Background
Antiphospholipid syndrome is an autoimmune, hypercoagulable state that is caused by
antiphospholipid antibodies. Anticardiolipin antibodies, anti-β2 glycoprotein-I, and
lupus anticoagulant are the main autoantibodies found in antiphospholipid syndrome.
Despite the amassed body of clinical knowledge, the risk of obstetric complications
that are associated with specific antibody profile has not been well-established.
Objective
The purpose of this study was to assess the risk of obstetric complications in women
with primary antiphospholipid syndrome that is associated with specific antibody profile.
Study Design
The Pregnancy In Women With Antiphospholipid Syndrome study is a multicenter, retrospective,
cohort study. Diagnosis and classification of antiphospholipid syndrome were based
on the 2006 International revised criteria. All women included in the study had at
least 1 clinical criteria for antiphospholipid syndrome, were positive for at least
1 antiphospholipid antibody (anticardiolipin antibodies, anti-β2 glycoprotein-I, and/or
lupus anticoagulant), and were treated with low-dose aspirin and prophylactic low
molecular weight heparin from the first trimester. Only singleton pregnancies with
primary antiphospholipid syndrome were included. The primary outcome was live birth, defined as any delivery of a live infant after 22 weeks gestation. The secondary
outcomes were preeclampsia with and without severe features, intrauterine growth restriction,
and stillbirth. We planned to assess the outcomes that are associated with the various
antibody profile (test result for lupus anticoagulant, anticardiolipin antibodies,
and anti-β2 glycoprotein-I).
Results
There were 750 singleton pregnancies with primary antiphospholipid syndrome in the
study cohort: 54 (7.2%) were positive for lupus anticoagulant only; 458 (61.0%) were
positive for anticardiolipin antibodies only; 128 (17.1%) were positive for anti-β2
glycoprotein-I only; 90 (12.0%) were double positive and lupus anticoagulant negative,
and 20 (2.7%) were triple positive. The incidence of live birth in each of these categories
was 79.6%, 56.3%, 47.7%, 43.3%, and 30.0%, respectively. Compared with women with
only 1 antibody positive test results, women with multiple antibody positive results
had a significantly lower live birth rate (40.9% vs 56.6%; adjusted odds ratio, 0.71;
95% confidence interval, 0.51–0.90). Also, they were at increased risk of preeclampsia
without (54.5% vs 34.8%; adjusted odds ratio, 1.56; 95% confidence interval, 1.22–1.95)
and with severe features (22.7% vs 13.8%, adjusted odds ratio, 1.66; 95% confidence
interval, 1.19–2.49), of intrauterine growth restriction (53.6% vs 40.8%; adjusted
odds ratio, 2.31; 95% confidence interval, 1.17–2.61) and of stillbirth (36.4% vs
21.7%; adjusted odds ratio, 2.67; 95% confidence interval, 1.22–2.94). In women with
only 1 positive test result, women with anti-β2 glycoprotein-I positivity present
alone had a significantly lower live birth rate (47.7% vs 56.3% vs 79.6%; P<.01) and a significantly higher incidence of preeclampsia without (47.7% vs 34.1%
vs 11.1%; P<.01) and with severe features (17.2% vs 14.4% vs 0%; P=.02), intrauterine growth restriction (48.4% vs 40.1% vs 25.9%; P<.01), and stillbirth (29.7% vs 21.2% vs 7.4%; P<.01) compared with women with anticardiolipin antibodies and with women with lupus
anticoagulant present alone, respectively. In the group of women with >1 antibody
positivity, triple-positive women had a lower live birth rate (30% vs 43.3%; adjusted
odds ratio,0.69; 95% confidence interval, 0.22–0.91) and a higher incidence of intrauterine
growth restriction (70.0% vs 50.0%; adjusted odds ratio,2.40; 95% confidence interval,
1.15–2.99) compared with double positive and lupus anticoagulant negative women.
Conclusion
In singleton pregnancies with primary antiphospholipid syndrome, anticardiolipin antibody
is the most common sole antiphospholipid antibody present, but anti-β2 glycoprotein-I
is the one associated with the lowest live birth rate and highest incidence of preeclampsia,
intrauterine growth restriction, and stillbirth, compared with the presence of anticardiolipin
antibodies or lupus anticoagulant alone. Women with primary antiphospholipid syndrome
have an increased risk of obstetric complications and lower live birth rate when <1
antiphospholipid antibody is present. Despite therapy with low-dose aspirin and prophylactic
low molecular weight heparin, the chance of a liveborn neonate is only 30% for triple-positive
women.
Key words
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Article Info
Publication History
Published online: January 30, 2017
Accepted:
January 19,
2017
Received in revised form:
January 2,
2017
Received:
November 18,
2016
Footnotes
The authors report no conflict of interest.
Cite this article as: Saccone G, Berghella V, Maruotti GM, et al. Antiphospholipid antibody profile based obstetric outcomes of primary antiphospholipid syndrome: the PREGNANTS study. Am J Obstet Gynecol 2017;216:525.e1-12.
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- ReplyAmerican Journal of Obstetrics & GynecologyVol. 217Issue 6
- PreviewWe thank Dr De Carolis et al for their interest in the PREGNancy in women with ANTiphospholipid Syndrome (PREGNANTS) study.1 PREGNANTS is a multicenter cohort study of women with primary antiphospholipid syndrome (APS) referred to 7 Italian university hospitals. Strict inclusion criteria were used. Only women treated with both low-dose aspirin and prophylactic low-molecular-weight heparin (LMWH) were included. Those who received other therapies, including hydroxychloroquine, were intentionally excluded to provide a homogenous study group.
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- Hydroxychloroquine as additional treatment in pregnant patients with refractory APSAmerican Journal of Obstetrics & GynecologyVol. 217Issue 6
