BOF: Clotting (Thrombosis)

Which of ONE of the following treatment strategies has been shown to successfully reduce the incidence of miscarriage in women suffering recurrent fetal loss in the presence of persistently positive lupus anticoagulant or antiphospholipid syndrome associated antibodies?

a) Aspirin 75mg daily

b) Intravenous immunoglobulin 1g/kg for 2 days every 4 weeks

c) Prednisolone 1mg/kg daily

d) Unfractionated heparin (UFH) prophylactic dose daily

e) Unfractionated heparin (UFH) prophylactic dose plus aspirin 75mg daily

Answer:

e) Unfractionated heparin (UFH) prophylactic dose plus aspirin 75mg daily

*Note that while UFH has the strongest evidence base, in practice most guidelines would now propose the use of LMWH*

Explanation:

There is evidence that UFH and aspirin reduces risk of pregnancy loss in this situation compared with aspirin alone, but that aspirin alone has no benefit over placebo. The risk of osteoporosis and HITT is increased with the use of therapeutic doses of UFH without any clear benefit, and the use of LMWH seems to be equivalent to UFH although there is less supportive evidence than for UFH. Trials are awaited to assess UFH alone against UFH and aspirin. Prednisolone and IVIG are not effective.

Reference:

Keeling D, Mackie I, Moore GW, Greer IA, Greaves M, British Committee for Standards in Haematology. Guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol 2012;157:47–53.