Review Question - QID 104326

This patient most likely has antiphospholipid antibody syndrome given her recurrent miscarriages and history of DVTs and systemic lupus erythematosus. Patients with this syndrome can take aspirin and heparin to reduce the risk of pregnancy loss.

Antiphospholipid antibody syndrome is a prothrombotic autoimmune disorder in which the body develops antibodies against phospholipid-bound proteins. While patients may be asymptomatic, this condition can present with recurrent pregnancy loss as well as both arterial and venous thrombosis. Diagnosis depends on the fulfillment of both clinical and laboratory criteria. The clinical criteria include confirmed venous, arterial, or small vessel thrombosis, or pregnancy complications (such as placental insufficiency, miscarriage, or prematurity). Laboratory diagnosis involves testing for anti-cardiolipin or lupus anticoagulant enzymes. Asymptomatic patients with antiphospholipid syndrome may require no treatment. Patients with a history of DVTs or pulmonary emboli may require anticoagulation. In pregnancy, aspirin and heparin or low molecular weight heparin may improve outcomes and reduce thromboses. Both of these medications are safe in pregnancy in contrast to other medications like warfarin (strictly contraindicated) or the novel-anticoagulants which do not have a proven safety profile in pregnancy.

Incorrect Answers:
Answer 1: Aspirin by itself may improve outcomes in antiphospholipid syndrome and is safe in pregnancy; however, heparin should also be started in this patient given her recurrent pregnancy losses and DVTs.

Answer 3: Aspirin and warfarin is inappropriate. Warfarin is effective as a secondary prevention measure to prevent venous thromboembolic events in patients with antiphospholipid antibody syndrome; however, it is teratogenic and should not be used during pregnancy.

Answer 4: No treatment indicated is inappropriate as this woman has a history of DVTs, pulmonary emboli, and recurrent pregnancy loss and is likely to experience another pregnancy loss without treatment.

Answer 5: Rivaroxaban may be dangerous in pregnancy and its safety and utility in pregnancy and antiphospholipid syndrome has not been verified.

Bullet Summary:
Pregnant patients with a history of DVTs, pulmonary emboli, and recurrent pregnancy loss can be given heparin and aspirin during their pregnancy as anticoagulation.