Pregnancy morbidity associated with APS

≥3 consecutive otherwise unexplained* prefetal deaths (<10 weeks 0 days) and/or early fetal deaths (10 weeks 0 days to 15 weeks 6 days)

≥1 fetal death (16 weeks 0 days to 34 weeks 0 days) alone (ie, no preeclampsia with severe features or placental insufficiency with severe features^¶)

Preeclampsia with severe features (<34 weeks 0 days) with or without fetal death

Placental insufficiency with severe features (<34 weeks 0 days)^¶ with or without fetal death

APS: antiphospholipid syndrome; aPL: antiphospholipid antibodies.

* If a detailed analysis of fetal morphology or genetic studies is not performed or unavailable, reasonable clinical judgment that the loss is unexplained should be used based on careful history and review of available medical records.

¶ Placental insufficiency with severe features is defined by fetal/newborn growth restriction (estimated fetal weight <10^th percentile for gestational age or postnatal birth weight <10^th percentile for gestational age) in the absence of fetal-neonatal syndromes or genetic conditions associated with growth restriction and at least one of the following severe features:

Abnormal or nonreassuring fetal surveillance test(s) suggestive of fetal hypoxemia (eg, nonreactive nonstress test, low biophysical profile score [0 to 4 out of 10])
Abnormal Doppler velocimetry suggestive of fetal hypoxemia (eg, absent or reversed end-diastolic flow in the umbilical artery)
Severe fetal/newborn growth restriction (eg, estimated fetal or postnatal birth weight <3^rd percentile for gestational age)
Oligohydramnios (eg, amniotic fluid index ≤5 cm, deepest vertical pocket <2 cm)
Placental histology showing maternal vascular malperfusion (eg, placental thrombosis/infarction, inadequate remodeling of the uterine spiral arteries [decidual vasculopathy], decreased vasculosyncytial membranes, increased syncytial knots, or decidual inflammation)
NOTE: Maternal vascular malperfusion can be detected in the placentas of aPL-negative patients with growth restriction and/or preeclampsia and in normal pregnancies, thus these findings are not specific for APS. Whether to send the placenta for histopathologic evaluation is a clinical judgment. Postdelivery histopathologic placental examination is performed when the clinician believes that the information may aid understanding of obstetric, fetal, or neonatal abnormalities. Refer to UpToDate content on placental examination for more information.
Although placental abruption has been associated with placental insufficiency, APS is not associated with placental abruption, and placental abruption is not a defining morbidity for APS.

Adapted from: Barbhaiya M, Zuily S, Naden R, et al. 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Arthritis Rheumatol 2023.

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Pregnancy morbidity associated with APS