Education, Awareness, Support

March 2019

by Professor Graham R V Hughes MD FRCP

February is the month for the Barcelona ‘Ten Topics’ meeting – an outstanding annual event – and this year was no exception.  A brilliant two day meeting, this year attracting 230 trainee doctors.

The atmosphere was wonderful – a packed auditorium and a mega volume noise level in the coffee break.  As in previous years (the Barcelona Ten Topics meeting is 21 years old this year) there was an emphasis on Lupus and Hughes syndrome, and the meeting was enlivened by a series of “pavement consults” (an idea borrowed from America I think, in which difficult cases are discussed by a small team of experts).  

Ten Topics is now held in seven international venues – London, Barcelona, Rome, Nice, Beirut, Buenos Aires, and Hong Kong – I estimate that well over 1500 young doctors internationally are taught with the help of the ‘Ten Topics’ programme.  Incidentally, the London Ten Topics 2019 meeting, organised by Professor Chris Edwards is planned for London Bridge on July 11thand 12th.

Patient of the month

Infertility

This month, a short case report and an equally short discussion.  But a major, major topic.

Mrs T.T., aged 24 got married and she and her husband planned to have a family sooner, rather than later.

But the months turned into four years, and still no pregnancy.  Both she and her husband were tested in an IVF clinic – but still no pregnancy.

Mrs T.T’s health was good (apart from – guess what – a tendency to migraine attacks).  However, out of the blue, at the age of 28, she developed a big DVT – with a possible pulmonary embolus.  She was treated firstly with heparin, followed by warfarin.  Three months later her pregnancy test was positive. The warfarin was stopped and the pregnancy was completed on heparin.  (And with no migraines during the whole eight months).

At some stage, she was blood tested for aPL (anti-phospholipid antibodies) and found to be strongly positive.

Any further pregnancies?  Yes.  Three. All with the same pattern – warfarin now continued by her physicians because of fears of more thrombosis, but stopped when the pregnancy tests became positive (standard practice) and changed to heparin for the pregnancy.

What is the patient teaching us?

Recurrent miscarriages and even later pregnancy loss (stillbirth) are well recognised features of Hughes syndrome.  But infertility?  Certainly many cases of recurrent very early pregnancy losses have been labelled as “infertility” in the past, and in the literature there are one or two published studies of aPL infertile patients.

Although probably rare, ‘sticky blood’ should be considered – especially if the background history (migraines? thrombosis?) is suspicious.

If there is a link, possible mechanisms could include antibody attack, or, impaired circulation to the reproductive organs.

Lots of maybes – but potentially important.

Professor Graham R V Hughes MD FRCP

Professor Graham R V Hughes MD FRCP

Head of The London Lupus Centre
London Bridge Hospital