Antiphospholipid syndrome and second- or third-trimester fetal death: follow-up in the next pregnancy

Objective: To evaluate the efficacy of a uniform management protocol in antiphospholipid-antibody-positive obstetric patients with at least one second- or third-trimester intra-uterine fetal death. Study design: A prospective study of 33 successive pregnancies in antiphospholipid-antibody-positive patients, diagnosed after an intra-uterine fetal death. The management included treatment by a combination of aspirin and low-molecular-weight heparin, and a close follow-up with at least clinical examination, ultrasonography, uterine, and umbilical artery Doppler monthly from the first trimester. In the absence of any anomaly, delivery was induced between 37 and 38 weeks' gestation. Results: In this high risk population, seven recurrences of vascular pathology occurred: five cases of mild, isolated fetal growth retardation and one of preeclampsia associated with fetal growth retardation requiring preterm delivery. Eight patients were delivered before 37 weeks. No recurrence of second- or third-trimester fetal death was observed. Uterine artery Doppler was informative as early as the first trimester (12-15 weeks): a bilateral notch was associated with a lower birthweight (2626 +/- 688 g versus 3178 +/- 353 g, respectively, P = 0.01), despite similar gestational age. The negative predictive value of uterine Doppler was more than 92% at 12-15 weeks' gestation and remained high throughout pregnancy. Conclusion: Although intra-uterine fetal death is considered at high risk of recurrence in case of antiphospholipid syndrome (APS), a uniform management protocol including aspirin and heparin and close obstetrical follow-up led to a favorable outcome in most cases. (C) 2003 Elsevier Ireland Ltd. All rights reserved.