Obstetric Antiphospholipid Syndrome: Lobsters Only? Or Should We Also Look for Selected Red Herrings?

In this issue, a provocative editorial by Clark, Spitzer, and Laskin on obstetric antiphospholipid syndrome (APS), “Has the black swan swallowed a red herring?”1 endorses and strengthens the concerns the Obstetric APS Task Force expressed during the 14th International Congress on Antiphospholipid Antibodies2. Such worry relates to the excessive enthusiasm displayed by clinicians when diagnosing and treating obstetric APS, and originates from the paucity of data in support of the association of antiphospholipid antibodies (aPL) and obstetric morbidity as well as from the lack of incontrovertible evidence of the benefit of treatment. Indeed, despite the strong evidence for the pathogenic role of β2-glycoprotein-I (β2-GPI) dependent-aPL in vitro and in vivo models, drawing meaningful conclusions about the clinical significance of aPL is undoubtedly prevented by the several limitations marring available studies. The strength of association is particularly weak when considering aPL and recurrent early miscarriages (REM), as emerged in the critical revision of literature conducted by the international network APS ACTION3,4. The concerns over such scarcely supported fervor therefore are not without basis but may go too far, especially when the exclusion of REM from the classification criteria for APS is advocated. In support of such a proposal, the Toronto group claims that aPL-positive women experiencing REM present a favorable outcome regardless of therapeutic intervention, quoting a 2010 study by Cohn, et al . This work does suggest that combining low-dose aspirin [acetylsalicylic acid (LDASA)] plus heparin does not confer any improvement in obstetric outcome among patients with prior REM, but Clark, et al omit that an exception was identified, which concerned women carrying aPL5. Available data about the efficacy of treatment in aPL-positive REM are not univocal, even though all 4 metaanalyses concluded that unfractioned heparin plus … Address correspondence to Prof. Meroni, Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Italy. E-mail: pierluigi.meroni{at}unimi.it

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