytopenia refractory to glucocorticoid therapy.
Anticoagulation therapy
Heparin induced osteopenia –
o dose >15000 IU/day(combined with normal osteoporosis
associated with pregnancy .
o Heparin-induced osteoporosis occurs in 1-2% of cases
risks of osteopenia-
o Bone density studies should be considered
Anticoagulation therapy
• Warfarin may be substituted for heparin during the
postpartum period to limit further risk of heparin-
induced osteoporosis and bone fracture
UFH vs LMWH
• LMWH-have therapeutic effect with less side effect.
• LMWH-single daily dose.Prophyllactic LMWH- enoxaparin -40mg,s/c once/day dalteparin-5000u s/c once/dayTherapeutic LMWH-enaxaparin-1mg/kg/12 hr dalteparin-200u/kg once daily.Prophyllactic UFH-5000 u sc every 12 hr.Therapeutic UFH-10,000 u s/c every 12 hr.
Calcium and vitamin-D
The heparinised pregnant patient
• increase her calcium to 600 mg BD
• along with vitamin D to optimise the absorption of calcium
and
• reduce the risk of osteopenia.
Delivery plan
• Elective termination of pregnancy at term.• Caesarean delivery associated with higher rate
of peripartum thrombosis.• Vaginal delivery is preferred. Obs gynecol clin N Am 2007
• Epidural anaesthesia is not recommended in marked drop in the maternal platelet count
Postpartum surveillance• Post vaginal delivery-ambulation as soon as possible.• Post cesarean delivery-pneumatic compression
stocking untill ambulation.• Aspirin low dose –reinitiated.
• Heparin should be restarted post partum at lowest
predelivery dosage –continue for 4-6 week.
• In pt. With thromboembolic events-full anticoagulant -
6 wk.
postpartum surveillance
• Supplemental calcium to be continued as long as pt is
on heparin.
• No evidence indicates adverse effects related to
breastfeeding with low dose aspirin and heparin.
• Breastfeeding is not recommended if high doses of
cytotoxic or immunosuppressive agents are
required(secondary APS)
Consultations and Follow-up
• Once the diagnosis-diagnosis for life long. (inspite of resolution).
• Informed about potential maternal and obstetric problems.
• Consultation with specialists in Maternal-Fetal Medicine
and Rheumatology .
• APS and 1 or more prior thrombotic events, lifelong
anticoagulation with warfarin - to avoid recurrent
thrombosis.
Consultations and Follow-upcont..
• Life style modificationmaintain a normal weight.Increased cholesterol –correction.Avoid tobbaco related product.Lifelong aspirin (low dose)/day-should be
continued.
contraception
• Estrogen containing oral contraceptives should be
avoided in repeated positive aPL.
• Progesterone only pills,barrier method,IUD can be
used.
Other drugs in pregnancy
• Previously prednisolone was used-no benifit as per trial.
• IVIG and HCQ –pt. With failed treatment with heparin.
• Warfarin only after organogenesis is complete.(pauzner et al)
new drugs
Rituximab• Helpful intreating low platelets,anemia small
vessel clots
Eculizumab• In refractory APS-under evaluation.Autologous haematopoietic stem cell transplantation (HSCT)
Future
• More specific ,targeted ,immunomodulatory approach in the future.
• Specific compliment inhibitor for pregnancy complication.
• Long term follow up of children born to APS mother.
Recommendations
• Women with recurrent pregnancy loss before 10 weeks
gestation should be screened for aPL.
• For women with APS with recurrent pregnancy loss, antenatal
administration of heparin combined with low dose aspirin is
recommended throughout pregnancy .
• Treatment should begin as soon as pregnancy is confirmed.
Recommendations
• For women with APS and a history of pre-
eclampsia or FGR, low dose aspirin is
recommended.
• Women with aPL should be considered for
post-partum thromboprophylaxis.
Take home message
Be APS minded• It is a correctable cause of RPL,so one has to be APS
minded in patients presenting with pregnancy morbidity.
Identify the at risk women• To identify the at risk women and screen out patient
who warrant thromboprophylaxis and thus we can prevent potentially life threatening complications of thrombosis.
• thanks
Thank you