Treatment of antiphospholipid syndrome during pregnancy

• once the diagnosis is confirmed, patients are initially anticoagulated with unfractionated heparin or low molecular weight heparin (LMWH), followed by oral anticoagulation with a vitamin K antagonist (e.g., warfarin), providing there are no contraindications to therapy with these agents (1)
• usually, self-administered low-molecular weight heparin is given if there is a past history of thrombosis or a particularly stormy pregnancy history (1)
  • the use of combined unfractionated heparin and aspirin may reduce pregnancy loss by 54% in patients with antiphospholipid antibody or lupus anticoagulant (2)
• For women with APS with recurrent (≥3) pregnancy loss, antenatal administration of low molecular weight heparin combined with low-dose aspirin is recommended throughout pregnancy. (3) Treatment should begin as soon as pregnancy is confirmed. For women with APS and a history of pre-eclampsia or IUGR, low-dose aspirin is recommended.

Note - direct oral anticoagulants are not recommended for APS. (4) The European Medicines Agency, the UK-based Medicines and Healthcare products Regulatory Agency, and the International Society of Haemostasis and Thrombosis do not recommend these drugs in patients with APS, particularly high-risk patients (i.e., those who test positive for all 3 antiphospholipid tests, have prior arterial thrombosis, small vessel thrombosis or organ involvement, or heart valve disease according to Sydney criteria). This is due to the associated increased rates of recurrent thrombotic events compared with warfarin. (5)

Reference:

1. Tektonidou MG, Andreoli L, Limper M, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis. 2019 Oct;78(10):1296-304.
2. Empson M et al. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Cochrane Database Syst Rev 2005;2:CD002859
3. Ziakas PD, Pavlou M, Voulgarelis M; Heparin treatment in antiphospholipid syndrome with recurrent pregnancy loss: a systematic review and meta-analysis. Obstet Gynecol. 2010 Jun;115(6):1256-62.
4. Khairani CD, Bejjani A, Piazza G, et al. Direct oral anticoagulants vs vitamin K antagonists in patients with antiphospholipid syndromes: meta-analysis of randomized trials. J Am Coll Cardiol. 2023 Jan 3;81(1):16-30.
5. Medicines and Healthcare products Regulatory Agency. Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome. June 2019 [internet publication].