Antiphospholipid syndrome (APS) is an autoimmune disorder that significantly impacts women's reproductive health, being present in approximately 15% of women with recurrent miscarriage. APS is characterised by the presence of lupus anticoagulant (LA) or anticardiolipin (aCL) antibodies. The presence of a history of venous thromboembolism (VTE) in a patient with recurrent miscarriage strongly suggests APS.

Clinical Features

  • Venous or Arterial Thrombosis:
    • Presenting with history of deep vein thrombosis (DVT), pulmonary embolism, or stroke. 
  • Pregnancy Morbidity:
    • Recurrent Miscarriage: Women with APS are at higher risk of repeated pregnancy loss, particularly in the first trimester.
    • Premature Birth: APS can lead to premature delivery, often due to complications such as pre-eclampsia or eclampsia, which are linked to the syndrome.
  • Antibodies:
    • Lupus Anticoagulant (LA)
    • Anticardiolipin (aCL) Antibodies
    • Anti-β2-glycoprotein I Antibodies

Management

Management focuses on preventing thrombotic events and managing pregnancy-related complications.

  • Anticoagulation: Long-term anticoagulation with warfarin is the mainstay of treatment for patients with a history of thrombosis.
    • The target INR is usually between 2.0 and 3.0, but it may be higher for recurrent events.
  • Antiplatelet Therapy: Low-dose aspirin is often considered, particularly in patients without a history of thrombosis but with positive antibodies, or in combination with anticoagulation for added protection.
  • Pregnancy Management: During pregnancy, women with APS are typically managed with low molecular weight heparin (LMWH) and low-dose aspirin to reduce the risk of miscarriage and other complications such as pre-eclampsia.
    • Warfarin must be avoided due to teratogenicity.