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Vol. 7. Núm. 2.
Páginas 59-69 (junio 2006)
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Vol. 7. Núm. 2.
Páginas 59-69 (junio 2006)
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Tratamiento del síndrome antifosfolipídico en el embarazo
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53104
Irama Villar, Guillermo Ruiz-Irastorza
Servicio de Medicina Interna. Hospital de Cruces. Universidad del País Vasco. Barakaldo. Bizkaia. España
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Resumen

El síndrome antifosfolipídico (SAF) es una reconocida causa de complicaciones en el embarazo, como la trombosis materna, la preeclampsia y la mortalidad embriofetal. El tratamiento de las mujeres embarazadas con SAF exige un abordaje multidisciplinario médico-obstétrico, así como intervención terapéutica basada en la combinación de ácido acetilsalicílico y heparina. Si bien las pautas concretas son discutibles por las importantes limitaciones de los estudios existentes, hay cierto grado de consenso en la recomendación del tratamiento combinado en mujeres con trombosis y/o muertes fetales previas. Las pacientes con historia exclusiva de abortos tempranos son el grupo en el que más se debate sobre la actitud a seguir, si bien el ácido acetilsalicílico en monoterapia sigue siendo una opción. En cualquiera de las situaciones, es fundamental una correcta tromboprofilaxis periparto en todas las mujeres con anticuerpos antifosfolipídicos.

Palabras clave:
Síndrome antifosfolipídico
Gestación
Aborto
Abstract

The antiphospholipid syndrome (APS) is a well known cause of pregnancy complications, including maternal thrombosis and preeclampsia as well as embryofetal losses. A multidisciplinary, medical-obstetric approach is of great importance in the clinical management of pregnant women with APS. Therapeutic interventions are based on the combination acilsalycilic acid-heparin. Although the specific combinations in different situations are still a matter of debate – due to important limitations of the available studies–, combined treatment with both drugs is usually recommended in women with previous thrombosis and/or fetal death. Aspirin alone is still a reasonable option for women with early losses, although controversy is particularly important in this group. In any situation, an adequate thromboprophylaxis in the peripartum period is warranted.

Key words:
Antiphospholipid Syndrome
Pregnancy
Miscarriage
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Bibliografía
[1.]
D.W. Branch, M.A. Khamashta.
Antiphospholipid syndrome: obstetric diagnosis, management and controversies.
Obstet Gynecol, 101 (2003), pp. 1333-1344
[2.]
A.E. Gharavi, S.S. Pierangeli, R.A. Levy, et al.
Mechanisms of pregnancy loss in antiphospholipid syndrome.
Clin Obstet Gynecol, 44 (2001), pp. 11-19
[3.]
G. Girardi, P. Redecha, J.E. Salmon.
Heparin prevents antiphospholid antibody-induced fetal loss by inhibiting complement activation.
Nature Med, 10 (2004), pp. 1222-1226
[4.]
S.S. Pierangeli, M. Vega-Ostertag, X. Liu, et al.
An anti C5 monoclonal antibody reverses antiphospholipid-induced thrombosis [abstract].
Arthritis Rheum, 50 (2004), pp. S639-S640
[5.]
G. Ruiz-Irastorza, M.A. Khamashta.
Lupus eritematoso sistémico, síndrome antifosfolípido y embarazo.
Semin Fund Esp Reumatol, (2000), pp. 1332-1341
[6.]
M.R. Toglia, J.G. Weg.
Venous thromboembolism during pregnancy.
N Engl J Med, 355 (1996), pp. 108-114
[7.]
T. Godfrey, D. D’Cruz.
Antiphospholipid syndrome: general features.
Hughes’ syndrome, pp. 8-19
[8.]
R. Cervera, J.C. Piette, J. Font, et al.
Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients.
Arthritis Rheum, 46 (2002), pp. 1019-1027
[9.]
M.J. Cuadrado, L.L.F. Mendoza, M.A. Khamashta, et al.
Maternal and fetal outcome in antiphospholipid syndrome pregnancies with a history of previous cerebral ischemia.
Arthritis Rheum, 42 (1999), pp. S265
[10.]
D.W. Branch, R.M. Silver, J.L. Blackwell, et al.
Outcome of treated pregnancies in women with antiphospholipid syndrome: an update of the UTA experience.
Obstet Gynecol, 80 (1992), pp. 614-620
[11.]
F. Lima, M.A. Khamashta, N.M. Buchanan, et al.
A study of sixty pregnancies in patients with the antiphospholipid syndrome.
Clin Exp Rheumatol, 14 (1996), pp. 131-136
[12.]
R. Pauzner, M. Dulitzki, P. Langevitz, et al.
Low molecular weight heparin and warfarin the treatment of patients with antiphospholipid syndrome during pregnancy.
Thromb Haemost, 86 (2001), pp. 1379-1384
[13.]
M.D. Lockshin, M.L. Druzin, T. Qamar.
Prednisone does not prevent recurrent fetal death in women with antiphospholipid antibody.
Am J Obstet Gynecol, 160 (1989), pp. 439-443
[14.]
D.L.T. Huong, B. Wechsler, O. Bletry, et al.
A study of 75 pregnanciesin patients with antiphospholipid syndrome.
J Rheumatol, 28 (2001), pp. 2025-2030
[15.]
S. Stone, M.A. Khamashta, L. Poston.
Placentation, antiphospholipid syndrome and pregnancy outcome.
Lupus, 10 (2001), pp. 67-74
[16.]
D.W. Branch, T.F. Porter, L. Rittenhouse, et al.
Antiphospholipid antibodies in women at risk for pre-eclampsia.
Am J Obstet Gynecol, 184 (2001), pp. 825-832
[17.]
K. Duckitt, D. Harrington.
Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies.
[18.]
G.A. Dekker, J.I. De Vries, P.M. Doelitzsch, et al.
Underlying disorders associated with severe early-onset pre-eclampsia.
Am J Obstet Gynecol, 173 (1995), pp. 1042-1048
[19.]
M. Petri.
Hopkins lupus pregnancy center: 1987 to 1996.
Rheum Dis Clin North Am, 23 (1997), pp. 1-13
[20.]
M.H. Orstein, J.H. Rand.
An association between refractory HELLP syndrome an antiphospholipid antibodies during pregnancy: a report of 2 cases.
J Rheumatol, 21 (1994), pp. 1360-1364
[21.]
N. Galie, A. Manes, K.V. Farahani, et al.
Pulmonary arterial hypertension associated to connective tissue diseases.
Lupus, 14 (2005), pp. 713-717
[22.]
M. Lupton, E. Oteng-Ntim, G. Ayida, et al.
Cardiac disease in pregnancy.
Curr Opin Obstet Gynecol, 14 (2002), pp. 137-143
[23.]
M. Humbert, O. Sitbon, G. Simonneau.
Treatment of pulmonary arterial hypertension.
N Engl J Med, 351 (2004), pp. 1425-1436
[24.]
R.H. Derksen, M.A. Khamashta, D.W. Branch.
Management of the obstetric antiphospholipid syndrome.
Arthritis Rheum, 50 (2004), pp. 1028-1039
[25.]
G. Ruiz-Irastorza, M.A. Khamashta, C. Nelson-Piercy, et al.
Effects of lupus and antiphospholipid syndrome on pregnancy.
Yearbook of Obstetrics and Gynaecology, 10 (2002), pp. 105-119
[26.]
S. Loizou, M.A. Byron, H.J. Englert, et al.
Association of quantitative anticardiolipin antibody levels with fetal loss and time of loss in systemic lupus erythematosus.
Q J Med, 68 (1988), pp. 525-531
[27.]
B.T. Oshiro, R.M. Silver, J.R. Scott, et al.
Antiphospholipid antibodies and fetal death.
Obstet Gynecol, 87 (1996), pp. 489-493
[28.]
R.C.W. Wong.
Consensus guidelines for anticardiolipin antibody testing.
Thromb Res, 114 (2004), pp. 559-571
[29.]
R.H.W.M. Derksen, P.G. De Groot.
Tests for lupus anticoagulante revisited.
Throm Res, 114 (2004), pp. 521-526
[30.]
M.D. Lockshin.
Which patients with antiphospholipid antibody should be treated and how?.
Rheum Dis Clin North Am, 19 (1993), pp. 235-247
[31.]
S. Welsch, D.W. Branch.
Antiphospholipid syndrome in pregnancy: obstetric concerns and treatment.
Rheum Dis Clin North Am, 23 (1997), pp. 71-84
[32.]
R.M. Silver, T.F. Porter, I. Van Leeuween, et al.
Anticardiolipin antibodies: clinical consequences of “low titers”.
Obstet Gynecol, 87 (1996), pp. 494-500
[33.]
A. Lynch, R. Silver, W. Emlen, et al.
Antiphospholipid antibodies in healthy pregnant women.
Rheum Dis Clin North Am, 23 (1997), pp. 55-70
[34.]
M. Petri.
Diagnosis of antiphospholipid antibodies.
Rheum Dis Clin North Am, 20 (1994), pp. 443-469
[35.]
R.H.W.M. Derksen, H.J. Out, L. Blokzijl, et al.
Detection of the lupus anticoagulant in pregnancy.
Clin Exp Rheumatol, 10 (1992), pp. 323-324
[36.]
D.W. Branch, J.R. Scott, N.K. Kochenour, et al.
Obstetric complications associated with the lupus anticoagulant.
N Engl J Med, 313 (1985), pp. 1322-1326
[37.]
L.H. Silveira, C.L. Hubble, L.J. Jara, et al.
Prevention of anticardiolipin antibody-related pregnancy losses with prednisone and aspirin.
Am J Med, 93 (1992), pp. 403-411
[38.]
G. Ruiz-Irastorza, M.J. Cuadrado, M.A. Khamashta.
Enfermedades autoinmunes sistémicas durante el embarazo: una aproximación práctica.
Med Clin (Barc), 111 (1998), pp. 785-797
[39.]
R.K. Silver, S.N. MacGregor, J.S. Sholl, et al.
Comparative trial of prednisone plus aspirin versus aspirin alone in the treatment of anticardiolipin antibody-positive obstetric patients.
Am J Obstet Gynecol, 169 (1993), pp. 1411-1417
[40.]
F.S. Cowchock, E.A. Reece, D. Balaban, et al.
Repeated fetal losses associated with antiphospholipid antibodies: a collaborative randomized trial comparing prednisone with lowdose heparin.
Am J Obstet Gynecol, 166 (1992), pp. 1318-1323
[41.]
G. Ruiz-Irastorza, M.A. Khamashta, G.R.V. Hughes.
Treatment of pregnancy loss in Hughes’ syndrome: a critical update.
Autoimmun Rev, 1 (2002), pp. 298-304
[42.]
G. Ruiz-Irastorza, M.A. Khamashta, G.R.V. Hughes.
Antiaggregant and anticoagulant therapy in systemic lupus erythematosus and Hughes’ syndrome.
Lupus, 10 (2001), pp. 241-245
[43.]
S. Bates, I.A. Greer, J. Hirsh, et al.
Use of antithrombotic agents during pregnancy. The seventh ACCP conference on antithrombotic and thrombolytic therapy.
Chest, 126 (2004), pp. S627-S644
[44.]
R. Pauzner, M. Dulitzki, P. Lanevitz, et al.
Low molecular weight heparin and warfarin in the treatment of patients with antiphospholipid syndrome during pregnancy.
Thromb Haemost, 86 (2001), pp. 1379-1384
[45.]
G. Ruiz-Irastorza, M.A. Khamashta, G.R. Hughes.
Systemic lupus erythematosus and antiphospholipid syndrome during pregnancy: maternal and fetal complications and their management.
Isr Med Assoc J, 2 (2000), pp. 462-469
[46.]
G. Ruiz-Irastorza, M.A. Khamashta.
Management of thrombosis in antiphospholipid syndrome and systemic lupus erythematosus in pregnancy.
Ann N Y Acad Sci, 1051 (2005), pp. 606-612
[47.]
C. Patrono, B. Coller, J.E. Dalen, et al.
Platelet-active drugs: the relationships among dose, effectiveness and side-effects.
Chest, 114 (1998), pp. S470-S488
[48.]
J.I. Weitz.
Low-molecular-weight heparins.
N Engl J Med, 337 (1997), pp. 688-698
[49.]
D. Fitzmaurice, F.D. Hobbs.
Thromboembolism.
Clinical Evidence, 3 (2000), pp. 135-142
[50.]
M. Natajaran.
Unstable angina.
Clinical Evidence, 3 (2000), pp. 143-154
[51.]
A. Tincani, W. Branch, R.A. Levy, et al.
Treatment of pregnant patients with antiphospholipid syndrome.
Lupus, 12 (2003), pp. 524-529
[52.]
R. Rai, H. Cohen, M. Dave, et al.
Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies).
BMJ, 314 (1997), pp. 253-257
[53.]
R.G. Farquharson, S. Quenby, M. Greaves.
Antiphospholipid syndrome in pregnancy: a randomized, controlled trial of treatment.
Obstet Gynecol, 100 (2002), pp. 408-413
[54.]
W.H. Kutteh.
Antiphospholipid antibody-associated recurrent pregnancy loss: treatment with heparin and low-dose aspirin is superior to low-dose aspirin alone.
Am J Obstet Gynecol, 174 (1996), pp. 1584-1589
[55.]
F. Carmona, J. Font, M. Azulay, et al.
Risk factors associated with fetal losses in treated antiphospholipid syndrome pregnancies: a multivariate analysis.
Am J Reprod Immunol, 46 (2001), pp. 274-279
[56.]
R. Kaaja, H. Julkunen, P. Ämmälä, et al.
Intravenous immunoglobulin treatment of pregnant patients with recurrent pregnancy losses associated with antiphospholipid antibodies.
Acta Obstet Gynecol Scand, 72 (1993), pp. 63-66
[57.]
J. Arnout, B. Spitz, C. Wittevrongel, et al.
High-dose intravenous immunoglobulin treatment of a pregnant patient with an antiphospholipid syndrome: immunological changes associated with a successful outcome.
Thromb Haemost, 71 (1994), pp. 741-747
[58.]
J.A. Spinnato, A.L. Clark, S.S. Pierangeli, et al.
Intravenous immunoglobulin therapy for the antiphospholipid syndrome in pregnancy.
Am J Obstet Gynecol, 172 (1995), pp. 690-694
[59.]
D.W. Branch, A.M. Peaceman, M. Druzin, et al.
A multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy.
Am J Obstet Gynecol, 182 (2000), pp. 122-127
[60.]
G. Triolo, A. Ferrante, F. Ciccia, et al.
Randomized study of subcutaneous low molecular weight heparin plus aspirin versus intravenous immunoglobulin in the tratment of recurrent fetal loss associated with antiphospholipid antibodies.
Arthritis Rheum, 48 (2003), pp. 728-731
[61.]
A.T. Papageorghiou, N. Roberts.
Uterine artery Doppler screening for adverse pregnancy outcome.
Curr Opin Obstet Gynecol, 17 (2005), pp. 584-590
[62.]
A. Caruso, S. De Carolis, S. Ferrazzani, et al.
Pregnancy outcome in relation to uterine artery flow velocity waveforms and clinical characteristics in women with antiphospholipid syndrome.
Obstet Gynecol, 82 (1993), pp. 970-977
[63.]
E. Guzman, H. Schulman, L. Bracero, et al.
Uterine-umbilical artery doppler velocimetry in pregnant women with systemic lupus erythematosus.
J Ultrasound Med, 11 (1992), pp. 275-281
[64.]
S. Kerslake, K.E. Morton, E. Versi, et al.
Early doppler studies in lupus pregnancy.
Am J Reprod Immunol, 28 (1992), pp. 172-175
[65.]
J.S. Levine, D.W. Branch, J. Rauch.
The antiphospholipid syndrome.
N Engl J Med, 346 (2002), pp. 752-763
[66.]
M.A. Khamashta, M.J. Cuadrado, F. Mujic, et al.
The management of thrombosis in the antiphospholipid-antibody syndrome.
N Engl J Med, 332 (1995), pp. 993-997
[67.]
M.H. Rosove, P.M.C. Brewer.
Antiphospholipid thrombosis: clinical course after the first thrombotic event in 70 patients.
Ann Intern Med, 117 (1992), pp. 303-308
[68.]
S. Schulman, E. Svenungsson, S. Granqvist, And the Duration of Anticoagulation Study Group.
Anticardiolipin antibodies predict early recurrence in thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy.
Am J Med, 104 (1998), pp. 332-338
[69.]
C. Kearon, M. Gent, J. Hirsh, et al.
A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism.
N Engl J Med, 340 (1999), pp. 901-907
[70.]
R.G. Wetzl.
Anestesiological aspects of pregnancy in patients with rheumatic diseases.
Lupus, 13 (2004), pp. 699-702
[71.]
B.J. Hunt, M.A. Khamashta, L. Lakasing, et al.
Thromboprophylaxis in antiphospholipid syndrome pregnancies with previous cerebral arterial thrombotic events: is warfarin preferable?.
Thromb Haemost, 79 (1998), pp. 1060-1061
[72.]
N.S. Pattison, L.W. Chamley, M. Birdsall, et al.
Does aspirin have a role in improving pregnancy outcome for women with the antiphospholipid syndrome? A randomized controlled trial.
Am J Obstet Gynecol, 183 (2000), pp. 1008-1012
[73.]
B.J. Sanson, A.W.A. Lensing, M.H. Prins, et al.
Safety of low-molecular-weight heparin in pregnancy: a systematic review.
Thromb Haemost, 81 (1999), pp. 668-672
[74.]
C. Nelson-Piercy, E. Letsky, M. De Swiet.
Low-molecularweight heparin for obstetric thromboprophylaxis: experience of sixty-nine pregnancies in sixty-one women at high risk.
Am J Obstet Gynecol, 176 (1997), pp. 1062-1068
[75.]
B.J. Hunt, H.A. Doughty, G. Majumdar, et al.
Thromboprophylaxis with low molecular weight heparin (fragmin) in high risk pregnancies.
Thromb Haemost, 77 (1997), pp. 39-43
[76.]
M. Bazaan, V. Donvito.
Low-molecular-weight heparin during pregnancy.
Thromb Res, 101 (2001), pp. V175-V186
[77.]
British Committee for Standards in Haematology.
Guidelines on oral anticoagulation: third edition.
Br J Haematol, 101 (1998), pp. 374-387
[78.]
G. Ruiz-Irastorza, M.A. Khamashta, C. Nelson-Piercy, et al.
Lupus pregnancy: is heparin a risk factor for osteoporosis?.
Lupus, 10 (2001), pp. 597-600
[79.]
G. Ruiz-Irastorza, M.A. Khamashta, G.RV. Hughes.
Heparin and osteoporosis during pregnancy: 2002 update.
Lupus, 11 (2002), pp. 680-682
[80.]
S. Schulman, M. Hellgren-Wangdahl.
Pregnancy, heparin and osteoporosis.
Thromb Haemost, 87 (2002), pp. 180-181
[81.]
M. Monreal, E. Lafoz, A. Olive, et al.
Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin®) in patients with venous thromboembolism and contraindications to coumarin.
Thromb Haemost, 71 (1994), pp. 7-11
[82.]
M. Monreal, F.J. Roncales, J. Ruiz, et al.
Secondary prevention of venous thromboembolism: a role for low-molecularweight heparin.
Haemostasis, 28 (1998), pp. 236-243
[83.]
T.C. Dahlman.
Osteoporotic fractures and the recurrence of thromboembolism during pregnancy and the puerperium in 184 women undergoing thromboprophylaxis with heparin.
Am J Obstet Gynecol, 168 (1993), pp. 1265-1270
[84.]
J. Shefras, R.G. Farquharson.
Bone density studies in pregnant women receiving heparin.
Eur J Obstet Gynecol Reprod Biol, 65 (1996), pp. 171-174
[85.]
V. Pettilä, P. Leinonen, A. Markkola, et al.
Postpartum bone mineral density in women treated for thromboprophylaxis with unfractionated heparin or LMW heparin.
Thromb Haemost, 87 (2002), pp. 182-186
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