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  • Antiphospholipid syndrome( APS) - Causes, symptoms and treatment. MF.

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    Antiphospholipid syndrome( APS) is an autoimmune disease characterized by the production in large quantities of antibodies to phospholipids - the chemical structures from which parts of the cell are built.

    Antiphospholipid syndrome occurs in about 5% of pregnant women. In 30% of cases, APS is the main cause of miscarriage - the most urgent problem of modern obstetrics. In case of non-compliance with certain measures, APS can lead to the most unfavorable and life-threatening complications during pregnancy and after childbirth.

    Causes of AFS

    The main provoking factors leading to the development of APS are:

    - genetic predisposition;
    - bacterial or viral infections;
    - autoimmune diseases - systemic lupus erythematosus( SLE), nodular periarteritis;
    - long reception of medical products( hormonal contraceptives, psychotropic preparations);
    - oncological diseases.

    Symptoms of antiphospholipid syndrome

    How does antiphospholipid syndrome manifest? Clinical manifestations of the disease are diverse, but may be completely absent. The latter occurs quite often, when against a background of absolute health in a healthy woman there are spontaneous miscarriages. And if not to be examined, then the diagnosis of antiphospholipid is suspect. The main reason for miscarriage in APS is an increase in the activity of the blood coagulation system. For this reason there is a thrombosis of the vessels of the placenta, which inevitably leads to the termination of pregnancy.

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    The most "harmless" symptoms of APS include the appearance of an underlined vascular pattern on various parts of the body. Most often the vascular pattern is expressed on the legs, feet, thighs.

    In more severe cases, APS can manifest itself as a non-healing ulcer on the lower leg, gangrene of the toes( due to chronic impairment of blood supply).Increased thrombus formation in vessels with APS can lead to pulmonary embolism( acute clotting of the blood vessel with a thrombus), which is deadly dangerous!

    Less common symptoms of APS include a sudden decline in vision, until the appearance of blindness( due to thrombosis of the arteries and veins of the retina);the development of chronic renal failure, which can manifest as an increase in blood pressure and the appearance of protein in the urine.

    By itself, pregnancy further exacerbates the manifestations of APS, so if you have already been diagnosed with AFS-an obstetrician gynecologist should consult even before the planned pregnancy. If you have the above symptoms, you should do it immediately!

    AFS examination

    To confirm the diagnosis of "Antiphospholipid syndrome", it is necessary to take a blood test from the vein to the APS markers for lupus anticoagulant( VA) and antibodies to cardiolipin( aCL).If the analysis is positive( i.e., if the AFS markers are found), it should be retested at 8-12 weeks. And if the repeated analysis was also positive, then treatment is prescribed.

    To determine the degree of severity of the disease, a general blood test( with a decrease in platelet counts) and a coagulogram( haemostasiram) - a blood test for hemostasis( coagulating blood system) is mandatory. With AFS, the coagulogram is given at least once every 2 weeks. In the postpartum period, this analysis is given on the third and fifth days after birth.

    Ultrasound and dopplerometry( blood flow in the mother-placenta-fetus system) are performed in pregnant women with APS more often than in pregnant women without pathologies. Since 20 weeks, these studies are conducted every month to anticipate and reduce the risk of developing placental insufficiency( impairment of blood circulation in the placenta).

    To assess the condition of the fetus, CTG( cardiotography) is also used. This study is compulsory, starting at 32 weeks of gestation. In the presence of chronic fetal hypoxia, placental insufficiency( which is often the case with AFS) - CTG is carried out daily.

    Treatment of an antiphospholipid syndrome

    What is the treatment for APS that is prescribed during pregnancy? As already mentioned, if you know about your diagnosis and examined, before planning pregnancy, you need to contact an obstetrician-gynecologist.

    To prevent the development of disorders from the blood coagulation system, even before pregnancy, glucocorticoids are prescribed in small doses( Prednisolone, Dexamethasone, Metipred).Further, when a woman becomes pregnant, she continues to take these drugs until the postpartum period. Only two weeks after the birth, these drugs are gradually canceled.

    In those cases, if the diagnosis of APS is established during pregnancy - the tactics of reference are the same. Treatment with glucocorticoids is prescribed in any case, if there is an APS, even if the pregnancy is completely normal!

    Because long-term administration of glucocorticoids leads to a weakened immunity, then in parallel, immunoglobulin is administered in small doses.

    Total for pregnancy immunoglobulin is administered 3 times - up to 12 weeks, at 24 weeks and immediately before childbirth.

    Antiaggregants( Trental, Curantil) are mandatory for the correction of the blood coagulation system.

    Treatment is carried out under the control of hemostasiogram indicators. In some cases, additionally prescribed Heparin and Aspirin in small doses.

    In addition to the main treatment, plasmapheresis is used( purification of blood by removing the plasma).This is done to improve the rheological properties of blood, to improve immunity, as well as to increase the sensitivity to the drugs administered. When using plasmapheresis, the doses of glucocorticoids and antiaggregants can be reduced. This is especially true for pregnant women who do not tolerate glucocorticoids.

    During labor, the blood coagulation system is closely monitored. Childbirth must necessarily be carried out under the control of CTG.

    With timely diagnosis, careful observation and treatment, pregnancy and childbirth pass favorably and result in the birth of healthy children. The risk of postpartum complications will be minimal.

    If you are diagnosed with ASF, do not get upset and deprive yourself of the pleasure of being a mother. Even if a miscarriage occurs, do not adjust to the fact that the next time will be the same. Thanks to the capabilities of modern medicine, the ASF is not currently a verdict. The main thing is to follow the prescription of the doctor and be prepared for long-term treatment and numerous examinations, which are done for the sole purpose - to protect you and the unborn child from extremely unpleasant complications.

    Complications of ASA

    The complications listed below appear in 95 of 100 APS patients in the absence of dynamic observation and treatment. These include:
    - miscarriage( repeated miscarriages in the early stages of pregnancy);
    - delay in fetal development, fetal hypoxia( lack of oxygen);
    - placental abruption;
    - development of severe gestosis( complication of pregnancy, accompanied by increased blood pressure, the appearance of pronounced edema, protein in the urine).In the absence of treatment, gestosis can lead not only to the death of the fetus, but also to the mother;
    - thromboembolism of the pulmonary artery.

    Preventing the antiphospholipid syndrome

    Prevention of APS includes a pre-planned pregnancy check for the APS markers - lupus anticoagulant( VA), antibodies to cardiolipin( aCL).

    Consultation of obstetrician-gynecologist for ASF

    Question: Is it possible to protect with oral contraceptives if there is APS?
    Answer: No way! Taking oral contraceptives will aggravate the course of APS.

    Question: Does the APS lead to infertility?
    Answer: No.

    Question: If the pregnancy is normal, is it worth to take for "reinsurance" on the markers of the AFS?
    Answer: No, if the coagulogram is normal.

    Question: How long should I take antiaggregants during pregnancy if I have AFS ?
    Answer: The whole pregnancy, without interruptions.

    Question: Can the emergence of the AFS provoke smoking?
    Answer: It is unlikely, but if the APS is already there, then smoking further aggravates it.

    Question: How long can you not become pregnant after a miscarriage because of APS?
    Answer: At least 6 months. During this time, it is necessary to fully examine and begin taking antithrombotic drugs.

    Question: Is it true that pregnant women with APS can not do Cesarean?
    Answer: Yes and no. The operation itself increases the risk of thrombotic complications. But if there is evidence( placental insufficiency, fetal hypoxia, etc.), then the operation is mandatory.

    Obstetrician-gynecologist, Ph. D.Christina Frambos.