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Old 11-30-2011
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Question Treatment of positive anticariolipin!

A 33-year-old woman is very depressed about her recurrent pregnancy loss. She has had four pregnancies that all have ended in spontaneous abortion before 8 weeks. Her past medical history is otherwise unremarkable. She has never had surgery. She takes acetaminophen occasionally for headaches, but otherwise uses no medications and has no known drug allergies. Physical examination is normal. Laboratory evaluation demonstrates that she is positive for lupus anticoagulant and that she is positive for anticardiolipin IgG. These results are again positive 8 weeks later. Which of the following is the most appropriate management of this patient during her next pregnancy?

A. Daily heparin
B. Daily heparin and low dose aspirin
C. Daily low dose aspirin
D. Paternal leukocyte immunization
E. Paternal leukocyte immunization and intravenous immune globulin
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Old 11-30-2011
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A. Daily heparin
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Old 11-30-2011
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Daily heparin - with low dose aspirin
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Old 11-30-2011
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B.daily lmwh with low dose aspirin
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That would prevent the placental infarction that accompanies the presence of antiphospholipid antibodies.
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Old 12-01-2011
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the management is daily heparin.
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Old 12-01-2011
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Daily heparin and low dose aspirin
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Old 12-01-2011
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The correct answer is B. Recurrent pregnancy loss is defined as two or three or more consecutive pregnancy losses. Most women with recurrent pregnancy loss have recurrent pre-embryonic or embryonic (<10 weeks’ gestation) losses. Recurrent pregnancy loss is relatively common in reproductive-aged women, with approximately 1% being affected. The condition is extremely emotionally difficult for most women and couples who are affected with this disorder. There are many causes of recurrent pregnancy loss that can be grouped into the following categories: genetic abnormalities, hormonal and metabolic disorders, uterine anatomic abnormalities, infectious causes, environmental factors, thrombophilias, autoimmune disorders, and unexplained reasons. This patient can be diagnosed with antiphospholipid syndrome on the basis of her positive lupus anticoagulant and positive anticardiolipin antibody levels. Randomized controlled trials have demonstrated that women with recurrent pregnancy losses and antiphospholipid syndrome have improved pregnancy outcomes when treated with a daily baby aspirin and heparin 10,000-25,000 U/day. Successful pregnancy rates for women treated with this regimen were 70 to 75% versus 50% for untreated patients.
Daily heparin alone (choice A) could be used, but the randomized controlled trials demonstrating the most success (i.e., successful pregnancy rates) used the combination of daily heparin together with baby aspirin.
Daily low dose aspirin (choice C) also could be used, but as noted previously the standard of care based on the randomized controlled trials is to use a combination of heparin and a daily baby aspirin.
Paternal leukocyte immunization (choice D) involves immunizing the female partner who is experiencing recurrent pregnancy loss with the leukocytes of the male partner. Several trials have been performed using this method and the results have shown that paternal leukocyte immunization does not seem to be helpful for improving pregnancy rates and may in fact be harmful.
Paternal leukocyte immunization and intravenous immune globulin (IVIG) (choice E) should not be used in an effort to improve pregnancy rates in patients experiencing recurrent pregnancy losses. As stated previously, paternal leukocyte immunization does not seem to be helpful and may in fact be harmful. IVIG also does not seem to be helpful.
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