The issue of obstetric consequences of APA syndrome is now well settled in the obstetric academics. It is pertinent now to take it from the realms of academic world to day to day practice. It is only a little over one and a half-decade that this syndrome has come into sharp focus in obstetrics. Its bearings were known well to physicians and soon obstetricians picked up the trail.


APA syndrome is an autoimmune condition that has profound bearing on obstetric conditions at times seemingly diverse. Recurrent spontaneous missed abortions, IUGR, recurrent still births, accidental hemorrhage and thromboembolism are some diverse conditions which have this as its etiological factor.


Antiphospholipid Antibodies or APA were identified to be of six types. Of these six, three were important for us clinicians:

  • Anticardiolipin antibodies ( ACA)

  • Lupus anti coagulant ( LAC)

  • Biologically False Positive Serological Test For Syphilis (BFPSTS).

These three are inter-related and presence of one may indicate the presence of other as well. However, the international recommendation today suggests that if one is interested in using LAC as a test for Antiphospholipids than it must fulfill the following criteria:
1) Prolongation of APTT
2) That the abnormality is caused by inhibition
3) That this inhibitor is directed against phospholipids.

In the same way for BFPSTS to be exclusively used for testing Antiphospholipids, the following are the criteria:

Person should serologically test continuously positive for syphilis for 6 months without treponemal infection.

No such recommendations are made for ACA and thus this is the test primarily involved in picking up APA cases. However, what clinical significant has the testing of IgM and IgG have in ACA, bearing their cross reactivity in mind, is a matter currently under investigations.


APA are antibodies with a strong activity against vascular tree. APA are a diverse family of auto antibodies which share a common reactivity with negatively charged phospholipids. The most common theories for their mechanism of action may be divided into:

1) Those that ascribe APA to disrupt platelet function and
2) Those that postulate that APA interfere with the function of endothelial cells.

A major advance was made by the demonstration that both LA and ACA require plasma protein cofactors to exert their action. They are charged particles. By this virtue they have a tendency to interact with the decidual-placental interface. They tend to bring about changes in vascular endothelium in such a way that it reduces the caliber of the vessels. The vascularity is affected and the effective number of vessels decline. This is known as a state of decidual vasculopathy. Immunological staining methods have shown a clear deposition of immune complexes at the vessels of the deciduo-placental interface so affected. These vascular changes in turn produce the resultant manifestations of pre- eclampsia.

Once the vasospasm and vasculopathy occurs, the BP rises to compensate for the poor vascularity. It is a natural mechanism to maintain the placental blood flow. This produces hypertension. Individual organs being so affected cause the manifestations specific to these organs. This includes renal prorteinurea, intracranial hemorrhage, IUGR, recurrent stillbirths, accidental hemorrhage.

These are all explainable by the vasculopathy of APA. No wonder these cases also consistently test positive for APA.


Lab diagnosis of APA is currently done by ELIZA technique. Usually the laboratory asks for an empty stomach of about 4 hours. Blood so collected is tested for Antiphospholipid antibodies. A strong index of suspicion and a good laboratory back up can make the diagnosis of APA syndrome in a given case, easy. Diagnosis is also helped by asking a history of allied complications of APA like RSA of missed type, Recurrent still births, Recurrent IUGR, etc. The standard classification used is:

Negative ® < 10 GPL units

Low positive ® 10-20 GPL units

Mod. Positive ® 20-100 GPL units

Strong positive ® > 100 GPL units.

Once the diagnosis is well established treatment plans are instituted.


Nearly 18 different protocols have been tried over the period of years for the treatment of APA syndrome. But the main stay is Heparin, Low dose Aspirin and corticosteroids. We use the following protocol: -

·  In interval period :

® For low and moderate positive, Aspirin in a dose of 1.2 mg/kg./day for three months – Allow a conception – Restart aspirin in the same dose upto 36 weeks.

® For High positive, Prednisolone in a dose of 10 mgms./day for 3 months in the interval period. Allow conception- start aspirin from 12 weeks upto 36 weeks.

· In Pregnancy:

® For these cases we give only the post-conception protocol of aspirin specified above.

We have satisfactory results that are written in the section to follow.


In our study 154 subjects testing positive for APA were given the above treatment protocols. In the group where treatment could be given pre conception as well as post conception, full term delivery rates achieved were 88.3%. In the group where only post conception treatment could be given, the same rate was 72.3%.The incidence of P.E. remote from term declined from 26.7% to 3.3 %.


APA syndrome is difficult to understand but easy to treat. This is in contrast to other conditions of RSA that are easy to understand but difficult to treat Results of treatment of APA syndrome are very satisfactory and gratifying.



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