A 34-year-old woman has a history of recurrent pregnancy loss, including two previous miscarriages. She likely has antiphospholipid syndrome (APS) due to her family history of blood clots and recurrent pregnancy losses. Further tests are needed to diagnose APS, including testing for antiphospholipid antibodies. If APS is confirmed, management should include low dose aspirin throughout pregnancy and heparin during pregnancy to reduce the risk of further pregnancy loss. Close monitoring is recommended.

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.