Navigating obstetric antiphospholipid syndrome: pathophysiology, diagnosis, and therapeutic advances

INTRODUCTION: Obstetric antiphospholipid syndrome (OAPS) is a complex autoimmune disorder that contributes significantly to pregnancy morbidity. Despite advances in understanding its mechanisms, 20-30% of women, especially those refractory to standard treatments, continue to face adverse outcomes. Emerging therapies, including biologics and immunomodulators, are under investigation; however, data in this field remain limited. AREAS COVERED: This review examines the current understanding of OAPS pathogenesis and risk stratification. It evaluates established management strategies such as aspirin and heparin, and explores adjunctive or investigational therapies, including hydroxychloroquine, corticosteroids, intravenous immunoglobulins, statins, plasma exchange, and biologics. Key knowledge gaps, concerning refractory cases and personalized treatment approaches, are highlighted, emphasizing the importance of multidisciplinary, risk-based care throughout preconception, pregnancy, and postpartum. This review focuses primarily on primary OAPS rather than secondary APS associated with systemic lupus erythematosus. EXPERT OPINION: Innovations in immunotherapy and targeted biologics hold promise for refractory OAPS; however, large trials are needed to confirm their safety and efficacy during pregnancy. Future management is likely to involve biomarker-driven strategies, incorporating machine learning to enhance prediction and individualization of treatment. The development of standardized diagnostic criteria and risk assessment tools, alongside multidisciplinary collaboration, will be crucial in advancing care, ultimately transforming maternal-fetal health outcomes.