APLA in Pregnancy: Treatment in Ahmedabad, With Lupus Care

APLA Syndrome Symptoms, and How APLA and Lupus Affect a Pregnancy

APLA itself usually causes no symptoms you can feel day to day. It shows itself through events instead. These include miscarriages one after another, a pregnancy lost after 10 weeks, early severe pre-eclampsia, or a baby who stops growing well. A clot in a leg vein, the lungs or the brain can also be the first sign. Some women also have a lace-like mottling of the skin on the legs or a low platelet count found on a routine blood test.

APLA antibodies inflame the lining of blood vessels and the placenta. Small clots form and blood flow through the placenta falls. This can show up as early pregnancy losses, severe pre-eclampsia or a baby who does not grow well.

Lupus that is active - lupus nephritis in particular - raises the chance of pre-eclampsia, preterm birth and growth restriction. Women with lupus or Sjögren's syndrome who carry anti-Ro or anti-La antibodies have a further issue: these antibodies can affect the rhythm of the baby's heart.

Pregnancy itself makes the blood more prone to clot, and this tendency peaks after the birth. That is why heparin is often continued for six weeks after delivery, and why I ask you to avoid dehydration, long journeys and long periods without moving.

What is the full form of APLA?

APLA is short for antiphospholipid antibodies, and doctors in India often use it to mean antiphospholipid antibody syndrome (APS). The antibodies attack proteins attached to fats in cell membranes, which is what makes the blood clot more readily.

APLA Test in Pregnancy and the Criteria I Use to Confirm It

To diagnose APS, two things are needed together: a qualifying clinical event, and antibodies that stay positive over time. A single positive result, or a weak one, is not enough. Infections can make the tests positive for a short while, so some women are labelled with APLA when they do not meet the criteria.

Clinical events that count

• three or more miscarriages in a row before 10 weeks
• loss of a normally formed baby after 10 weeks
• birth before 34 weeks because of severe pre-eclampsia or placental insufficiency
• a confirmed blood clot

Laboratory tests

• lupus anticoagulant
• anticardiolipin antibodies (IgG or IgM, at medium or high levels)
• anti-beta-2 glycoprotein I antibodies

Persistence: the result must be positive again on repeat testing at least 12 weeks later. Women who are positive on all three tests (triple-positive), or positive for lupus anticoagulant, carry the highest risk.

For lupus, my baseline tests are blood counts, kidney function, urine protein, C3 and C4, anti-dsDNA, and anti-Ro and anti-La antibodies.

Getting Ready Before You Conceive

• Let lupus settle first. I advise trying for pregnancy only after lupus has been quiet for at least six months; this roughly halves the chance of a flare.
• Continue hydroxychloroquine. It is recommended throughout pregnancy, it reduces flares and it may lower the risk of heart block in the baby.
• Change medicines that do not suit pregnancy. Mycophenolate, methotrexate and leflunomide are stopped and replaced - with azathioprine or tacrolimus if needed - at least three months before you start trying.
• Switch from warfarin to heparin as soon as your pregnancy test is positive and before 6 weeks. Warfarin taken between 6 and 12 weeks can affect the baby's bones and face.
• Start folic acid, and have your vitamin D, thyroid, BP and kidney function checked.
• Discuss contraception: pills containing oestrogen raise the risk of clots in APLA and should be avoided.

Antiphospholipid Syndrome in Pregnancy Treatment: The Medicines I Use

Low molecular weight heparin (LMWH), such as enoxaparin, does not cross the placenta. It is injected under the skin once or twice a day, and I teach you or a family member to give it at home. Bruising where the needle goes in is common and harmless.

Please do not stop hydroxychloroquine when you find out you are pregnant. Stopping it is one of the commonest triggers of a lupus flare.

Lupus in Pregnancy Management: How I Monitor You and Your Baby

You receive a written scan plan:

• an early dating scan
• the NT scan, combined with pre-eclampsia screening
• a detailed anomaly scan with uterine artery Doppler at about 20–24 weeks
• growth scans with umbilical artery Doppler every 2–4 weeks in the third trimester

Your BP and urine are checked at every visit. If you have lupus, your blood counts, kidney function, urine protein, complement and anti-dsDNA are repeated each trimester.

One of the harder judgements is telling a lupus flare apart from pre-eclampsia, because they can look alike. A flare is treated with steroids or immune-suppressing medicines; pre-eclampsia is treated by choosing the right time for delivery.

If you carry anti-Ro or anti-La antibodies, I check the baby's heart rhythm every 1–2 weeks between about 16 and 26 weeks. Congenital heart block affects about 2% of babies of anti-Ro-positive mothers, and about 15–20% if an earlier baby was affected.

Complications I Watch For, and How Each Is Reduced

Birth and the Weeks That Follow

If all is well, I usually plan delivery at about 38–39 weeks, or earlier if there are concerns about growth or BP. Many women give birth vaginally.

Heparin timing matters for an epidural or spinal: a preventive dose is stopped about 12 hours before, and a treatment dose about 24 hours before. Injections restart a few hours after the birth. Heparin, warfarin after delivery, and hydroxychloroquine can all be used while breastfeeding.

Babies of anti-Ro-positive mothers are checked for the rash of neonatal lupus and for heart rhythm. Afterwards, I advise long-term follow-up with your physician or rheumatologist, because the tendency to clot remains raised for life. Any future pregnancy follows the same planned approach.

APLA Test Price and What Your Treatment Cost Depends On

I do not quote a single figure for the APLA test price, because it depends on what is ordered. A full APLA profile is usually three investigations - lupus anticoagulant, anticardiolipin antibodies and anti-beta-2 glycoprotein I antibodies. The antibody tests may be run for IgG alone or for both IgG and IgM. A positive result has to be repeated at least 12 weeks later, so many women pay for the profile twice. Lupus adds its own baseline tests, such as complement levels, anti-dsDNA and anti-Ro and anti-La.

For treatment, the largest variable is heparin. It depends on whether you need a preventive or a treatment dose, once or twice a day, the brand chosen, and the number of weeks until six weeks after the birth. The number of growth and Doppler scans, any admission, and the type of delivery also change the total. The hospital gives current charges for its tests, scans and delivery packages on request. I am happy to explain which items in your plan are essential.

How I Organise Your APLA or Lupus Care at Divine Women's Hospital

• At the first consultation - ideally before you conceive - I go through your earlier reports, scans and discharge summaries.
• You get a written plan covering your medicines, when heparin starts, the scan schedule and the blood tests for each trimester.
• I share the plan with your rheumatologist or physician so that everyone follows the same approach.
• I perform and report your growth and Doppler scans myself and discuss the results with you at the same visit.
• Delivery takes place at Divine Women's Hospital in Gota (NABH-certified), where the hospital's labour, anaesthesia and neonatal service runs 24×7.
• Your heparin plan and contraception plan for after the birth are agreed before you go home.

Five Steps in My APLA and Lupus Pregnancy Plan

1. Confirming the diagnosisI review your antibody reports and history, and repeat the tests 12 weeks apart if needed.
2. Planning before conceptionwith your rheumatologist, we make your medicines suitable for pregnancy and agree when aspirin and heparin start.
3. Early pregnancyheparin starts once the pregnancy test is positive; you are taught the injections and have an early viability scan.
4. Treatment and scansDoppler and growth scans, BP and lupus blood tests follow a written plan, week by week.
5. Delivery and afterwardsheparin is paused for the birth and restarted for about six weeks.

Reasons to See Me About APLA or Lupus

• Positive APLA antibodies, or a diagnosis of lupus or Sjögren's syndrome.
• Three or more miscarriages, a loss after 10 weeks, or a stillbirth.
• Early severe pre-eclampsia or a very small baby in an earlier pregnancy.
• A previous clot in the leg, lung or brain.
• Taking warfarin, mycophenolate or methotrexate and planning a pregnancy.
• Anti-Ro or anti-La antibodies, whether you are pregnant or planning.

APLA and Lupus Myths I Hear in Clinic

Questions Patients Often Ask Me About APLA and Lupus in Pregnancy