Author:
john
Add date:
09/12/2008
Publishing date:
03/01/2014
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Systematic review
Results
Comment
What's worse than being asked a question to which you don't know the answer (or even
understand the question)? It could be having only half of the answer, but not knowing
which half. Such a position could arise with treatments for antiphospholipid
antibodies in pregnancy.
Antiphospholipid antibodies are antibodies directed against several phospholipids in
the body. There is an association between antiphospholipid antibodies in the
circulation and pregnancy loss, and between 3% and 7% of pregnant women have the
antibodies. In low risk pregnancies, the antibodies are associated with a nine-fold
increase in pregnancy loss, while in high risk pregnancies with at least three
previous losses, they are associated with a 90% risk of further pregnancy loss.
The mechanism of pregnancy loss is thought to be through thrombosis of placental
vessels, though this is a complicated, and perhaps controversial area. The important
question is whether there are effective treatments. A new systematic review [1]
begins to answer that.
Systematic review
The searching strategy for this review was impressive, using the usual electronic
databases, plus the Cochrane controlled trials register, plus hand-searching of
specialist journals and abstracts of relevant symposia. Trials sought were those that
sought to prevent pregnancy loss in pregnant women with a history of at least one
previous loss and serological evidence of antiphospholipid antibodies. The primary
outcome sought from the trials was pregnancy loss, though many others, including
birth weight, prematurity and even issues around maternal bone mineral density were
looked for.
Results
There were 10 randomised or quasi-randomised trials included with 627 women, and
their design and results are given in detail in the review. In most trials women had
at least two and often three previous miscarriages, and both treatments and the
results of serology tests are described. Trials were not large, though, with 90 women
being the biggest, and some were very small. Trial design was generally adequate,
most being properly randomised, some blind, and with intention to treat analysis and
100% follow up in all. The biggest difficulty was the plethora of different
treatments used, from aspirin alone, to heparin plus aspirin, prednisolone plus
aspirin or intravenous immunoglobulin.
In direct comparisons, aspirin alone was no better than placebo or usual care, with
the important qualification that these were small trials with only 70 women in total,
and with what appeared to be a lowish rate of loss without treatment. Heparin and
aspirin was better than aspirin in two trials with 140 patients, with a relative risk
of loss of 0.45 (95% CI 0.29 to 0.70) and number needed to treat of 3.2 (2.1 to 6.3).
A trial of high dose heparin versus low dose heparin, both with aspirin, showed no
difference, and with rates of pregnancy loss consistent with the comparisons of
heparin plus aspirin with aspirin.
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Antiphospholipid antibodies and pregnancy loss