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Obstetric antiphospholipid syndrome in pregnancy — SCE Rheumatology MCQ

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ModerateSLE and Antiphospholipid SyndromeObstetric antiphospholipid syndrome in pregnancySCE Rheumatology

A 32-year-old woman with systemic lupus erythematosus is reviewed at 5 weeks’ gestation. Her lupus is clinically inactive on hydroxychloroquine. She has previously had three consecutive, otherwise unexplained miscarriages at 6–9 weeks. Lupus anticoagulant was detected before conception on two samples obtained 13 weeks apart, and the recurrent miscarriage service diagnosed obstetric antiphospholipid syndrome. She has never had venous or arterial thrombosis and received no antithrombotic treatment in her previous pregnancies. Which antithrombotic regimen should now be recommended?

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Correct answer: E — Commence low-dose aspirin with prophylactic-dose LMWH now and continue both until at least 34 weeks’ gestation

This is treatment-naive obstetric antiphospholipid syndrome presenting in early pregnancy. The absence of previous thrombosis determines anticoagulant intensity: low-dose aspirin combined with prophylactic, rather than therapeutic, heparin is appropriate. RCOG guidance recommends offering aspirin and heparin from a positive pregnancy test and continuing treatment until at least 34 weeks. Treatment should therefore begin now rather than awaiting demonstration of fetal cardiac activity. A is insufficient because aspirin monotherapy is not the recommended regimen for established APS associated with recurrent miscarriage. B contains the appropriate drugs and heparin intensity but introduces an unnecessary delay during the gestational period in which her previous losses occurred. C uses excessive anticoagulant intensity for a woman without thrombotic APS or failure of standard obstetric APS therapy; therapeutic-dose heparin is appropriate when therapeutic anticoagulation is independently indicated, particularly after APS-related thrombosis, and may be considered in refractory obstetric disease. E starts appropriate treatment but stops heparin too early: APS is also associated with later placental complications, and UK guidance continues treatment beyond the first trimester to at least 34 weeks. Her hydroxychloroquine treatment does not replace the indicated antithrombotic regimen.

Reference: Recurrent Miscarriage (Green-top Guideline No. 17) (19 June 2023) — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/recurrent-miscarriage-green-top-guideline-no-17/ Recurrent Miscarriage: Green-top Guideline No. 17 (19 June 2023) — https://pubmed.ncbi.nlm.nih.gov/37334488/ Managing antiphospholipid syndrome (2019) — https://www.eular.org/document/download/216/e47c6f27-399e-40d5-80d2-b4be8b733861/302