Syndrome of the Black Swan

Management of the obstetric antiphospholipid syndrome

“…Soon, APS in individuals without another autoimmune disease was described as primary APS (6). Criteria for the diagnosis of APS were proposed in 1987 (7), with (recurrent) fetal loss being the obstetric criterion. Terms such as recurrent pregnancy loss (8) and recurrent spontaneous abortion (9) were also used.…”

“…The serologic criteria for APS are the persistent presence of lupus anticoagulant (LAC) or medium-tohigh levels of IgG or IgM anticardiolipin antibodies (aCL) (7,14). LAC refers to antibodies that prolong in vitro clotting times of plasma by interference with assemblage of components of the coagulation cascade on a phospholipid template (15).…”

“…Patients were defined as "a normal pregnancy population" (28), "women with no more than 2 consecutive abortions and no stillbirth" (41,40), and "absence of recurrent fetal wastage" (although women with fetal loss after 24 weeks of gestation were included) (42). Because all studies used results from a single blood sample to categorize women as positive or negative for aPL, by definition no patient met the serologic criteria for APS (7,14). Other breaches of the criteria were testing for IgG aCL only (42) and the absence of a neutralization procedure (to confirm that the addition of extra phospholipids corrects abnormal coagulation times) in LAC tests (28,40,41).…”

“…Many patients in these studies had SLE (77% [53], 36% [54], 32% [52], 13% [55], not specified [51]), previous thrombotic events (56% [55], 41% [52], 30% [53], 29% [54], not specified [51]), or both. All patients had APS according to the 1987 criteria (7), but many did not fulfill the obstetric criteria (7,14), because several studies included primigravidae (accounting for 11% [52], 17% [53], 36% [51], and an unspecified percentage [55] of included women) or included women with 1 or 2 first trimester losses or only successful pregnancies (52)(53)(54). All patients fulfilled the serologic criteria for APS, because all studies apparently used adequate tests for LAC and aCL and included patients with at least medium levels of aCL.…”

Inhibition of the thrombogenic and inflammatory properties of antiphospholipid antibodies by fluvastatin in an in vivo animal model

“…Recurrent venous and/or arterial thrombosis, pregnancy losses, and the presence of either medium or high levels of anticardiolipin (aCL) antibodies or positivity on the lupus anticoagulant test are the most significant features of the antiphospholipid syndrome (APS) (1,2). Experimental evidence shows that antiphospholipid antibodies (aPL) not only are markers of the disease, but also may play a causative role in the development of vascular thrombosis and pregnancy morbidity (3)(4)(5)(6)(7)(8).…”