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Antiphospholipid syndrome: obstetric diagnosis, management, and controversies
LETTERS TO THE EDITOR
Antiphospholipid Syndrome: Obstetric Diagnosis, Management, and Controversies To the Editor: The article by Branch and Khamashta1 about the antiphospholipid syndrome is certainly timely and of great interest. There is significant controversy and debate regarding the diagnosis, clinical implications, and management of this potentially devastating disorder. As the authors state, the diagnosis requires both clinical and laboratory criteria. The authors reference the 1999 international conference consensus statement on preliminary classification criteria for the diagnosis of antiphospholipid antibody syndrome.2 Under “pregnancy morbidity,” the authors include the obstetric criterion of “one or more premature births of a morphologically normal neonate at or before the 34th week of gestation (Table 1 in article).”1 This statement appears to be incomplete. The original international conference consensus statement includes the same pregnancy criterion as the authors, but adds the following qualification: “Because of severe preeclampsia or eclampsia, or severe placental insufficiency.”2 Thus, testing for the laboratory criteria of antiphospholipid syndrome seems to be indicated for the preterm delivery at 34 weeks’ gestation or less complicated by severe preeclampsia, eclampsia, or severe fetal growth restriction. To include all morphologically normal preterm deliveries at 34 weeks’ gestation or less, without regard to underlying pathology or pregnancy complication, would result in substantially more patients being tested for antiphospholipid syndrome. This would in-
crease medical costs and the possibility of false-positive results, leading to inappropriate treatment. Dana P. Damron, MD Department of Obstetrics and Gynecology University of Vermont 111 Colchester Avenue Burlington, VT 015401 REFERENCES 1. Branch DW, Khamashta MA. Antiphospholipid syndrome: Obstetric diagnosis, management, and controversies. Obstet Gynecol 2003;101:1333–44. 2. Wilson WA, Gharavi AE, Koike T, Lockshin MD, Branch DW, Piette J-C, et al. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome. Report of an international workshop. Arthritis Rheum 1999;42:1309–11.
In Reply: We acknowledge the letter received from Dr. Damron and thank him for bringing this matter to our attention. Because we were among the original authors of the criteria, we were astounded to notice the oversight. Dr Damron is correct. Table 1, 2B under “clinical criteria” should read as follows: “One or more premature births of a morphologically normal neonate at or before the 34th week of gestation because of severe preeclampsia or eclampsia, or severe placental insufficiency. . . .” Ware Branch, MD Department of Obstetrics and Gynecology The University of Utah Health Science Center Salt Lake City, UT
INSTRUCTIONS FOR LETTERS TO THE EDITOR Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology within the last 8 weeks will be considered for publication. Letters that raise new or controversial issues of interest to readers of this journal will also be considered. Please note the following: • Your letter must be typewritten and double spaced. • Letters are limited to a maximum of 400 words, including signatures and references. • A word count must be provided. • You must submit a signed author agreement form with your letter. • You must disclose any financial association and potential conflicts of interest. • Please include your full address, telephone number, fax number, and e-mail address. • In order to expedite the review of your letter, we prefer that you submit it via e-mail. Please do not use the Editorial Manager system to submit letters. The author agreement form must be submitted by mail and contain original signatures. Our address: Letters to the Editor, Obstetrics & Gynecology, 409 12th Street, SW, Washington, DC 20024 Our fax number: 202-479-0830 Our e-mail address: [email protected] The editor reserves the right to shorten letters, delete irrelevant or objectionable comments, and make changes to comply with journal style. To facilitate rapid publication, proofs are not provided.
VOL. 102, NO. 4, OCTOBER 2003 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier.
0029-7844/03/$30.00 doi:10.1016/S0029-7844(03)00866-4
873
Antiphospholipid Syndrome: Obstetric Diagnosis, Management, and Controversies To the Editor: The article by Branch and Khamashta1 about the antiphospholipid syndrome is certainly timely and of great interest. There is significant controversy and debate regarding the diagnosis, clinical implications, and management of this potentially devastating disorder. As the authors state, the diagnosis requires both clinical and laboratory criteria. The authors reference the 1999 international conference consensus statement on preliminary classification criteria for the diagnosis of antiphospholipid antibody syndrome.2 Under “pregnancy morbidity,” the authors include the obstetric criterion of “one or more premature births of a morphologically normal neonate at or before the 34th week of gestation (Table 1 in article).”1 This statement appears to be incomplete. The original international conference consensus statement includes the same pregnancy criterion as the authors, but adds the following qualification: “Because of severe preeclampsia or eclampsia, or severe placental insufficiency.”2 Thus, testing for the laboratory criteria of antiphospholipid syndrome seems to be indicated for the preterm delivery at 34 weeks’ gestation or less complicated by severe preeclampsia, eclampsia, or severe fetal growth restriction. To include all morphologically normal preterm deliveries at 34 weeks’ gestation or less, without regard to underlying pathology or pregnancy complication, would result in substantially more patients being tested for antiphospholipid syndrome. This would in-
crease medical costs and the possibility of false-positive results, leading to inappropriate treatment. Dana P. Damron, MD Department of Obstetrics and Gynecology University of Vermont 111 Colchester Avenue Burlington, VT 015401 REFERENCES 1. Branch DW, Khamashta MA. Antiphospholipid syndrome: Obstetric diagnosis, management, and controversies. Obstet Gynecol 2003;101:1333–44. 2. Wilson WA, Gharavi AE, Koike T, Lockshin MD, Branch DW, Piette J-C, et al. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome. Report of an international workshop. Arthritis Rheum 1999;42:1309–11.
In Reply: We acknowledge the letter received from Dr. Damron and thank him for bringing this matter to our attention. Because we were among the original authors of the criteria, we were astounded to notice the oversight. Dr Damron is correct. Table 1, 2B under “clinical criteria” should read as follows: “One or more premature births of a morphologically normal neonate at or before the 34th week of gestation because of severe preeclampsia or eclampsia, or severe placental insufficiency. . . .” Ware Branch, MD Department of Obstetrics and Gynecology The University of Utah Health Science Center Salt Lake City, UT
INSTRUCTIONS FOR LETTERS TO THE EDITOR Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology within the last 8 weeks will be considered for publication. Letters that raise new or controversial issues of interest to readers of this journal will also be considered. Please note the following: • Your letter must be typewritten and double spaced. • Letters are limited to a maximum of 400 words, including signatures and references. • A word count must be provided. • You must submit a signed author agreement form with your letter. • You must disclose any financial association and potential conflicts of interest. • Please include your full address, telephone number, fax number, and e-mail address. • In order to expedite the review of your letter, we prefer that you submit it via e-mail. Please do not use the Editorial Manager system to submit letters. The author agreement form must be submitted by mail and contain original signatures. Our address: Letters to the Editor, Obstetrics & Gynecology, 409 12th Street, SW, Washington, DC 20024 Our fax number: 202-479-0830 Our e-mail address: [email protected] The editor reserves the right to shorten letters, delete irrelevant or objectionable comments, and make changes to comply with journal style. To facilitate rapid publication, proofs are not provided.
VOL. 102, NO. 4, OCTOBER 2003 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier.
0029-7844/03/$30.00 doi:10.1016/S0029-7844(03)00866-4
873