Paper presented at the East Zone Yuva FOGSI 2012- held at Hotel Hindusthan International, Kolkata on May, 2012

2.  These are a heterogeneous
family of autoantibodies
that bind to negatively
charged phospholipids,
phopholipid binding proteins,
or a combination of the two
 More than 20 aPL antibodies have been described
 Most clinically significant
 Lupus Anticoagulant (LA) and
 Anticardiolipin antibodies (aCA)

3.  Recurrent pregnancy loss
 Intrauterine growth restriction (IUGR)
 Intrauterine fetal death (IUFD)
 Preterm brith
 Pre-eclampsia (early/ late onset)
 Abruptio placentae
 Thrombocytopaenia
 Deep vein thrombosis/ Pulmonary embolism
 Stroke
 Postpartum/ Catastrophic APS

5.  Some aPL positive women have
uncomplicated pregnancy outcomes
without treatment
 Variation in opinion on the rate of
detection of aPL antibodies in women
with adverse pregnancy outcomes
 Paucity of prospective studies on the
natural history of aPL in pregnant women and
identifying the subset of aPL positive mothers
who need medical therapy
 Disagreement regarding clinically relevant
levels, isotypes and specificities of aPL
antibodies
 Whether aPL antibodies other than LA & aCA
are relevant

6. We studied
 The prevalence of aPL antibodies in
selected at-risk obstetric cases
 The significance of these antibodies with
respect to pregnancy outcomes
 Comparison of the results with a cohort
of obstetric cases with past history of
uncomplicated pregnancy outcome
having similar demographic
characteristics

7. MATERIALS AND METHODSMATERIALS AND METHODS

8.  STUDY AREASTUDY AREA
 R G Kar Medical College and Hospital, Kolkata
 Medical College and Hospital, Kolkata
 STUDYSTUDY PERIODPERIOD
3 years (March 2006- February 2009)
 STUDY DESIGNSTUDY DESIGN
Prospective comparative study
 STUDY POPULATIONSTUDY POPULATION
Antenatal mothers who conform to inclusion criteria

9.  STUDY DESIGNSTUDY DESIGN
INCLUSION CRITERIA
I. Study group
120 Antenatal mothers attending OPD
1. Having past H/O-
 Pre-eclampsia
 Eclampsia
 Recurrent abortion
 Intrauterine growth restriction (IUGR)
 Intrauterine Fetal death (IUFD)
 Abruptio placentae
 Without any apparent aetiologyWithout any apparent aetiology
1. Registered into AN Clinic during 1st
trimester

10. II. Control Group
Cohort of 120 Antenatal mothers attending OPD
1. Of comparable age, gravidity, parity, Body Mass Index
(BMI)
2. Having past H/O uncomplicated pregnancy
3. Followed similar registration protocol
EXCLUSION CRITERIA
Presence of known medical disorders which might
adversely affect pregnancy outcome

11.  STUDY OBJECTIVESSTUDY OBJECTIVES
 Primary- Prevalence of aPL antibodies in both groups
 Secondary- Obstetric outcome in those women
 STUDY TOOLSTUDY TOOL
 Anti Cardiolipin antibody (aCA)-
IgG and IgM
by solid phase ELISA
 Lupus Anticoagulant (LA)-
by dilute Russle Viper venom test (dRVVT)
 Single referral laboratory tests were used

15.  Analysis of dataAnalysis of data
 Visually double checked by an
independent second
investigator
 Analysed using MedCalc
(version 10.0.0.0) statistical
software (
http://www.medcalc.be)
 P value less than 0.05 was
considered as statistically
significant

16. RESULTSRESULTS

17. DEMOGRAPHIC PROFILEDEMOGRAPHIC PROFILE
Characteristics Study group
(n = 112)
(mean ± SD)
Control group
(n = 112)
(mean ± SD)
p value
Age (years) 26.4 ± 2.28 25.8 ± 2.42 0.0608
Gravidity 2.90 ± 0.52 2.86 ± 0.24 0.4708
Parity 1.48 ± 0.34 1.76 ± 0.22 0.0001
BMI (Kg/M2
) 24.2 ± 1.8 23.8 ± 2.06 0.1278
Gestational age at
sampling (weeks)
15.08 ± 0.31 15.04 ± 0.34 0.3646

19. DISTRIBUTION OF CASES ACCORDING TODISTRIBUTION OF CASES ACCORDING TO
PAST OBSTETRICS IN STUDY GROUPPAST OBSTETRICS IN STUDY GROUP

20. PREVALENCE OF aPL ANTIBODIES INPREVALENCE OF aPL ANTIBODIES IN
STUDY AND CONTROL GROUPSTUDY AND CONTROL GROUP
Study group
(n = 112)
Control group
(n = 112)
Characteristics n (%) n (%) p value
LA activity 15 13.39 2 1.89 0.0036
IgG aCA >10 GPL units 17 15.18 3 2.83 0.0035
IgM aCA >10 MPL units 21 18.75 4 3.77 0.0011
Both IgG aCA > 10 and
IgM aCA >10
12 10.71 0 0 0.0015
Both LA and aCA +ve 11 9.82 2 1.89 0.0289
Total No. of aPL +ve
cases
41 36.61 9 8.49 <0.0001

22. INCIDENCE OFINCIDENCE OF
ANTI-PHOSPHOLIPID ANTIBODIESANTI-PHOSPHOLIPID ANTIBODIES
ACCORDING TOACCORDING TO
PAST OBSTETRIC HISTORYPAST OBSTETRIC HISTORY

23. aPL Positive
cases
Character
istics
Cases
(n)
Total
aPL
+ve
(%) LA
+ve
Only
IgG aCA
>10 GPL
Only IgM
aCA > 10
MPL
Both IgG &
IgM aCA
>10 units
Study
Group
Pre-
eclampsia
14 4 28.57 2 2
Eclampsia 10 1 10 1
Recurrent
abortion
32 15 46.87 6 2 3 4
IUGR 24 10 41.66 3 2 3 2
IUFD 22 8 36.36 3 2 3
Abruptio
placentae
10 3 30 1 1 1
TOTAL 112 41 15 5 9 12
Control Group 106 9 8.49 2 3 4 0

25. In SummaryIn Summary
aPL POSITIVEaPL POSITIVE aPL NEGATIVEaPL NEGATIVE
STUDY group 41 97
CONTROL Group 9 71
Total 50 168
Dropped out 2 14
Net Total 48 154

26. INCIDENCE OF OBSTETRICINCIDENCE OF OBSTETRIC
COMPLICATIONSCOMPLICATIONS

27. ObstetricObstetric
ComplicationsComplications
aPL Positive
mothers (n= 48)
aPL Negative
mothers (n= 154)
n (%) n (%) p value
Early
Abortion 12 25 11 07.14 0.0017
Pre-eclampsia <28 wk 7 14.58 2 01.3 0.0005
IUFD <28 wk 3 06.25 0 0 0.0146
Late
Pre-eclampsia 12 25 9 05.84 0.0004
Eclampsia 1 02.08 0 0 0.5382
IUGR 13 27.08 14 09.09 0.0031
Oligohydramnios 16 33.33 10 06.49 <0.0001
Abruptio placentae 9 18.75 6 03.9 0.0019
IUFD >28 wk 2 04.17 2 01.3 0.5104

28. OBSTETRIC COMPLICATIONSOBSTETRIC COMPLICATIONS

29. LIVE BIRTH RATESLIVE BIRTH RATES
aPL POSITIVE aPL NEGATIVE
Total cases 48 154
Live
birth
n 31 141
(%)
64.58 91.56

30. OUTCOMES OF LIVE BIRTHOUTCOMES OF LIVE BIRTH
aPL Positive
mothers
(n = 31)
aPL negative
mothers
(n = 141)
Characteristics n (%) n (%) p value 95% CI
No. of Vaginal
deliveries (VD)
17 54.84 120 85.11 0.0004 12.88- 48.04
No. of Caesarean
Section (SC)
14 45.16 21 14.89 0.0004 12.88-48.04
Gestational age at
VD (weeks)
(Mean ± SD)
35.9 ± 0.8 37.4 ± 0.8 <0.0001 1.19-1.81
Gestational age at
CS (weeks)
(Mean ± SD)
35.4 ± 0.5 37.8 ± 0.4 <0.0001 2.24-2.56
Early neonatal
death
3 9.68 3 2.13 0.1252 0.09-22.84

31. OUTCOMES OF LIVE BIRTHOUTCOMES OF LIVE BIRTH

32. DIFFERENCES IN WEIGHTDIFFERENCES IN WEIGHT
Placental
weight
Birth Weight
aPL
Negative
(Mean ±
SD)
488.7 ± 22.3 3024.3 ± 229.5
aPL
positive
(Mean ±
SD)
424.2 ± 9.5 2523.6 ± 216.3
p value <0.0001 <0.0001
95% CI 56.42- 72.58 411.72- 589.68

33. DISCUSSIONDISCUSSION

34. There is high prevalence of aPL
antibodies in complicated
pregnancy
Both lupus anticoagulant and
anticardiolipin antibodies
significantly affect pregnancy
outcome

35. In our study outcome was
worse in aPL positive mothers
despite heparin treatment
 Commencement of treatment after
repeat test result for aPL positivity,
which was not before 20-22 weeks’
gestation
 Poor patient compliance
(OPD based treatment)

36. CONCLUSIONCONCLUSION

37. Following women should be screened
for antiphospholipid antibodies-
 Whose previous pregnancies were
complicated by
Recurrent abortion
Pre-eclampsia (particularly early
onset)
Eclampsia
IUGR
IUFD
Abruption placentae
 With no apparent aetiology

38. THANK YOUTHANK YOU