Young women should be referred to an obstetrician or gynaecologist

Editor—I read the Grand Round about a patient with systemic lupus erythematosus and the antiphospholipid antibody syndrome with concern.1 The absence of an obstetrician and gynaecologist from the discussion group led to inaccuracies and omissions in the management advised.

In women–with or without systemic lupus erythematosus–the presence of antiphospholipid antibodies is the most sensitive indicator of late fetal death2 and necessitates treatment with low dose aspirin and either subcutaneous heparin at an anticoagulant dose or steroids. Despite the morbidity associated with this regimen, previous fetal loss should not be a prerequisite for its prescription. One study reported a successful outcome of pregnancy in six untreated women with the antiphospholipid antibody syndrome; it used Doppler studies for fetal monitoring.3 While obstetricians agree that careful fetal monitoring is the essence of successful management in most high risk pregnancies, the relative contributions of surveillance versus treatment in the antiphospholipid antibody syndrome have yet to be studied. No amount of scanning, however, will prevent fetal or neonatal death before 24 weeks' gestation.

The group also failed to mention the importance of future adequate contraception and the role of prenatal counselling. Systemic …