**6. Management of the obstetric antiphospholipid syndrome**

The current standard of care (**Table 3** and **Figure 1**) for the management of APS pregnancies [83], although controversial and supported by only a limited number of well-designed studies, is the prophylactic administration of heparin plus LDA for individuals with pregnancy morbidity alone. Mothers with a history of thrombosis alone or in association with pregnancy morbidity are usually treated with therapeutic heparin in combination with LDA to prevent both thrombosis and pregnancy morbidity. The data supporting these recommendations come almost exclusively from clinical trials evaluating the prevention of recurrent early miscarriages rather than late pregnancy complications. A total of 140 women with APS-related recurrent early miscarriages, were enrolled in two randomized control trials comparing treatment with LDA alone or in combination with heparin [84, 85]. The combination of LDA with heparin showed a significantly higher live birth rate than LDA alone. These data were however not confirmed in two subsequent studies [86, 87]. Nevertheless, a subsequent follow-up meta-analysis [88] and a recent Cochrane review [89] concluded that combining heparin with LDA during pregnancy may increase the live birth rate in women with APS compared with LDA alone. Since low


*APS: antiphospholipid syndrome, aPLs: antiphospholipid antibodies, LDA: low dose aspirin, HCQ: hydroxychloroquine, IVIG: intravenous immunoglobulin, SLE: systemic lupus erythematosus.*

### **Table 3.**

*Current recommendation [83] for the management of pregnant women with antiphospholipid antibodies or APS.*

molecular weight heparin (LMWH) is easier to administer and have less adverse events it is the drug of choice in most cases. Furthermore, the dose of LMWH should be personalized. Case-control studies comparing a fixed dose of LMWH with a weight-adjusted dose of LMWH have shown a higher live birth rate with the latter [80, 90]. Several studies, recently summarized [91] suggest that women with either clinical and/or laboratory non-criteria manifestations of obstetric APS may benefit from standard obstetric APS treatment with LMWH plus LDA, with good pregnancy outcomes.
