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作者：Sciascia S 等 翻译：刘杰 发布者：翟佳羽 审校者：李常虹 在门诊，常常有抗心磷脂综合征患者使用标准阿司匹林联合低分子肝素治疗后出现自然流产，对于标准治疗后仍未能如愿的患者该如何治疗呢？
摘要： 低剂量阿司匹林和肝素可提高产科抗磷脂抗体综合征（APS）患者妊娠结局。然而，现有的治疗方法对20%-30%抗磷脂综合征妊娠患者是失败的，因此需要探寻其他治疗方法以提高分娩结果。羟氯喹（HCQ）因具有抗炎、抗细胞聚集合免疫调节特性而被广泛应用于自身免疫系统疾病患者，主要是系统性红斑狼疮（SLE）。体外及动物模型研究表明羟氯喹对产科抗磷脂综合征有潜在的保护作用。我们的目的是系统回顾有效的证据，评估专家们对羟氯喹在改善抗磷脂综合征孕妇妊娠结局上的临床判断。可参考文献中，关于羟氯喹在改善抗磷脂综合征孕妇妊娠结局的临床数据是非常有限的。只有一项调查研究证明了服用羟氯喹的狼疮患者母亲及妊娠胎儿的结局。14例应用羟氯喹治疗的患者中有4例妊娠失败（29%），而24例未应用羟氯喹治疗的患者中有6例妊娠失败（25%）。然而，羟氯喹的作用不能被应用其他药物如阿司匹林、肝素或激素取代。通过e-mail联系受邀专家，请求专家审查工作组提供的证据总结并简要地回答每一位提出的问题。总的来说，部分专家们认为在特定情况下或经标准剂量阿司匹林和肝素治疗失败后可考虑加用羟氯喹，特别是在某些特别情况下，如之前有过血栓病史（动脉和/或静脉），伴或不伴既往缺血性胎盘所致并发症，大多数专家认为应当加用羟氯喹。有关抗磷脂抗体综合征孕妇怀孕期间应用羟氯喹的前瞻性研究是必要的，应该被常规推荐为临床实践。
附原文： ABSTRACT: The use of low-dose aspirin and heparinoids has improved the pregnancy outcome in obstetric antiphospholipid syndrome (APS). However, current treatment fails in 20-30?% of APS pregnancies, raising the need to explore other treatments to improve obstetrical outcome. Hydroxychloroquine (HCQ) is widely used in patients with autoimmune diseases, mainly systemic lupus erythematous (SLE), due to its anti-inflammatory, anti-aggregant and immune-regulatory properties. Evidence from in vitro and animal models suggests a potential protective effect of HCQ in obstetric APS. Pending the availability of prospective trials, we aimed to systematically review the available evidence and to assess the clinical judgment of a panel of experts regarding the use of HCQ in improving pregnancy outcome in women with antiphospholipid antibodies (aPL). Clinical data on the ability of HCQ to improve pregnancy outcome in women with aPL are very limited in the available literature. Only one cohort study evaluating maternal and fetal outcome of pregnancy in patients with SLE who were exposed to HCQ was identified. Four of 14 (29?%) treated with HCQ patients had pregnancy failure, compared with six of 24 (25?%) of patients not treated with HCQ. However, the effect of HCQ was not adjusted for the use of other medications such as aspirin, heparins or steroids. Selected experts were contacted by e-mail and asked to review the summary of the evidence provided by the working group and to briefly answer each of the proposed questions. Overall, the panel of experts agreed that adding HCQ could be considered in selected cases or after failure of standard treatment with aspirin and a heparin agent. Specifically, the majority of experts considered adding HCQ in specific scenarios, such as women with previous thrombosis (either arterial and/or venous), and/or with previous ischaemic placenta-mediated complications. Prospective studies are necessary before the use of HCQ during pregnancy in women with aPL should be routinely recommended for clinical practice.
引自： Sciascia S, Branch DW, Levy RA, et al. The efficacy of hydroxychloroquine in altering pregnancy outcome in women with antiphospholipid antibodies. Evidence and clinical judgment. Thromb Haemost. 2016 Jan 27;115(2):285-90. doi: 10.1160/TH15-06-0491. Epub 2015 Sep 17.
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