Investigation and management of antiphospholipid syndrome

Most of this guideline is aimed at specialists. However it is a useful overview for us. I am summarising the things that we need to be aware of.

Antiphospholipid syndrome (APS) can be secondary (eg to SLE or Rheumatoid Arthritis) or primary. Diagnosis isn’t based on rigid criteria, but generally a patient must have had either a thromboembolic event (venous, arterial or microvascular) or an adverse pregnancy outcome (recurrent miscarriage, pre-eclampsia or placental insufficiency). They must also have positive antibody tests (lupus, anticardiolipin or anti-b2-glycoprotein I).

Who should be investigated?

  • Unprovoked promixal DVT or PE. Leave at least 1/52 post anticoagulation.
  • CVA (ischaemic)  if under age 50.
  • Miscarriage – if ≥ 3 (normally done by referral to recurrent miscarriage clinic).

What treatment is required for APS?

  • DVT / PE – lifelong anticoagulation
  • CVA < 50, consider warfarin given their increased risk (though the evidence base for this is small).
  • Pregnancy . If they’ve had ≥ 3 previous miscarriages – give heparin and aspirin as soon as pregnancy diagnosed (ie from booking – so we need to start it).
  • Eclampsia or Fetal Growth Restriction – if they have a history of this, use aspirin throughout pregnancy.
  • Post-partum – consider heparin prophylaxis

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