Микроангиопатический антифосфолипидный синдром в акушерской практике – риск генерализованной тромботической микроангиопатии


DOI: https://dx.doi.org/10.18565/nephrology.2018.4.66-73

Т.В. Кирсанова, М.А. Виноградова, А.И. Колыванова

1 ФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии им. акад. В.И. Кулакова» МЗ РФ; Москва, Россия; 2 Московский государственный институт им. М.В. Ломоносова, факультет фундаментальной медицины, кафедра внутренних болезней; Москва, Россия
Проведен систематический анализ данных, имеющихся в современной литературе, о микроангиопатическом антифосфолипидном синдроме (АФС) и других вариантах развития тромботической микроангиопатии (ТМА), в т.ч. HELLP-синдрома и преэклампсии, до 20 недель гестации, вариантах ведения таких беременностей и рисках акушерских осложнений у пациенток с АФС. Приведено описание 2 клинических случаев различных микроангиопатических АФС в акушерской практике, осложненных развитием HELLP-синдрома до 20-й недели. Данные случаи не только демонстрируют возможность дебюта HELLP-синдрома до 20-й недели беременности, но и развитие HELLP-синдрома при нормальном уровне Sflt1/PLGF, что, по-видимому, подтверждает обособленность HELLP-синдрома от преэклампсии. В обоих случаях зарегистрирована позитивность по всем трем группам основных антифосфолипидных антител, что исходно увеличивало риск возникновения акушерских осложнений, несмотря на адекватность лечения. Необходимость выделения микроангиопатического АФС подтверждается опасностью, которую несут все случаи развития признаков ТМА у больных АФС: риск генерализации ТМА вплоть до катастрофического АФС неоправданно высок. Только использование гепаринов (в т.ч. низкомолекулярных) в сочетании с ацетилсалициловой кислотой может считаться «золотым» стандартом ведения таких пациенток. Добавление гидроксихлорохина, возможно, улучшает исходы таких беременностей, что требует подтверждения в крупных многоцентровых исследованиях.
Ключевые слова: антифосфолипидный синдром, микроангиопатический антифосфолипидный синдром, тромботические микроангиопатии, HELLP-синдром, преэклампсия, катастрофический антифосфолипидный синдром
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Об авторах / Для корреспонденции

Т.В. Кирсанова – к.м.н., ст. науч. сотр. отделения репродуктивной гематологии и клинической гемостазиологии ФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии им. акад. В.И. Кулакова» Минздрава РФ;Москва, Россия. Е-mail: a_tatya@mail.ru
М.А. Виноградова – к.м.н., гематолог, зав. отделением репродуктивной гематологии и клинической гемостазиологии ФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии им. акад. В.И. Кулакова» МЗ РФ; Москва, Россия.
А.И. Колыванова – абитуриент кафедры внутренних болезней, факультет фундаментальной медицины МГУ им. М.В. Ломоносова; Москва, Россия.

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