London Bridge Hospital

About: London Bridge Hospital is a healthcare organization based out in London, United Kingdom. It is known for research contribution in the topics: Antiphospholipid syndrome & Systemic lupus erythematosus. The organization has 107 authors who have published 122 publications receiving 4523 citations.

Miscarriage and heart attack.

Abstract: Once in a while, the stimulus for a research project comes not from a medical conference, or from a learned journal, but from an unlikely source – such as a newspaper. Even a throwaway newspaper. Thus, it was in my free daily London issue of the METRO, the headline appeared ‘‘Miscarriage link to risk of heart attack’’. The newspaper quoted a research paper from Heidelberg published online in the journal ‘‘Heart’’. A quarter of more than 11,500 women taking part in the study had suffered at least one miscarriage. Those who had more than three miscarriages were nine times more likely to have a subsequent heart attack, and a stillbirth increased the risk by 3.5 times. In response to the study, the British Heart Foundation said that in some cases of multiple miscarriages, women had previously undiagnosed heart and circulation disease which carried heart attack risks that may be unrelated to pregnancy. Do you believe that? Possibly in rare cases. For me, there is a far, far more likely link – antiphospholipid antibodies (aPL) and the antiphospholipid syndrome. Three decades of clinical experience since the description of the antiphospholipid syndrome have thrown up some clear clinical lessons in the world of obstetrics. The syndrome might be the commonest, treatable cause of recurrent miscarriage. Indeed, for late pregnancy loss the association with aPL is so strong that routine testing of all women with this tragic pregnancy outcome is considered mandatory – if only to alert obstetricians to the risks in any future pregnancy. Recognition of the syndrome has become an important component of obstetric care. But there is still a way to go. In particular, two weaknesses remain. Firstly, the decision as to whether to test after a single, or even two miscarriages. As miscarriage is common, statistics and socio-economic constraints currently advocate the need for aPL testing only after 3 or more miscarriages – something that in the view of this author is debatable: aPL testing could protect against further miscarriages or even a tragic future late pregnancy loss. This is an area which has been debated by APS experts and obstetricians for years, as clearly outlined in an excellent series of reviews at the 13 International Congress on Antiphospholipid Antibodies held in Galveston, April 2010, and elsewhere. The arguments are well rehearsed and based on selection and on the relatively small number of positive aPL/APS women seen in the ocean of miscarriage patients. However, one weakness of the ‘‘wait for 3 miscarriages’’ school is that studies are often limited to patients fulfilling the Sapporo criteria for APS. As with lupus, criteria are for classification rather than diagnosis and, as with lupus, clinical experience teaches us that there are many, many patients with less than classical APS, or in whom tests are borderline or even negative. The second weakness in obstetric care concerns the longer term follow-up. The aPL positive patient who, when treated, has a successful pregnancy, is congratulated, discharged and . . . . . .? The long (and sometimes short) term risks of aPL positivity are now well known and include DVT, pulmonary embolism, migraine and stroke. Another arterial thrombotic risk of APS is myocardial infarction. This complication, recognised early on in clinical descriptions of the syndrome has, if anything, been underreported. Recently, however, two major studies highlighted a strong link between the presence of aPL and heart attack. Greco and colleagues studied 344 acute coronary syndrome patients and found 40% aPL positive in one or more tests. Urbanus and colleagues looked at women under 50 with myocardial infarction or ischaemic stroke. The odds ratio for MI in aPL positive women and oral contraceptive was 22. Thus, it is possible that the excellent epidemiological study from Heidleberg linking miscarriage and later heart attack may have a clear – and measurable – link.

Pregnancy and Fetal Loss

Abstract: For the purpose of clinical definition, pregnancy is divided into two halves, each of 20 weeks. Any pregnancy loss before 20 weeks is classified as abortion and after 20 weeks, when the fetus is well-formed, as fetal loss.

Bones and Joints

Abstract: A number of cases of “idiopathic” bone necrosis have been reported in aPL-positive individuals with no other risk factors and who have never received steroids These include avascular lesions in the hip and shoulder, for example (Fig 171)