Treatment of APS in pregnancy as recommended by contemporary guidelines65 ,67
| APS history . | European League Against Rheumatism . | American College of Rheumatology . |
|---|---|---|
| Obstetric APS without a history of thrombosis | Heparin or LMWH, thromboprophylactic dose,∗ initiated with demonstration of intrauterine viability and continued for 6 weeks postpartum LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE | LMWH, thromboprophylaxis dose,∗ initiated with demonstration of intrauterine viability and continued for 6-12 weeks postpartum LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS |
| Thrombotic APS with or without a history of obstetric APS§ | Heparin or LMWH, therapeutic dose, typically started before conception or by 6 weeks of gestation LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum | LMWH, therapeutic dose, typically started before conception or by 6 weeks of gestation LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum |
| APS with history of adverse pregnancy outcome despite standard treatment | Heparin or LMWH, typically started before conception or by 6 weeks of gestation. Consider increasing dose to therapeutic if prior adverse outcome occurred on thromboprophylactic dose LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE; consider addition of HCQ in patients without SLE Consider prednisolone, 10 mg daily in first trimester Use of IVIG in highly selected patients For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum | LMWH at dose appropriate for thrombosis history‖, LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS IVIG, low-dose prednisone, increased dose of heparin/LMWH, and HCQ have all been suggested as additional or alternative treatments Strong recommendation against adding prednisone For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum |
| APS history . | European League Against Rheumatism . | American College of Rheumatology . |
|---|---|---|
| Obstetric APS without a history of thrombosis | Heparin or LMWH, thromboprophylactic dose,∗ initiated with demonstration of intrauterine viability and continued for 6 weeks postpartum LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE | LMWH, thromboprophylaxis dose,∗ initiated with demonstration of intrauterine viability and continued for 6-12 weeks postpartum LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS |
| Thrombotic APS with or without a history of obstetric APS§ | Heparin or LMWH, therapeutic dose, typically started before conception or by 6 weeks of gestation LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum | LMWH, therapeutic dose, typically started before conception or by 6 weeks of gestation LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum |
| APS with history of adverse pregnancy outcome despite standard treatment | Heparin or LMWH, typically started before conception or by 6 weeks of gestation. Consider increasing dose to therapeutic if prior adverse outcome occurred on thromboprophylactic dose LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE; consider addition of HCQ in patients without SLE Consider prednisolone, 10 mg daily in first trimester Use of IVIG in highly selected patients For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum | LMWH at dose appropriate for thrombosis history‖, LDA beginning before conception or with documentation of pregnancy HCQ† recommended for patients with SLE and conditionally‡ recommended for patients with APS IVIG, low-dose prednisone, increased dose of heparin/LMWH, and HCQ have all been suggested as additional or alternative treatments Strong recommendation against adding prednisone For patients on long-term anticoagulation postpartum, bridge to warfarin postpartum |
HCQ, hydroxychloroquine; IVIG, intravenous immune globulin.
There is no consensus regarding the optimal thromboprophylactic dose of LMWH in APS. For enoxaparin, 0.5 mg per kilogram body weight once daily is reasonable for patients without additional thrombosis risk(s) beyond that of APS. For patients with additional thrombosis risk factor(s), 0.5 mg per kilogram body weight every 12 hours would seem prudent.
The usual dose of HCQ dose is 400 mg per day.
Conditional recommendations generally reflect a lack of data, limited data, or conflicting data that lead to uncertainty.
Patients with APS with a history of thrombosis are commonly managed with long-term, oral anticoagulation.
In patients with obstetric APS without a history of thrombosis, the American College of Rheumatology conditionally recommends against treatment with IVIG or an increased LMWH dose, because these have not been demonstrably helpful in cases of pregnancy loss despite standard therapy with low-dose aspirin and prophylactic heparin or LMWH.