pregnancy treatment and labour management in antiphospholipid syndrome
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Pregnancy Treatment
and Labour Management
in Antiphospholipid
Syndrome
NUS PURN W N PUTR 0861050031
MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY
FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA
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PRELUDE
Antiphospholipid syndrome (APS) is a syste
autoimmune disease characterized by the
presence of arterial or venous thrombosi
pregnancy morbidity and the presence of a
persistent increase in serum titer positive
antiphospholipid antibodies (aPL).
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PRELUDE
In the United States noted that the
prevalence of APS in the general populati
of the country reached 2-4%.
In Singapore, 134 APS patients treated dur
2004 to 2005, 43.3% had a positive outcomof LA, and 66.4% of aCL.
In Indonesia, there is no research data
regarding the prevalence of women diagno
with antiphospholipid syndrome (APS).
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PRELUDE
Current first-line treatment for APS is lo
dose aspirin(LDA) plus unfractioned hepar
with low molecular weight heparin(LMWH
However, in about 20% of cases of APS, th
expected final destination, include live bircan not be achieved.
Without treatment, the rate of miscarriag
subsequent pregnancies in these condition
90%.
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PRELUDE
The purpose of this paper is to
investigate the pregnancy treatment
and management of labour in
antiphospholipid syndrome, so as to
reduce the morbidity and mortality ofboth mother and fetus by selecting
the appropriate treatment.
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TR
MEN
NPHOSHOLPD
SNOME
Non-medically
Clinical andLaboratorymonitoring duringantenatal care
Management of la
MedicallyAnti coagulant
Anti aggregation
Steroid
HCQ
IVIG
Others
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Follow-upbefore or during pregnancy
after delivery, including fetal viability
confirmed by transvaginal ultrasound
Serial ultrasound examinations to mon
fetal growth and amniotic fluid volum
velocity of blood velocity in the uteri
umbilical arteries were also assessed.
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The examination of platelets to monitor the
occurrence of thrombocytopenia should be
routinely.
Primary assessment is the level of live-bornand the secondary assessment is excessive b
thrombocytopenia, IUGR, pre-eclampsia, IUFD
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Timing of heparin can be initiated in the early
stages of pregnancy, without waiting for th
results of an ultrasound examination.
In another study from the Laboratory ofHormonology, Maternity, and Haemostatis U
Geneva University Hospitals, Switzerland, h
administration begins when the heart starts
activity seen on ultrasound (about 7-8 week
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Aspirin given in APS patients at a dose
of 75 mg daily when the gestational
sac (gestational sac)seen on
ultrasound around 6 weeks gestation
until the end of 35 weeks.
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Large doses of corticosteroids (0.5-1 mg /
day) was associated with an increased risk o
gestational diabetes, infections, hypertens
to pregnancy and preterm delivery. Side effects did not seem to occur when th
of prednisone is used in low doses (10-20 mg
day).
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Hydroxychloroquine (HCQ) annexin A5
protect from disruption by antiphosph
antibodies.
However, clinical evidence is still lim
the successful outcome of them in th
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The effectiveness of rituximab in
combination with chemotherapy inclu
plasmapahresis, has been widely used i
treatment of B cell malignancies, the
clinical manifestations of APS or just
reduce the levels of aPL.
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Department of Obstetrics and Gynecology,
University of Utah Health Sciences Center an
Intermountain Healthcare, USA, said that in th
handling of labor in patients with antiphosph
syndrome, obstetric patients depending on th
of the pregnancy.
Indications for cesarean delivery is poor obs
history, IUGR, pre-eclampsia, failure in the pro
of labor, and breech presentation.
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DISCUSSION
Department of Obstetrics and Gynecology in the Uof Sheffield, UK, explained that Enoxaparin is used
of 20 mg subcutaneously produces 80% live birth
In line with the above result, the Department of In
Medicine, Niguarda Hospital, Milan, Italy, reported
results of a study involving 27 patients APS. The u
subcutaneous heparin at a dose of 5000 IU twice arecommended in this case, as well as oral administ
100 mg aspirin.
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DISCUSSION
Of the 32 pregnancies studied 84.4%
managed to deliver the baby alive and
15.6% had a miscarriage.
This suggests that combination thera
produces slightly better results.
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DISCUSSION
Another study from the Department ofObstetrics and Gynecologic, Academic Me
Center, University of Amsterdam,
Netherlands, involving 364 APS patients w
subsequently received treatment with 80 m
aspirin combined with subcutaneous nadro(at a dose of 2,850 IU, started immediately a
the diagnosis of pregnancy is established)
80 mg aspirin alone, or placebo.
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DISCUSSION
The results also support from previous studcombination therapy better than monotherap
reported by the Department of Obstetrics an
gynaecologic, Liverpool Women's Hospital, U
study involving 176 patients APS.
When analyzed, 53/67 (79%) live-born infants
women who had received aspirin and heparin,
compared with 64/104 (62%) of women with A
who received aspirin alone.
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DISCUSSION
In line with the research before, the study othe Laboratory of Hormonology, Maternity
Haemostatis Unit, Geneva University Hospita
Switzerland, reported the APS patients with
anti-thrombotic therapy (aspirin 75 mg and 4
Enoxaparin inj.).
Of the 60 patients, 56 patients (93%) had a l
birth.
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DISCUSSION
Another study from the Department ofObstetrics and Gynecology, University of
Health Sciences Center and Intermountain
Healthcare, USA, APS involving 42 patient
treated with UFH and aspirin.
In this study, the live birth rate reached 85
in the treatment, and in previously untreat
pregnancies, only reached 4.6%.
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DISCUSSION
Another study by the Departmentof Obstetrics aGynecology, University of Chicago, USA, reporte
therapy with IVIG, of the 22 women in the IVIG gro
only 10 women (45%) who had a live birth at term.
In contrast to these findings, other studies of
the Operative Unit of Gynecology, University of R
Italy,which did HIVIg therapy in 60 patients with th
HIVIg APS (intact immunoglobulin type 20 g daily f
days, total dose 100 g), the live birth rate was 73.
(44 / 60).
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DISCUSSION
Maternal and Fetal Research Unit, King'sCollege London, UK, in the study, 18 wome
with antiphospholipid antibodies who have
recurrent miscarriages therapy is given
prednisolone (10 mg). before low-dose
prednisolone given as treatment, 4 of the pregnancies have resulted in live births (4
Among the 23 pregnancies that comes with
prednisolone, 9 women had 14 live births (6
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DISCUSSION
The European Registry on Obstetricantiphospholipid syndrome (Europas)repo
194 patients with APS have done therapy w
low molecular weight heparin (LMWH), wit
dose prophylaxis, low-dose aspirin combin
well (LDA) and prednisone.
Overall, produce live births obtained in
174/194 (89.69%).
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DISCUSSION
In another study, Department of Gynecology andObstetrics, New York University School of Medic
New York, USA, APS reported on 87 patients trea
with prednisone and aspirin, live birth rate was 83
(73/87) and the rate of miscarriage fetus reache
16.09% (14/87).
Of the 42 patients treated with prednisone and as
plus LMWH and IVIG, live birth rate was 97.62% (4
and fetal miscarriage rate was 2.38% (1/42).
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DISCUSSION
From these studies, therapy in APS patient
with a combination of aspirin, LMWH,prednisone, and IVIG, resulting in the live
birth rate is very high compared with
monotherapy or combination therapy to
another, reaching 97.62%.
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DISCUSSION
But according to the author, IVIG should n
included in the combination of the above duthe relatively high cost and the research a
their effectiveness is still small and
controversy.
By simply using a combination of aspirin, LM
and prednisone was live birth rate can reac
89.69% based research that has been previ
explained above.
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DISCUSSION
Department of Obstetrics and Gynecolog
University of Utah Health Sciences CenterIntermountain Healthcare, USA, reported t
study of labour management in patients wit
A total of 7 (17.5%) of 40 patients in the st
through elective Caesarean section and 3
of 40 patients by emergency Caesarean sec
the remaining 75% using a vaginal delivery.
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DISCUSSION
This is in line with another study of the Department of
Obstetrics and Gynaecology, King's College, St ThomHospital, London, UK, reported the study, from 39 APS
patients, 12 through childbirth by caesarean section
and the rest are normal vaginal birth (69.2 %).
In contrast to the two studies above, Laboratory of
Hormonology, Maternitym and Haemostatis Unit, Gene
University Hospitals, Switzerland, reported that in 56
with APS syndrome, 49 childbirth (87.5%) by caesarean
due to obstetric causes patients. The remaining 7 patie
(12.5%) by vaginal delivery.
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CONCLUSION
1. Best management in patients with antiphospholipid sya combination of LDA (dose 75 mg, once daily beginnin
conception and continuing through 36 weeks of gest
plus LMWH (dose of 5000 IU or 40 mg once daily star
cardiac activity began to look at the ultrasound ( ab
weeks) to gestational age 37 weeks) and prednisolon
dose, starting from a positive pregnancy test until 14gestation), which will reach 89.69% live birth rate.
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CONCLUSION
2. Handling of labor in patients withantiphospholipid syndrome still
prioritizing vaginal delivery for live-birth
that can reached 75%. It is actually not
accompanied with poor obstetric
morbidity.
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Thank YouNusa Purnawan Putra 0861050031MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY
FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA
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