RPL

1. RPL
Case scenario2
Prof. Aboubakr
Elnashar
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

2. A 34-year-old woman
She normally has regular 28-day cycle.
Obs HX:
She is gravida 3 para 0.
Her first pregnancy ended in a complete
miscarriage 2 years ago.
Five months ago she had a missed miscarriage at
9 weeks and required ERPC
3rd pregnancy: missed miscarraige at 7w

3. Family History:
The woman’s mother died from a pulmonary
embolism after her last child.
Her brother also had a deep venous thrombosis at
the age of 29 years.
Her sister has two children, both born preterm
because of severe pre-eclampsia.

4. WHAT IS THE LIKELY UNDERLYING DIAGNOSIS
FOR RPL?

5.  HOW TO DIAGNOSE ANTIPHOSPHOLIPID
SYNDROME?

6. Sydney clinical criteria for APS (2006)Australia.
 An acquired autoimmune disorder characterized by
1. Moderate to high levels of antiphospholipid
antibodies:
LA or aCl or a-ß2GPI &
2. Specific clinical features
arterial or venous thrombosis or
pregnancy morbidity
 At least 1 clinical and 1 laboratory criterion.

7. ABOUBAKR ELNASHAR

8. Non-criteria (clinical and laboratory) obstetric APS.
Diagnosis:
a) Non-criteria clinical manifestations with
international consensus laboratory criteria OR
b) International consensus clinical criteria with
non-criteria laboratory manifestation.
[Arachchillage et al, 2015],
ABOUBAKR ELNASHAR

9.  WHAT FURTHER INVESTIGATION SHOULD BE
PERFORMED?

10.  Antiphospholipid Ab
 must be confirmed by a second positive
anticardiolipin test
 Antinuclear and anti-double-stranded DNA. Ab
{antiphospholipid syndrome is often secondary to
SLE}.

11.  HOW SHOULD THIS PATIENT BE MANAGED?

12. 1. LDA:
•initiated before conception
•discontinued 2-4 w before EDD
•resumed postpartum
•continued for life unless otherwise
•contraindicated.

13. 2. Heparin
Dose:
A. No history of thrombosis: O APS
UFH:
1st T: 5000-10000 U /12 h
2nd and 3rd T: 10000 U/12 hrs
LMWH:
thromboprophylactic doses:
enoxaparin40 mg/d sc. or
dalteparin 5000 U/d sc. or
tinzaparin 4500 U/d sc

14. B. History of thrombosis: T APS
UFH:
/8-12 hrs
{maintain the midinterval heparin levels in the
therapeutic range}.
(Heparin level = anti-factorXa levels.)
Women without a LA in whom APTT is normal
can be observed using APTT.
LMWH
enoxaparin1 mg/kg sc. or
dalteparin 100 U/kg, sc. every 12 h or
enoxaparin 1.5 mg/kg/day sc.or
dalteparin 200 U/kg/day sc.

15. initiated
when pregnancy is confirmed
continued until
Patient initiates spontaneous labor or
the night before any scheduled induction or
operative delivery.
Restarted postpartum at the lowest pre delivery
dosage and continued for 4 ws
T APS:
full anticoagulation should continue for 6 ws
postpartum.