Heparin therapy for pregnant women with lupus anticoagulant or anticardiolipin antibodies

Management of the obstetric antiphospholipid syndrome

“…In all published series maternal-fetal monitoring was optimized by including frequent antena-1034 DERKSEN ET AL tal visits, continuity of the care providers, a liberal admissions policy, a multidisciplinary approach to the management of autoimmune diseases, obstetric ultrasound scans every 2-4 weeks, monthly Doppler velocimetry of the umbilical arteries starting at 16 weeks of gestation, and weekly cardiotocography starting at 24 weeks, with more frequent testing if clinically indicated (30,32,44,49,53,54). Some studies additionally included weekly nonstress testing beginning at 26-30 weeks (44,49).…”

“…In the small retrospective study of heparin treatment by Rosove et al (54), pregnancy outcome was very good, with live birth in 14 of 15 pregnancies (93%) and 1 miscarriage at 12 weeks. Half of the live births occurred before 37 weeks of gestation.…”

“…Many patients in these studies had SLE (77% [53], 36% [54], 32% [52], 13% [55], not specified [51]), previous thrombotic events (56% [55], 41% [52], 30% [53], 29% [54], not specified [51]), or both. All patients had APS according to the 1987 criteria (7), but many did not fulfill the obstetric criteria (7,14), because several studies included primigravidae (accounting for 11% [52], 17% [53], 36% [51], and an unspecified percentage [55] of included women) or included women with 1 or 2 first trimester losses or only successful pregnancies (52)(53)(54). All patients fulfilled the serologic criteria for APS, because all studies apparently used adequate tests for LAC and aCL and included patients with at least medium levels of aCL.…”

“…Branch et al (55) started with a dosage of 15,000 IU of unfractionated heparin per day and increased the dosage to 20,000 IU/day in the second trimester. Rosove et al (54) used unfractionated heparin with a daily dose divided into 2 subcutaneous injections, with dose adjustments to obtain a mid-interval APTT of 1.5-2 times the control value (daily dose 10,000-36,000 IU).…”

“…Lima et al (53) indicated that patients with a history of thrombosis were switched from warfarin to heparin preconception or after a positive pregnancy test, and that patients continued to receive heparin for 6 weeks after delivery or were converted back to warfarin. Rosove et al (54) reported that they discontinued treatment of patients with heparin briefly at the time of delivery and then resumed and continued heparin for variable periods thereafter.…”