Costedoat-Chalumeau N, Guettrot-Imbert G, Leguern V, Leroux G, Le Thi Huong D, Wechsler B, Morel N, Vauthier-Brouzes D, Dommergues M, Cornet A, Aumaître O, Pourrat O, Piette J-C, Nizard J
Service de médecine interne, centre de référence national pour le lupus systémique et le syndrome des antiphospholipides, hôpital Pitié-Salpêtrière, AP-HP, université Pierre-et-Marie-Curie Paris 6, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
Rev Med Interne. 2012 Apr;33(4):209-16. doi: 10.1016/j.revmed.2012.01.003. Epub 2012 Feb 14.
Antiphospholipid syndrome (APS) is associated with a risk of obstetrical complications, affecting both the mother and the fetus. Obstetrical APS is defined by a history of three consecutive spontaneous miscarriages before 10 weeks of gestation (WG), an intra-uterine fetal death after 10 WG, or a premature birth before 34 WG because of severe pre-eclampsia, eclampsia or placental adverse outcomes (intrauterine growth retardation, oligohydramnios). Pregnancy in women with a diagnosis of obstetric APS is at increased risk for placental abruption, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome and thrombosis that may be part of a catastrophic antiphospholipid syndrome (CAPS). A previous thrombosis and the presence of a lupus anticoagulant are risk factors for pregnancy failure. A multidisciplinary approach, associating the internist, the anesthesiologist and the obstetrician, is recommended for these high-risk pregnancies. Preconception counseling is proposed to identify pregnancy contraindications, and to define and adapt the treatment prior and during the upcoming pregnancy. Heparin and low-dose aspirin are the main treatments. The choice between therapeutic or prophylactic doses of heparin will depend on the patient's medical history. The anticoagulant therapeutic window for delivery should be as narrow as possible and adapted to maternal thrombotic risk. There is a persistent maternal risk in the postpartum period (thrombosis, HELLP syndrome, CAPS) justifying an antithrombotic coverage during this period. We suggest a monthly clinical and biological monitoring which can be more frequent towards the end of pregnancy. The persistence of notches at the Doppler-ultrasound evaluation seems to be the best predictor for a higher risk of placental vascular complications. Treatment optimization and multidisciplinary antenatal care improve the prognosis of pregnancies in women with obstetric APS, leading to a favorable outcome most of the time.
抗磷脂综合征（APS）与产科并发症风险相关，对母亲和胎儿均有影响。产科抗磷脂综合征的定义为妊娠10周前（WG）连续三次自然流产史、妊娠10周后胎儿宫内死亡，或因重度子痫前期、子痫或胎盘不良结局（胎儿宫内生长受限、羊水过少）导致妊娠34周前早产。诊断为产科抗磷脂综合征的女性妊娠时，发生胎盘早剥、HELLP（溶血、肝酶升高、血小板减少）综合征和血栓形成的风险增加，后者可能是灾难性抗磷脂综合征（CAPS）的一部分。既往血栓形成和狼疮抗凝物的存在是妊娠失败的危险因素。对于这些高危妊娠，建议采用内科医生、麻醉医生和产科医生联合的多学科方法。建议进行孕前咨询，以确定妊娠禁忌，并确定和调整即将到来的妊娠之前及期间的治疗方案。肝素和小剂量阿司匹林是主要治疗方法。肝素治疗剂量或预防剂量的选择将取决于患者的病史。分娩时的抗凝治疗窗口应尽可能窄，并根据母亲的血栓形成风险进行调整。产后期间母亲仍持续存在风险（血栓形成、HELLP综合征、CAPS），因此在此期间需要进行抗血栓治疗。我们建议每月进行临床和生物学监测，在妊娠末期可更频繁监测。多普勒超声评估中切迹的持续存在似乎是胎盘血管并发症风险较高的最佳预测指标。治疗优化和多学科产前护理可改善产科抗磷脂综合征女性妊娠的预后，大多数情况下可获得良好结局。
