1
|
Kirovakov Z, Konova E, Hinkova N, Markova S, Penchev P. Immunological Risk Factors in Recurrent Pregnancy Loss in Patients With Hereditary Thrombophilia. Cureus 2024; 16:e56555. [PMID: 38533322 PMCID: PMC10965193 DOI: 10.7759/cureus.56555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Recurrent pregnancy loss (RPL) is a complicated reproductive disorder with underlying genetic and immunological causes. RPL may be influenced by hereditary thrombophilia, a class of blood clotting-related genetic abnormalities, via the vascular and immune systems. This study examines the immunological characteristics that hereditary thrombophilia patients have in common with RPL. METHODS A prospective cohort study included 300 patients split into two groups: a control group without hereditary thrombophilia and a group with the condition. Interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ) levels were measured, along with demographic specifics, antiphospholipid antibodies, natural killer (NK) cell counts, and other cytokines. Group differences were found using statistical analysis. RESULTS Antiphospholipid antibodies were significantly more common in the thrombophilia group (42% testing positive, p=0.001) compared to the control group (12% testing positive), despite demographic factors being similar between groups (p=0.372 and p=0.093). When body mass index (BMI) was taken into account, the study found a statistically significant difference (p=0.046), with the thrombophilia group having a higher mean BMI (26.3 kg/m2, standard deviation (SD): 2.8) than the control group (24.7 kg/m2, SD: 3.1). IL-6 (14.8 pg/mL, SD: 3.2, p=0.029) were higher than the control group (12.4 pg/mL, SD: 2.1), and TNF-α levels were higher in the thrombophilia group (10.5 pg/mL, SD: 2.0, p=0.012) compared to the control group (8.9 pg/mL, SD: 1.5), but NK cell counts did not differ significantly (p=0.213). CONCLUSION This study emphasizes the role of elevated pro-inflammatory cytokines (IL-6 and TNF-α) and antiphospholipid antibodies in RPL among people with hereditary thrombophilia. In this population, early detection and immunomodulatory interventions may improve pregnancy outcomes. To fully comprehend these mechanisms and create customized treatments, collaborative research is required.
Collapse
Affiliation(s)
- Zlatko Kirovakov
- Department of Midwifery Care, Faculty of Health Care, Medical University - Pleven, Pleven, BGR
- Department of Obstetrics and Gynecology, University Hospital for Active Treatment - Burgas, Burgas, BGR
| | - Emiliana Konova
- Clinical Institute for Reproductive Medicine, Medical University - Pleven, Pleven, BGR
| | - Nadezhda Hinkova
- Department of Midwifery Care, Faculty of Health Care, Medical University - Pleven, Pleven, BGR
| | - Stefani Markova
- Department of Obstetrics and Gynecology, University Hospital for Active Treatment - Burgas, Burgas, BGR
| | - Plamen Penchev
- Faculty of Medicine, Medical University of Plovdiv, Plovdiv, BGR
| |
Collapse
|
2
|
Lv Q, Wang Y, Tian W, Liu Y, Gu M, Jiang X, Cai Y, Huo R, Li Y, Li L, Wang X. Exosomal miR-146a-5p derived from human umbilical cord mesenchymal stem cells can alleviate antiphospholipid antibody-induced trophoblast injury and placental dysfunction by regulating the TRAF6/NF-κB axis. J Nanobiotechnology 2023; 21:419. [PMID: 37957714 PMCID: PMC10641965 DOI: 10.1186/s12951-023-02179-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Exosomes originating from human umbilical cord mesenchymal stem cells (hucMSC-exos) have become a novel strategy for treating various diseases owing to their ability to regulate intercellular signal communication. However, the potential of hucMSC-exos to improve placental injury in obstetric antiphospholipid syndrome and its underlying mechanism remain unclear. Our objective was to explore the potential application of hucMSC-exos in the treatment of obstetric antiphospholipid syndrome and elucidate its underlying mechanism. In our study, hucMSC-exos ameliorated the functional impairment of trophoblasts caused by antiphospholipid antibodies in vitro and attenuated placental dysfunction in mice with obstetric antiphospholipid syndrome by delivering miR-146a-5p. Exosomal miR-146a-5p suppressed the expression of tumor necrosis factor receptor-associated factor 6 (TRAF6) and inhibited the activation of NF-κB signaling, leading to the down-regulation of IL-1β and IL-18 to rescue inflammation and modulation of Cleaved-CASP3, BAX, and BCL2 to inhibit apoptosis in HTR8/SVneo cells and mice placenta. This study identified the potential molecular basis of how hucMSC-exos improved antiphospholipid antibody-induced placental injury and highlighted the functional importance of the miR-146a-5p/TRAF6 axis in the progression of obstetric antiphospholipid syndrome. More importantly, this study provided a fresh outlook on the promising use of hucMSC-exos as a novel and effective treatment approach in obstetric antiphospholipid syndrome.
Collapse
Affiliation(s)
- Qingfeng Lv
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China
| | - Yuan Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Wei Tian
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Yuqiu Liu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Mengqi Gu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Xiaotong Jiang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Yanjun Cai
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China
| | - Ruiheng Huo
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China
| | - Yuchen Li
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China
| | - Lei Li
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China.
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
- The Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences) of China, Jinan, 250117, Shandong, China.
- The Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Shandong Provincial Maternal and Child Health Care Hospital, Jinan, 250014, Shandong, China.
| |
Collapse
|
3
|
Yi Y, Fu J, Xie S, Zhang Q, Xu B, Wang Y, Wang Y, Li B, Zhao G, Li J, Li Y, Zhao J. Association between ovarian reserve and spontaneous miscarriage and their shared genetic architecture. Hum Reprod 2023; 38:2247-2258. [PMID: 37713654 DOI: 10.1093/humrep/dead180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Indexed: 09/17/2023] Open
Abstract
STUDY QUESTION Can potential mechanisms involved in the likely concurrence of diminished ovarian reserve (DOR) and miscarriage be identified using genetic data? SUMMARY ANSWER Concurrence between ovarian reserve and spontaneous miscarriage was observed, and may be attributed to shared genetic risk loci enriched in antigen processing and presentation and autoimmune disease pathways. WHAT IS KNOWN ALREADY Previous studies have shown that lower serum anti-Müllerian hormone (AMH) levels are associated with increased risk of embryo aneuploidy and spontaneous miscarriage, although findings have not been consistent across all studies. A recent meta-analysis suggested that the association between DOR and miscarriage may not be causal, but rather a result of shared underlying causes such as clinical conditions or past exposure. Motivated by this hypothesis, we conducted the present analysis to explore the concurrence between DOR and miscarriage, and to investigate potential mechanisms using genetic data. STUDY DESIGN, SIZE, DURATION Three data sources were used in the study: the clinical IVF data were retrospectively collected from an academically affiliated Reproductive Medicine Center (17 786 cycles included); the epidemiological data from the UK Biobank (UKB), which is a large-scale, population-based, prospective cohort study (35 316 white women included), were analyzed; and individual-level genotype data from the UKB were extracted for further analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS There were three modules of analysis. First, clinical IVF data were used to test the association between ovarian reserve biomarkers and the subsequent early spontaneous miscarriage risk. Second, the UKB data were used to test the association of spontaneous miscarriage history and early menopause. Third, individual-level genotype data from the UKB were analyzed to identify specific pleiotropic genes which affect the development of miscarriage and menopause. MAIN RESULTS AND THE ROLE OF CHANCE In the analysis of clinical IVF data, the risk of early spontaneous miscarriage was 1.57 times higher in the group with AMH < 1.1 ng/ml group (P < 0.001), 1.62 times for antral follicular count <5 (P < 0.001), and 1.39 times for FSH ≥10 mIU/ml (P < 0.001) in comparison with normal ovarian reserve groups. In the analysis of UKB data, participants with a history of three or more miscarriages had a one-third higher risk of experiencing early menopause (odds ratio: 1.30, 95% CI 1.13-1.49, P < 0.001), compared with participants without spontaneous miscarriage history. We identified 158 shared genetic risk loci that affect both miscarriage and menopause, which enrichment analysis showed were involved in antigen processing and presentation and autoimmune disease pathways. LIMITATIONS, REASONS FOR CAUTION The analyses of the UKB data were restricted to participants of European ancestry, as 94.6% of the cohort were of white ethnicity. Further studies are needed in non-white populations. Additionally, maternal age at the time of spontaneous miscarriage was not available in the UKB cohort, therefore we adjusted for age at baseline assessment in the models instead. It is known that miscarriage rate in IVF is higher compared to natural conception, highlighting a need for caution when generalizing our findings from the IVF cohort to the general population. WIDER IMPLICATIONS OF THE FINDINGS Our findings have implications for IVF clinicians in terms of patient counseling on the prognosis of IVF treatment, as well as for genetic counseling regarding miscarriage. Our results highlight the importance of further research on the shared genetic architecture and common pathophysiological basis of DOR and miscarriage, which may lead to new therapeutic opportunities. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Hunan Youth Science and Technology Innovation Talent Project (2020RC3060), the International Postdoctoral Exchange Fellowship Program (Talent-Introduction Program, YJ20220220), the fellowship of China Postdoctoral Science Foundation (2022M723564), and the Natural Science Foundation of Hunan Province, China (2023JJ41016). This work has been accepted for poster presentation at the 39th Annual Meeting of ESHRE, Copenhagen, Denmark, 25-28 June 2023 (Poster number: P-477). The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- Yan Yi
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Jing Fu
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Shi Xie
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Qiong Zhang
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Bin Xu
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Yonggang Wang
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Yijing Wang
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Bin Li
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Guihu Zhao
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Jinchen Li
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Yanping Li
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Jing Zhao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| |
Collapse
|
4
|
Li Y, Niu Y, Liu M, Lan X, Qin R, Ma K, Zhao HJ. First-trimester serum antiphosphatidylserine antibodies serve as candidate biomarkers for predicting pregnancy-induced hypertension. J Hypertens 2023; 41:1474-1484. [PMID: 37382157 DOI: 10.1097/hjh.0000000000003498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVE The aim of this study was to explore whether antiphosphatidylserine (aPS) antibodies play roles in the early prediction of pregnancy-induced hypertension (PIH). METHODS The serum levels of different isotypes of aPS antibodies were compared in women diagnosed with PIH (PIH group, n = 30) and 1 : 1 matched normotensive controls (control group, n = 30). All patients underwent frozen embryo transfer (FET) cycles, and all serum samples were collected during 11-13 weeks of gestation. Receiver operating characteristic (ROC) curves were drawn to analyze the predictive values of aPS antibodies for PIH. RESULTS The women who developed PIH after FET had higher serum optical density values (450 nm) of aPS immunoglobulin (Ig) A (1.31 ± 0.43 vs. 1.02 ± 0.51, P = 0.022), aPS IgM (1.00 ± 0.34 vs. 0.87 ± 0.18, P = 0.046), and aPS IgG (0.50 ± 0.12 vs. 0.34 ± 0.07, P < 0.001) compared with the normotensive controls. The serum concentration of total IgG [48.29 ± 10.71 (g/dl) vs. 34.39 ± 11.62 (g/dl), P < 0.001] was also higher in the PIH group compared with that in the control group. The aPS IgG alone [area under the curve (AUC): 0.913, 95% confidence interval (CI): 0.842-0.985, P < 0.001] and the combined analysis of aPS IgA, aPS IgM, aPS IgG, and total IgG (AUC: 0.944, 95% CI: 0.888-1.000, P < 0.001) had high predictive values for PIH. CONCLUSION Serum aPS autoantibody levels during the first trimester of pregnancy are positively associated with the development of PIH. Further validation is needed to clearly identify the distinct contributions and underlying mechanisms for diagnostic applications of aPS autoantibodies in PIH prediction.
Collapse
Affiliation(s)
- Yan Li
- Center for Reproductive Medicine, Shandong University
- Medical Integration and Practice Center, Shandong University, Jinan, Shandong
- Suzhou Research Institute, Shandong University, Suzhou, Jiangsu
| | - Yue Niu
- Center for Reproductive Medicine, Shandong University
- Medical Integration and Practice Center, Shandong University, Jinan, Shandong
| | - Mingxi Liu
- Center for Reproductive Medicine, Shandong University
- Medical Integration and Practice Center, Shandong University, Jinan, Shandong
| | - Xiangxin Lan
- Center for Reproductive Medicine, Shandong University
- Medical Integration and Practice Center, Shandong University, Jinan, Shandong
| | - Rencai Qin
- Centre for Infection and Immunity Studies, School of Medicine, The Sun Yat-sen University, Shenzhen, Guangdong
| | - Kongyang Ma
- Centre for Infection and Immunity Studies, School of Medicine, The Sun Yat-sen University, Shenzhen, Guangdong
| | - Hong-Jin Zhao
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University
- Department of Cardiology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| |
Collapse
|
5
|
Tincani A, Fontana G, Mackworth-Young C. The history of antiphospholipid syndrome. Reumatismo 2023; 74. [PMID: 36942979 DOI: 10.4081/reumatismo.2022.1556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/27/2023] [Indexed: 03/23/2023] Open
Abstract
Antiphospholipid Syndrome (APS) is an autoimmune disease which was defined in the early 1980s. The principal features include thromboembolic events and/or pregnancy losses in association with antiphospholipid antibodies (aPL). As an historical note, the full-blown picture of the syndrome resembles the illness suffered by Anne Stuart, Queen of England in the XVIII century, whose repeated miscarriages caused the end of the royal Stuart line and the Hanoverian succession. The identification of aPL started in the early XX century and was linked to the introduction of the serological test for the diagnosis of syphilis. This involves a reaction between an antibody (reagin) and a phospholipid antigen derived from bovine heart (cardiolipin). Later on, it was observed that not all subjects with a positive test had syphilis, and that the so called "false positive reaction" was often reported in patients with systemic lupus erythematosus. Different tests for the identification of aPL were subsequently developed: first lupus anticoagulant (1971) and then immunoassays for anticardiolipin (1983) and anti-beta2 glycoprotein I (1990) antibodies. In the same period the association between the presence of circulating aPL and thrombotic and obstetric events was established, both in patients with autoimmune diseases and in otherwise healthy subjects, leading to the identification of APS as a distinct autoimmune disease. This has allowed better diagnosis and more targeted treatment for many patients.
Collapse
Affiliation(s)
- A Tincani
- Reumatologia e Immunologia Clinica; ASST-Spedali Civili e Università degli Studi di Brescia.
| | - G Fontana
- Reumatologia e Immunologia Clinica; ASST-Spedali Civili e Università degli Studi di Brescia.
| | | |
Collapse
|
6
|
Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
Collapse
Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
| |
Collapse
|
7
|
Li J, Hou Y, Zhang L, Li F, Liu Q, Li Y, Shen H, Xiong Z, Huang L, Qiao C. Clinical phenotype, treatment strategy and pregnancy outcome of non-criteria obstetric antiphospholipid syndrome. Am J Reprod Immunol 2023; 89:e13684. [PMID: 36756665 DOI: 10.1111/aji.13684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/10/2022] [Accepted: 01/28/2023] [Indexed: 02/10/2023] Open
Abstract
PROBLEM To illustrate the clinical features, treatment strategy, and pregnancy outcome of patients with obstetric antiphospholipid syndrome (OAPS), non-criteria obstetric antiphospholipid syndrome (NC-OAPS) METHOD OF STUDY: A single-center nested case-control study was designed. Patients with a diagnosis of OAPS and NC-OAPS were enrolled. The medical history, coagulation status, and antibody profile data were collected. Patients were given standard anticoagulation therapy with or without glucocorticoids (GC) and/or hydroxychloroquine (HCQ) during pregnancy and were observed for their pregnancy outcome. RESULTS A total of 47 patients with OAPS and 120 patients with NC-OAPS were finally included, of whom 55 patients met the clinical criteria (subgroup C) and 65 met the laboratory criteria (subgroup L). Pregnancy morbidity showed significant differences: gravida, pregnancy loss in OAPS versus NC-OAPS. The coagulation function was not significantly different between OAPS and NC-OAPS groups, while TT and FIB were significantly higher in the subgroup C. Thromboelastography (TEG) results showed a significantly lower ANGEL in the NC-OAPS group, a higher ANGEL and lower EPL, LY30 in the subgroup L. No differences between groups were observed in treatment strategy. The pregnancy outcomes were not significantly different between NC-OAPS and OAPS groups. CONCLUSIONS Clinical and laboratory differences were found between OAPS and NC-OAPS groups in this study. Patients in different subgroups of NC-OAPS could be identified with different clinical phenotypes. A relatively hypercoagulable status existed in the OAPS group compared to NC-OAPS, and also in the subgroup L.
Collapse
Affiliation(s)
- Jiapo Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Reproductive and Genetic Medicine, National Health Commission, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Yue Hou
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Liyang Zhang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Fan Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Qian Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Yuanyuan Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Hongfei Shen
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Ziyue Xiong
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Ling Huang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| | - Chong Qiao
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.,Key Laboratory of Reproductive and Genetic Medicine, National Health Commission, Shenyang, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, China.,Research Center of China Medical University Birth Cohort, Shenyang, China
| |
Collapse
|
8
|
D’Ippolito S, Barbaro G, Paciullo C, Tersigni C, Scambia G, Di Simone N. Antiphospholipid Syndrome in Pregnancy: New and Old Pathogenetic Mechanisms. Int J Mol Sci 2023; 24:3195. [PMID: 36834614 PMCID: PMC9966557 DOI: 10.3390/ijms24043195] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/08/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized, according to the Sydney criteria, by the persistent presence of autoantibodies directed against phospholipid-binding proteins associated with thrombosis and/or obstetrical complications. The most frequent complications in obstetric antiphospholipid syndrome are recurrent pregnancy losses and premature birth due to placental insufficiency or severe preeclampsia. In recent years, vascular APS (VAPS) and obstetric APS (OAPS) have been described as two different clinical entities. In VAPS, antiphospholipid antibodies (aPL) interfere with the mechanisms of coagulation cascade and the 'two hit hypothesis' has been suggested to explain why aPL positivity does not always lead to thrombosis. OAPS seems to involve additional mechanisms, such as the direct action of anti-β2 glycoprotein-I on trophoblast cells that can lead to a direct placental functional damage. Furthermore, new actors seem to play a role in the pathogenesis of OAPS, including extracellular vesicles, micro-RNAs and the release of neutrophil extracellular traps. The aim of this review is to investigate the state-of-the-art antiphospholipid syndrome pathogenesis in pregnancy, in order to provide a comprehensive overview of both old and new pathogenetic mechanisms involved in this complex disease.
Collapse
Affiliation(s)
- Silvia D’Ippolito
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), L. go A. Gemelli 8, 00168 Rome, Italy
| | - Greta Barbaro
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), L. go A. Gemelli 8, 00168 Rome, Italy
| | - Carmela Paciullo
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), L. go A. Gemelli 8, 00168 Rome, Italy
| | - Chiara Tersigni
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), L. go A. Gemelli 8, 00168 Rome, Italy
| | - Giovanni Scambia
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), L. go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, L. go A. Gemelli 8, 00168 Rome, Italy
| | - Nicoletta Di Simone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| |
Collapse
|
9
|
Shaikhomar OA, Ali ST. A Comparative Analysis of Anticardiolipin, Anti-Β2-Glycoprotein-1, and Lupus Anticoagulants in Saudi Women with Recurrent Spontaneous Abortions. J Pers Med 2022; 13:jpm13010002. [PMID: 36675663 PMCID: PMC9861935 DOI: 10.3390/jpm13010002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/02/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Association and pathogenesis of antiphospholipid antibodies (APAs) in patients with Antiphospholipid syndrome (APS) as well as systemic lupus erythematosus (SLE) suffering from unexplained spontaneous abortions is controversial. Moreover, the majority of the published evidence is based on the patient histories rather than the study groups. The main objective of the present study is to do a comparative analysis of the high levels of antiphospholipid antibodies (APAs) including anticardiolipin (ACA), anti-β2-glycoprotein-1 (β2 GP1), and Lupus anticoagulants (LA) and their association with the gestational age of abortion and duration past abortion in Saudi women. In this study, 100 women living in Makkah city, located in the Western region of Saudi Arabia, with a mean age of 30.5 ± 12.60 years (mean ± standard deviation), having a previous history of recurrent spontaneous abortions were enrolled as case group and 100 healthy pregnant women previously having one or more successful pregnancies were selected as control group. Based on the gestational age of the patient’s miscarriages, our results revealed consistently and significantly high levels of ACA, β2 GP1, and LA, being greatest at more than 15 weeks when compared with 10 weeks and 11−15 weeks, respectively. Based on duration of past miscarriages, a slightly increased level was observed at ≤4 years after their first miscarriage. In addition, less or more equal levels of these antibodies were observed at 5−12 and more than 12 years in all the cases of miscarriages. We concluded an elevated pattern of APAs in these patients with an increase in the age of abortion. A comparison between the levels of ACA, β2 GP1, and LA further indicated a highly significant level of LA in all the cases of abortions (p < 0.0005).
Collapse
|
10
|
Abdolmohammadi-Vahid S, Samaie V, Hashemi H, Mehdizadeh A, Dolati S, Ghodrati-Khakestar F, Niafar M, Yousefi M. Anti-thyroid antibodies and underlying generalized immunologic aberrations in patients with reproductive failures. J Reprod Immunol 2022; 154:103759. [PMID: 36332368 DOI: 10.1016/j.jri.2022.103759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
The link between autoimmune thyroid diseases and reproductive failures, including implantation failure and pregnancy loss, has been attracted a great deal of attention in the last two decades. In this regard, a considerable progress has been achieved in understanding the etiopathogenesis of the adverse pregnancy consequences related to the presence of anti-thyroid antibodies, however, the exact action mechanisms of these antibodies are not fully comprehended. Thyroid peroxidase antibodies (TPOAbs), thyroglobulin antibodies (TgAbs) and TSH receptor antibodies (TRAbs) are the anti-thyroid antibodies which are present in autoimmune thyroid disorder (AITD) patients, such as Hashimoto's thyroiditis. In this condition, the thyroid hormones production, which are essential for normal implantation and pregnancy, are disrupted, and compromise the embryo or fetus development. In addition, a hypothesis suggests that there is underlying generalized immune abnormalities behind the presence of these antibodies. On the other hand, similar immunologic aberrations have been observed in thyroid autoimmunity and reproductive complications, which are postulated to be the proper answer for the scientists who seek for the pathophysiology behind the presence of these antibodies. Elevated inflammatory responses and decreased immunoregulatory actions, seem to be the main interfering pathologic factors in maternal tolerance toward fetus. In addition, cross reactivity of these antibodies with antigenic determinants of egg, embryo and placenta is another suggested mechanism, causing implantation and pregnancy complications. The ability of anti-thyroid antibodies in passing through the placental barrier and affecting the fetal thyroid gland, makes them more threatening for maintenance of a pregnancy.
Collapse
Affiliation(s)
- Samaneh Abdolmohammadi-Vahid
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vajihe Samaie
- Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Huriyeh Hashemi
- Department of Internal Medicine, Isfahan University of Medical Science, Isfahan, Iran
| | - Amir Mehdizadeh
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanam Dolati
- Physical Medicine and Rehabilitation Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mitra Niafar
- Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
11
|
Kwak-Kim J, AlSubki L, Luu T, Ganieva U, Thees A, Dambaeva S, Gilman-Sachs A. The role of immunologic tests for subfertility in the clinical environment. Fertil Steril 2022; 117:1132-1143. [DOI: 10.1016/j.fertnstert.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Accepted: 04/06/2022] [Indexed: 11/04/2022]
|
12
|
Jarne-Borràs M, Miró-Mur F, Anunciación-Llunell A, Alijotas-Reig J. Antiphospholipid antibodies in women with recurrent embryo implantation failure: A systematic review and meta-analysis. Clin Exp Rheumatol 2022; 21:103101. [PMID: 35452853 DOI: 10.1016/j.autrev.2022.103101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/18/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Antiphospholipid antibodies (aPL) are related to poor pregnancy outcomes, but their effect on embryo implantation is unclear. We aimed to assess the prevalence of different aPL in women with recurrent implantation failure (RIF). METHODS We searched studies in PubMed (MEDLINE), Scopus and Cochrane Library. Quality of studies was scored by the Newcastle-Ottawa Scale and risk of bias assessment by items described in RevMan5 software. Statistical analyses were made using random-effects model and presented as pooled Odds Ratio (OR), 95% confidence interval (CI). Heterogeneity was assessed by I2% and D2%. RESULTS This systematic review and meta-analysis included 17 studies and showed a high degree of variability in aPL positivity in RIF. In the latter, the risk of bias assessment suggested unclear bias on study performance with a median sample size and interquartile range for RIF patients and fertile women of 96 (57-417) and 100 (60.5-202.5), respectively. Among the criteria aPL, IgG anticardiolipin autoantibodies (OR 5.02, 95% CI [1.95, 12.93]) were associated with RIF. Within the non-criteria aPL, anti-β2 glycoprotein I-IgA (OR 64.8, 95% CI [9.74, 431.0]), and antiphosphatidylglycerol-IgG and IgM (OR 10.74, 95% CI [5.25, 22.0]; OR 4.26, 95% CI [1.76,10.31]; respectively) were associated with RIF, too. CONCLUSIONS Anticardiolipin-IgG is a prevalent autoantibody in women with RIF. Three other non-criteria aPL, aβ2GP I-IgA, aPG-IgG and aPG-IgM also present a positive rate in RIF. Overall, these results advise about testing them as indicators of RIF risk in women seeking IVF treatment.
Collapse
Affiliation(s)
| | - Francesc Miró-Mur
- Systemic Autoimmune Research Unit, Vall d'Hebron Institut de Recerca, Barcelona, Spain.
| | | | - Jaume Alijotas-Reig
- Systemic Autoimmune Research Unit, Vall d'Hebron Institut de Recerca, Barcelona, Spain; Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| |
Collapse
|
13
|
Riancho-Zarrabeitia L, Lopez-Marin L, Cacho PM, López-Hoyos M, Barrio RD, Haya A, Martínez-Taboada VM. Treatment with low-dose prednisone in refractory obstetric antiphospholipid syndrome: A retrospective cohort study and meta-analysis. Lupus 2022; 31:808-819. [PMID: 35410552 DOI: 10.1177/09612033221091401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Glucocorticoids have been suggested as a potential therapy in refractory obstetric antiphospholipid syndrome (oAPS). Our aims were to describe a cohort of patients with oAPS treated with low-dose glucocorticoids and to perform a systematic review and meta-analysis evaluating the effects of additional glucocorticoids on the pregnancy outcomes in oAPS patients. METHODS Retrospective study that included 11 women diagnosed with primary antiphospholipid syndrome. The meta-analysis was conducted by fitting random effects models and was checked for heterogeneity. RESULTS All women had suffered from early pregnancy losses and two also had a history of fetal deaths. We studied 47 pregnancies that resulted in 32 abortions (68.1%) and 3 fetal deaths (6.4%). Twenty-six pregnancies were under treatment, mainly LDA and LMWH. Low-dose glucocorticoids were indicated in 13 pregnancies (always in association with LDA and LMWH). There was a decrease in pregnancy loss in those patients treated with LDA and LMWH. Treatment with glucocorticoids significantly increased the rate of successful pregnancy (38.5% abortions in treated vs 85.3% abortions in non-treated pregnancies; p=0.003). After multivariate GEE analysis, only glucocorticoids remained inversely associated with pregnancy loss (OR=0.157, (CI 0.025-0.968, p=0.046)). The meta-analysis showed that glucocorticoids tended to improve the frequency of successful pregnancy (OR= 0.509 (0.252-1.028), p=0.06). Three cases of gestational diabetes and one of preeclampsia were observed in our cohort. The meta-analysis, which mostly included studies using high-dose steroids, showed that glucocorticoids increased not only the frequency of preeclampsia and gestational diabetes, but also the rate of pre-term birth. CONCLUSIONS The efficacy of low-dose glucocorticoids in addition to the standard therapy in patients with refractory oAPS should be confirmed in well-designed clinical trials. However, high doses of steroids significantly increase the frequency of maternal and fetal morbidities, making their use strongly inadvisable.
Collapse
Affiliation(s)
| | | | - Pedro Muñoz Cacho
- Servicio Cántabro de Salud, Gerencia Atención Primaria, Santander, Spain
| | - Marcos López-Hoyos
- Immunology Department, 16516Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain. Universidad de Cantabria
| | - Rafael Del Barrio
- Obstetrics & Gynecology Department, 16516Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Ana Haya
- Obstetrics & Gynecology Department, 16516Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | |
Collapse
|
14
|
Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodríguez G, Londono J. Obstetric Antiphospholipid Syndrome From the Perspective of a Rheumatologist. Cureus 2022; 14:e21090. [PMID: 35165550 PMCID: PMC8830433 DOI: 10.7759/cureus.21090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/31/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease that can lead to thrombotic or obstetric complications. Recent histopathological studies have shown the absence of placental thrombosis, leading to the consideration of other pathophysiological pathways such as inflammation and complement activation. Due to this, various clinical studies are being carried out with different drug agents in order to avoid their complications. The combination of prophylactic heparin treatment and low doses of aspirin today result in successful pregnancies in most cases. Despite this, a minority of patients require alternative therapies to avoid recurrent miscarriage and decrease obstetric morbidity. Thanks to the better understanding of its pathophysiology, other treatments such as low doses of glucocorticoids, hydroxychloroquine (HCQ), immunoglobulin, pravastatin, and plasmapheresis have been considered in refractory cases, achieving favorable results. Despite the great advances regarding its treatment, unfortunately, there are no treatments with a good level of evidence to reduce late obstetric complications. The evaluation of preconception risk factors, as well as the antiphospholipid antibody profile, is necessary to establish individual risk and thus anticipate possible complications.
Collapse
Affiliation(s)
| | | | - Igor Rueda
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
| | - Sandra Pulido
- Rheumatology Department, Universidad Militar Nueva Granada, Bogotá, COL
| | - Gustavo Rodríguez
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
| | - John Londono
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
| |
Collapse
|
15
|
Kohli S, Isermann B. Crosstalk between inflammation and coagulation: Focus on pregnancy related complications. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
16
|
Yan X, Wang D, Yan P, Li H. Low molecular weight heparin or LMWH plus aspirin in the treatment of unexplained recurrent miscarriage with negative antiphospholipid antibodies: A meta-analysis of randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2021; 268:22-30. [PMID: 34794071 DOI: 10.1016/j.ejogrb.2021.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Unexplained recurrent miscarriage (uRM) has caused serious distress to women of childbearing age, and effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of low molecular weight heparin (LMWH) and LMWH combined with aspirin for uRM. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported the LMWH or LMWH combined with aspirin for women with uRM and negative antiphospholipid antibodies (aPL). The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data, and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS A total of 7 studies involving 1849 patients were included. The meta-analysis results showed that compared with the control group, both LMWH and LMWH + aspirin interventions showed no substantial influence on miscarriage rate (LMWH: RR = 0.69, 95%CI: 0.34-1.39, P = 0.293, LMWH + aspirin: RR = 0.62, 95%CI: 0.30-1.27, P = 0.19) and the occurrence of pre-eclampsia (LMWH: RR = 1.1, 95%CI: 0.53-2.31, P = 0.792; LMWH + aspirin: RR = 1.49, 95%CI: 0.25-8.79, P = 0.662). LMWH therapy had no influence on the live births (RR = 0.99, 95%CI: 0.92-1.06, P = 0.72). Subgroup analysis showed that enoxaparin is not effective in women with uRM and negative aPL (miscarriage rate: RR = 0.82, 95%CI: 0.31-2.19, P = 0.695; pre-eclampsia: RR = 1.03, 95%CI: 0.46-2.33, P = 0.936). CONCLUSIONS LMWH and LMWH combined with aspirin therapy cannot improve the pregnancy outcome of women with uRM and negative aPL. However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
Collapse
Affiliation(s)
- Xiaoli Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan Wang
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ping Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongyu Li
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
| |
Collapse
|
17
|
Fierro JJ, Velásquez M, Cadavid AP, de Leeuw K. Effects of anti-beta 2-glycoprotein 1 antibodies and its association with pregnancy-related morbidity in antiphospholipid syndrome. Am J Reprod Immunol 2021; 87:e13509. [PMID: 34738282 PMCID: PMC9285810 DOI: 10.1111/aji.13509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by venous, arterial, or small-vessel thrombosis and/or pregnancy-related morbidity, associated with persistent positivity of antiphospholipid antibodies (aPL). Pregnancy-related morbidity in APS patients is characterized by unexplained fetal deaths, premature birth of morphologically normal newborns, and/or consecutive pregnancy losses before the 10th week of gestation. Beta 2-glycoprotein 1 (ß2GP1) is the main antigen recognized by aPL and plays an essential role in the pathogenesis of APS. Antibodies against ß2GP1 (aß2GP1) are involved in damage-generating mechanisms in APS due to their interaction with trophoblasts, decidua, and endothelial cells. aß2GP1 might be used as a prognostic tool for obstetric risk stratification and ß2GP1 could be a target for molecular-targeted treatment to prevent pregnancy morbidity in APS. This review describes these aspects of aß2GP1, including effects on different cellular targets, its association with the severity of obstetric manifestations and the potential of ß2GP1-targeted therapies for APS.
Collapse
Affiliation(s)
- Juan J Fierro
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia.,Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Manuela Velásquez
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Angela P Cadavid
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia.,Grupo de Investigación en Trombosis, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia.,Red Iberoamericana de Alteraciones Vasculares Asociadas a TRanstornos del EMbarazo (RIVATREM), Chillán, Chile
| | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
18
|
Kaneko K, Ozawa N, Murashima A. Obstetric anti-phospholipid syndrome: from pathogenesis to treatment. Immunol Med 2021; 45:79-93. [PMID: 34470570 DOI: 10.1080/25785826.2021.1969116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by clinical manifestations such as thrombosis and obstetric complications with documented persistence of antiphospholipid antibodies (aPLs). Recent studies have revealed that the cause of aPL-related obstetric complications is dysfunction of placental trophoblasts and inflammation of the maternal-fetal interface induced by aPLs, not thrombosis. Although aPLs are associated with recurrence of serious complications during pregnancy, appropriate combination therapy with heparin and low-dose aspirin can improve the course of 70-80% of subsequent pregnancies. Preconception counseling and patient-tailored treatment are fundamental to improving maternal and fetal outcomes. Non-anticoagulant treatments such as hydroxychloroquine and statins are being developed for cases refractory to conventional treatment. Risk factors for thrombosis after pregnancy complications were identified based on the analysis of large databases of obstetric APS.
Collapse
Affiliation(s)
- Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuaki Ozawa
- Division of Reproductive Medicine and Maternal Care/Immunology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
19
|
Gerde M, Ibarra E, Mac Kenzie R, Fernandez Suarez C, Heer C, Alvarez R, Iglesias M, Balparda J, Beruti E, Rubinstein F. The impact of hydroxychloroquine on obstetric outcomes in refractory obstetric antiphospholipid syndrome. Thromb Res 2021; 206:104-110. [PMID: 34454240 DOI: 10.1016/j.thromres.2021.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of low-dose aspirin (LDA) and heparin has improved pregnancy outcomes in women with antiphospholipid syndrome (APS). However, 20-30% still have adverse outcomes despite treatment. Recent retrospective studies showed a beneficial effect of hydroxychloroquine (HCQ) in APS due to its anti-inflammatory, immunomodulatory and antithrombotic properties. Data in refractory obstetric APS (OAPS) remain scarce and include heterogeneous populations with various concomitant treatments. OBJECTIVE The objective of this study was to assess the impact on the obstetric outcomes of adding HCQ to classical treatments for women with refractory primary obstetric APS. METHODS In a retrospective single-centre cohort study, we compared pregnancy outcomes in women with refractory primary OAPS (2004-2019) who received two different treatments in subsequent pregnancies. Group A received 400 mg HCQ + 60 mg enoxaparin + LDA, while Group B received 60 mg enoxaparin + LDA. The main outcome was live birth rates, while pregnancy complications (early and late pregnancy losses and placental-mediated complications) were the secondary outcome. RESULTS A total of 101 pregnancies in 87 refractory primary OAPS patients were included. The rate of live-born babies in Group A (HCQ) was 97.1% (67/69) vs. 62.5% (20/32) in Group B (RR: 1.55 [95% CI, 1.19-2.1]; p < 0.001). Pregnancy complications in Group A were 8.7% (6/69) vs. 37.5% (12/32) in Group B (RR 0.22 [95% CI, 0.15-0.30]; p < 0.001). CONCLUSION Hydroxychloroquine was associated with a higher rate of live births and a lower prevalence of pregnancy complications in refractory primary obstetric APS. The addition of HCQ to classical treatment may present a promising approach that needs to be confirmed with prospective studies.
Collapse
Affiliation(s)
- M Gerde
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - E Ibarra
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - R Mac Kenzie
- Division of Vascular Surgery and Phlebology, FLENI, Montañeses 2325, Ciudad de Buenos Aires, Argentina
| | - C Fernandez Suarez
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - C Heer
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - R Alvarez
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - M Iglesias
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - J Balparda
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - E Beruti
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - F Rubinstein
- Departamento de Educación, Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024, Ciudad de Buenos Aires, Argentina
| |
Collapse
|
20
|
Pleguezuelo DE, Cabrera-Marante O, Abad M, Rodriguez-Frias EA, Naranjo L, Vazquez A, Villar O, Gil-Etayo FJ, Serrano M, Perez-Rivilla A, de la Fuente-Bitaine L, Serrano A. Anti-Phosphatidylserine/Prothrombin Antibodies in Healthy Women with Unexplained Recurrent Pregnancy Loss. J Clin Med 2021; 10:jcm10102094. [PMID: 34068095 PMCID: PMC8152729 DOI: 10.3390/jcm10102094] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/21/2021] [Accepted: 05/10/2021] [Indexed: 12/17/2022] Open
Abstract
Recurrent pregnancy loss (RPL) affects up to 6% of couples. Although chromosomal aberrations of the embryos are considered the leading cause, 50% of cases remain unexplained. Antiphospholipid Syndrome is a known cause in a few cases. Antiphospholipid antibodies (aPL) anticardiolipin, anti-Beta-2-Glycoprotein-I and Lupus Anticoagulant (criteria aPL) are recommended studies in RPL workup. We tested healthy women with unexplained RPL for criteria aPL and anti-Phosphatidylserine/Prothrombin antibodies (aPS/PT). Patients were classified into three groups according to the number and pregnancy week of RPL: Extra-Criteria (EC), with 2 miscarriages, Early Miscarriage (EM), with ≥3 before pregnancy at week 10 and Fetal Loss (FL), with ≥1 fetal death from pregnancy at week 10. Circulating criteria aPL were absent in 98.1% of EM, 90.9% of FL and 96.6% of EC groups. In contrast, aPS/PT were positive in 15.4% of EM, 15.1% of FL, 16.6% of EC patients and 2.9% in controls. aPS/PT posed a risk for RPL, with an odds ratio of 5.96 (95% confidence interval (CI): 1.85-19.13. p = 0.002) for EM, 7.28 (95% CI: 2.07-25.56. p = 0.002) for FL and 6.56. (95% CI: 1.77-24.29. p = 0.004) for EC. A successful live birth was achieved in all pregnant patients positive for aPS/PT who received treatment with heparin, aspirin and/or hydroxychloroquine.
Collapse
Affiliation(s)
- Daniel E. Pleguezuelo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
- Correspondence: ; Tel.: +34-917792756
| | - Oscar Cabrera-Marante
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
| | - Magdalena Abad
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (M.A.); (A.V.); (O.V.); (L.d.l.F.-B.)
| | - Edgard Alfonso Rodriguez-Frias
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
| | - Laura Naranjo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
| | - Alicia Vazquez
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (M.A.); (A.V.); (O.V.); (L.d.l.F.-B.)
| | - Olga Villar
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (M.A.); (A.V.); (O.V.); (L.d.l.F.-B.)
| | - Francisco Javier Gil-Etayo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
| | - Manuel Serrano
- Healthcare Research Institute, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Alfredo Perez-Rivilla
- Department of Microbiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Laura de la Fuente-Bitaine
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (M.A.); (A.V.); (O.V.); (L.d.l.F.-B.)
| | - Antonio Serrano
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (O.C.-M.); (E.A.R.-F.); (L.N.); (F.J.G.-E.); (A.S.)
| |
Collapse
|
21
|
Hamulyák EN, Scheres LJJ, Goddijn M, Middeldorp S. Antithrombotic therapy to prevent recurrent pregnancy loss in antiphospholipid syndrome-What is the evidence? J Thromb Haemost 2021; 19:1174-1185. [PMID: 33687789 PMCID: PMC8252114 DOI: 10.1111/jth.15290] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
Aspirin and heparin are widely used to reduce the risk of recurrent pregnancy loss in women with antiphospholipid syndrome. This practice is based on only a few intervention studies, and uncertainty regarding benefits and risk remains. In this case-based review, we summarize the available evidence and address the questions that are most important for clinical practice. We performed a systematic review of randomized controlled trials assessing the effect of heparin (low molecular weight heparin [LMWH] or unfractionated heparin [UFH]), aspirin, or both on live birth rates in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Eleven trials including 1672 women met the inclusion criteria. Aspirin only did not increase live birth rate compared to placebo in one trial of 40 women (risk ratio [RR] 0.94; 95% confidence interval [CI] 0.71-1.25). One trial of 141 women reported a higher live birth rate with LMWH only than with aspirin only (RR 1.20; 95% CI 1.00-1.43). Five trials totaling 1295 women compared heparin plus aspirin with aspirin only. The pooled RR for live birth was 1.27 (95% CI 1.09-1.49) in favor of heparin plus aspirin. There was significant heterogeneity between the subgroups of LMWH and UFH (RR for LWMH plus aspirin versus aspirin 1.20, 95% CI: 1.04-1.38; RR for UFH plus aspirin versus aspirin 1.74, 95% CI: 1.28-2.35; I2 78.9%, p = .03). Characteristics of participants and adverse events were not uniformly reported. Heparin (LMWH or UFH) plus aspirin may improve live birth rates in women with recurrent pregnancy loss and antiphospholipid antibodies, but evidence is of low certainty.
Collapse
Affiliation(s)
- Eva N. Hamulyák
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Luuk J. J. Scheres
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHSRadboud University Medical CenterNijmegenthe Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive MedicineDepartment of Obstetrics and GynecologyAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHSRadboud University Medical CenterNijmegenthe Netherlands
| |
Collapse
|
22
|
Alecsandru D, Klimczak AM, Garcia Velasco JA, Pirtea P, Franasiak JM. Immunologic causes and thrombophilia in recurrent pregnancy loss. Fertil Steril 2021; 115:561-566. [PMID: 33610320 DOI: 10.1016/j.fertnstert.2021.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
Certain miscarriages result from immunologic factors, but there is no clear identification of the precise causes of recurrent pregnancy loss (RPL). Miscarriages and RPL can arise from a disruption of maternal-fetal immune homeostasis. Remodeling of the maternal uterine spiral arteries is one of the key steps for normal growth and development of the fetus. An adequate oxygen supply is necessary for correct placentation, and it is accomplished by proper vascular changes. The development of fetal tissues creates a potential immunologic problem since the fetus can express paternal antigens and, in some cases, antigens of a gamete donor. The maternal immune system actively responds to fetal antigens, and dysregulation of this crosstalk could partly explain pregnancy complications such as miscarriages and RPL. RPL resulting from thrombophilia is primarily due to acquired thrombophilia, and therefore screening and treatment should be focused on antiphospholipid antibody syndrome.
Collapse
Affiliation(s)
- Diana Alecsandru
- Department of Immunology, IVI RMA Madrid, Spain; Rey Juan Carlos University, Madrid, Spain
| | | | - Juan A Garcia Velasco
- Rey Juan Carlos University, Madrid, Spain; Department of Reproductive Endocrinology and Infertility, IVI RMA Madrid; IVI Foundation, Health Research Institute La Fe, Valencia, Spain
| | - Paul Pirtea
- Department of Obstetrics and Gynecology, Hospital Foch, Paris, France.
| | | |
Collapse
|
23
|
Kolanska K, Alijotas-Reig J, Cohen J, Cheloufi M, Selleret L, d'Argent E, Kayem G, Valverde EE, Fain O, Bornes M, Darai E, Mekinian A. Endometriosis with infertility: A comprehensive review on the role of immune deregulation and immunomodulation therapy. Am J Reprod Immunol 2020; 85:e13384. [PMID: 33278837 DOI: 10.1111/aji.13384] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endometriosis is a multifactorial pathology dependent on intrinsic and extrinsic factors, but the immune deregulation seems to play a pivotal role. In endometriosis-associated infertility, this could raise the benefit of immunomodulatory strategies to improve the results of ART. In this review, we will describe (1) sera and peritoneal fluid cytokines and immune markers; (2) autoantibodies; and (3) immunomodulatory treatments in endometriosis with infertility. METHODS The literature research was conducted in MEDLINE, Embase, and Cochrane Library with the following keywords: "endometriosis", "unexplained miscarriage", "implantation failure", "recurrent implantation failure » and « IVF-ICSI », « biomarkers of autoimmunity", "TNF-α", "TNF-α antagonists", "infliximab", "adalimumab", "etanercept", "immunomodulatory treatment", "steroids", "intralipids", "intravenous immunoglobulins", "G-CSF", "pentoxyfylline". RESULTS Several studies analyzed the levels of pro-inflammatory cytokines in sera and peritoneal fluid of endometriosis-associated infertility, in particular TNF-α. Various autoantibodies have been found in peritoneal fluid and sera of infertile endometriosis women even in the absence of clinically defined autoimmune disease, as antinuclear, anti-SSA, and antiphospholipid autoantibodies. In few uncontrolled studies, steroids and TNF-α antagonists could increase the pregnancy rates in endometriosis-associated infertility, but well-designed trials are lacking. CONCLUSION Endometriosis is characterized by increased levels of cytokines and autoantibodies. This suggests the role of inflammation and immune cell deregulation in infertility associated with endometriosis. The strategies of immunomodulation to regulate these immune deregulations are poorly studied, and well-designed studies are necessary.
Collapse
Affiliation(s)
- Kamila Kolanska
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Jaume Alijotas-Reig
- Department of Internal Medicine, Sant Joan de Deu Hospital, Althaia Healthcare University Network of Manresa, Barcelona, Spain
| | - Jonathan Cohen
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Meryem Cheloufi
- Sorbonne Université, AP-HP, Hôpital Trousseau, service d'Obstétrique, Université Paris 06, Paris, France
| | - Lise Selleret
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Emmanuelle d'Argent
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Gilles Kayem
- Sorbonne Université, AP-HP, Hôpital Trousseau, service d'Obstétrique, Université Paris 06, Paris, France
| | - Enrique E Valverde
- Department of Internal Medicine, Sant Joan de Deu Hospital, Althaia Healthcare University Network of Manresa, Barcelona, Spain
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, service de Médecine Interne and Inflammation, Paris, France
| | - Marie Bornes
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Emile Darai
- Sorbonne Université, AP-HP, Hôpital Tenon, service de Gynécologie-Obstétrique et Médecine de la Reproduction, Université Paris 06, Paris, France.,GRC-6 Centre Expert En Endométriose (C3E), Sorbonne Université, Paris, France
| | - Arsene Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, service de Médecine Interne and Inflammation, Paris, France
| |
Collapse
|
24
|
Yang Z, Shen X, Zhou C, Wang M, Liu Y, Zhou L. Prevention of recurrent miscarriage in women with antiphospholipid syndrome: A systematic review and network meta-analysis. Lupus 2020; 30:70-79. [PMID: 33081590 DOI: 10.1177/0961203320967097] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare and rank currently available pharmacological interventions for the prevention of recurrent miscarriage (RM) in women with antiphospholipid syndrome (APS). METHODS A search was performed using PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, CNKI, ClinicalTrials.gov, and the UK National Research Register on December 15, 2019. Studies comparing any types of active interventions with placebo/inactive control or another active intervention for the prevention of RM in patients with APS were considered for inclusion. The primary outcomes were efficacy (measured by live birth rate) and acceptability (measured by all-cause discontinuation); secondary outcomes were birthweight, preterm birth, preeclampsia, and intrauterine growth retardation. The protocol of this study was registered with Open Science Framework (DOI: 10.17605/OSF.IO/B9T4E). RESULTS In total, 54 randomized controlled trials (RCTs) comprising 4,957 participants were included. Low-molecular-weight heparin (LMWH) alone, aspirin plus LMWH or unfractionated heparin (UFH), aspirin plus LMWH plus intravenous immunoglobulin (IVIG), aspirin plus LMWH plus IVIG plus prednisone were found to be effective pharmacological interventions for increasing live birth rate (ORs ranging between 2.88 to 11.24). In terms of acceptability, no significant difference was found between treatments. In terms of adverse perinatal outcomes, aspirin alone was associated with a higher risk of preterm birth than aspirin plus LMWH (OR 3.92, 95% CI 1.16 to 16.44) and with lower birthweight than LMWH (SMD -808.76, 95% CI -1596.54 to -5.07). CONCLUSIONS Our findings support the use of low-dose aspirin plus heparin as the first-line treatment for prevention of RM in women with APS, and support the efficacy of hydroxychloroquine, IVIG, and prednisone when added to current treatment regimens. More large-scale, high-quality RCTs are needed to confirm these findings, and new pharmacological options should be further evaluated.
Collapse
Affiliation(s)
- Ziyi Yang
- The First Clinical College of Chongqing Medical University, Chongqing, China
| | - Xiangli Shen
- Department of Obstetrics, Chengdu Jinjiang Maternity and Child Health Hospital, Chengdu, China
| | - Chuqing Zhou
- The First Clinical College of Chongqing Medical University, Chongqing, China
| | - Min Wang
- North Sichuan Medical College, Nanchong, China
| | - Yi Liu
- Department of Obstetrics, Chengdu Jinjiang Maternity and Child Health Hospital, Chengdu, China
| | - Lin Zhou
- Department of Obstetrics, Chengdu Jinjiang Maternity and Child Health Hospital, Chengdu, China
| |
Collapse
|
25
|
Di Simone N, Gratta M, Castellani R, D'Ippolito S, Specchia M, Scambia G, Tersigni C. Celiac disease and reproductive failures: An update on pathogenic mechanisms. Am J Reprod Immunol 2020; 85:e13334. [PMID: 32865829 DOI: 10.1111/aji.13334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 12/22/2022] Open
Abstract
Celiac disease (CD) is an autoimmune disorder that occurs in genetically predisposed people in which the ingestion of gluten leads to damage in the small intestine that clinically presents with malabsorption-related symptoms. CD can also be the underlying cause of several non-gastrointestinal symptoms. This review summarizes evidence on the relationship between CD and gynecological/obstetric disorders like reproductive failures. Although much has been reported on such a linkage, the pathogenic mechanisms remain unclear, especially those underlying extra-gastrointestinal clinical manifestations. Studies conducted on celiac subjects presenting gynecological/obstetric disorders have pointed to intestinal malabsorption, coagulation alterations, immune-mediated tissue damage, and endometrial inflammation as the main responsible pathogenic mechanisms. Currently, however, the knowledge of such mechanisms is insufficient, and further studies are needed to gain a more thorough understanding of the matter.
Collapse
Affiliation(s)
- Nicoletta Di Simone
- U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| | - Matteo Gratta
- Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Castellani
- Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia D'Ippolito
- U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| | - Monia Specchia
- Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy.,U.O.C. di Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - Chiara Tersigni
- U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
26
|
Li Y, Wang Y, Lan Y, Zhang J, Liang Y, Wang S. Antinuclear antibodies in follicular fluid may reduce efficacy of in vitro fertilization and embryo transfer by invading endometrium and granular cells. Am J Reprod Immunol 2020; 84:e13289. [PMID: 32564432 DOI: 10.1111/aji.13289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/26/2020] [Accepted: 06/12/2020] [Indexed: 01/28/2023] Open
Abstract
PROBLEM The mechanism(s) by which antinuclear antibodies (ANA) induce implantation failure are not clear, and little information regarding the function of autoantibodies in reproductive tissues is available. METHODS OF STUDY A total of 380 patients who underwent in vitro fertilization and embryo transfer (IVF-ET) were divided into control, serum positive, and follicular fluid (FF) positive groups based on the results of indirect immunofluorescence assay for ANA in the serum and FF. Immunofluorescence assay was performed to evaluate the existence of ANA in granular cells and endometrial tissues. Presence in FF of soluble apoptotic markers, including Bcl-2, Caspase-3, cleaved PARP, Cytochrome C, GAPDH, and p53, was assessed using magnetic bead based assays. RESULTS The patients in the FF positive group had the lowest numbers of retrieved oocytes, fertilizations, and high-quality embryos. The fertilization rate, and the proportion of two pronuclear (2PN) embryos in patients in the FF positive group were significantly lower than those in the other two groups. The FF positive group also had the lowest clinical pregnancy rate, and the highest early miscarriage rate. Granulosa cells and endometrial tissues in patients in the FF positive group were ANA positive. High levels of BCL-2, Caspase-3, Cytochrome C, GAPDH, and p53 were found in the FF of patients in the FF positive group. CONCLUSIONS Antinuclear antibodies in FF and endometrial tissues may cause imbalanced apoptosis, resulting in poor IVF-ET treatment outcomes. Local autoimmunity and cell apoptosis in reproductive tissues could be considered new therapeutic targets for improving IVF-ET treatment efficacy.
Collapse
Affiliation(s)
- Ying Li
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yipeng Wang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yonglian Lan
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yu Liang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shuyu Wang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
27
|
Ni R, Lu L. Comment on: Pregnancy and undifferentiated connective tissue disease: outcome and risk of flare in 100 pregnancies. Rheumatology (Oxford) 2020; 59:1457-1458. [PMID: 32176284 DOI: 10.1093/rheumatology/keaa065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ruoning Ni
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD, USA
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| |
Collapse
|
28
|
Hamulyák EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev 2020; 5:CD012852. [PMID: 32358837 PMCID: PMC7195627 DOI: 10.1002/14651858.cd012852.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aspirin and heparin are widely used as preventive strategy to reduce the high risk of recurrent pregnancy loss in women with antiphospholipid antibodies (aPL). This review supersedes a previous, out-of-date review that evaluated all potential therapies for preventing recurrent pregnancy loss in women with aPL. The current review focusses on a narrower scope because current clinical practice is restricted to using aspirin or heparins, or both for women with aPL in an attempt to reduce pregnancy complications. OBJECTIVES To assess the effects of aspirin or heparin, or both for improving pregnancy outcomes in women with persistent (on two separate occasions) aPL, either lupus anticoagulant (LAC), anticardiolipin (aCL) or aβ2-glycoprotein-I antibodies (aβ2GPI) or a combination, and recurrent pregnancy loss (two or more, which do not have to be consecutive). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 June 2019), and reference lists of retrieved studies. Where necessary, we attempted to contact trial authors. SELECTION CRITERIA Randomised, cluster-randomised and quasi-randomised controlled trials that assess the effects of aspirin, heparin (either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH]), or a combination of aspirin and heparin compared with no treatment, placebo or another, on pregnancy outcomes in women with persistent aPL and recurrent pregnancy loss were eligible. All treatment regimens were considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion criteria and risk of bias. Two review authors independently extracted data and checked them for accuracy and the certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Eleven studies (1672 women) met the inclusion criteria; nine randomised controlled trials and two quasi-RCTs. The studies were conducted in the USA, Canada, UK, China, New Zealand, Iraq and Egypt. One included trial involved 1015 women, all other included trials had considerably lower numbers of participants (i.e. 141 women or fewer). Some studies had high risk of selection and attrition bias, and many did not include sufficient information to judge the risk of reporting bias. Overall, the certainty of evidence is low to very low due to the small numbers of women in the studies and to the risk of bias. The dose and type of heparin and aspirin varied among studies. One study compared aspirin alone with placebo; no studies compared heparin alone with placebo and there were no trials that had a no treatment comparator arm during pregnancy; five studies explored the efficacy of heparin (either UFH or LMWH) combined with aspirin compared with aspirin alone; one trial compared LMWH with aspirin; two trials compared the combination of LMWH plus aspirin with the combination of UFH plus aspirin; two studies evaluated the combination of different doses of heparin combined with aspirin. All trials used aspirin at a low dose. Aspirin versus placebo We are very uncertain if aspirin has any effect on live birth compared to placebo (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71 to 1.25, 1 trial, 40 women, very low-certainty evidence). We are very uncertain if aspirin has any effect on the risk of pre-eclampsia, pregnancy loss, preterm delivery of a live infant, intrauterine growth restriction or adverse events in the child, compared to placebo. We are very uncertain if aspirin has any effect on adverse events (bleeding) in the mother compared with placebo (RR 1.29, 95% CI 0.60 to 2.77, 1 study, 40 women). The certainty of evidence for these outcomes is very low because of imprecision, due to the low numbers of women involved and the wide 95% CIs, and also because of risk of bias. Venous thromboembolism and arterial thromboembolism were not reported in the included studies. Heparin plus aspirin versus aspirin alone Heparin plus aspirin may increase the number of live births (RR 1.27, 95% CI 1.09 to 1.49, 5 studies, 1295 women, low-certainty evidence). We are uncertain if heparin plus aspirin has any effect on the risk of pre-eclampsia, preterm delivery of a live infant, or intrauterine growth restriction, compared with aspirin alone because of risk of bias and imprecision due to the low numbers of women involved and the wide 95% CIs. We are very uncertain if heparin plus aspirin has any effect on adverse events (bleeding) in the mother compared with aspirin alone (RR 1.65, 95% CI 0.19 to 14.03, 1 study, 31 women). No women in either the heparin plus aspirin group or the aspirin alone group had heparin-induced thrombocytopenia, allergic reactions, or venous or arterial thromboembolism. Similarly, no infants had congenital malformations. Heparin plus aspirin may reduce the risk of pregnancy loss (RR 0.48, 95% CI 0.32 to 0.71, 5 studies, 1295 women, low-certainty evidence). When comparing LMWH plus aspirin versus aspirin alone the pooled RR for live birth was 1.20 (95% CI 1.04 to 1.38, 3 trials, 1155 women). In the comparison of UFH plus aspirin versus aspirin alone, the RR for live birth was 1.74 (95% CI 1.28 to 2.35, 2 trials, 140 women). AUTHORS' CONCLUSIONS The combination of heparin (UFH or LMWH) plus aspirin during the course of pregnancy may increase live birth rate in women with persistent aPL when compared with aspirin treatment alone. The observed beneficial effect of heparin was driven by one large study in which LMWH plus aspirin was compared with aspirin alone. Adverse events were frequently not, or not uniformly, reported in the included studies. More research is needed in this area in order to further evaluate potential risks and benefits of this treatment strategy, especially among women with aPL and recurrent pregnancy loss, to gain consensus on the ideal prevention for recurrent pregnancy loss, based on a risk profile.
Collapse
Affiliation(s)
- Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luuk Jj Scheres
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mauritia C Marijnen
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
29
|
Antiphospholipid syndrome: Diagnosis and management in the obstetric patient. Best Pract Res Clin Obstet Gynaecol 2020; 64:31-40. [DOI: 10.1016/j.bpobgyn.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
|
30
|
Schreiber K, Hunt BJ. Managing antiphospholipid syndrome in pregnancy. Thromb Res 2020; 181 Suppl 1:S41-S46. [PMID: 31477227 DOI: 10.1016/s0049-3848(19)30366-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid antibodies (aPL). The antibodies currently included in the classification criteria include lupus anticoagulant (LA), anticardiolipin antibodies (aCL) and anti-^2-glycoprotein 1 antibodies (^2GPI). APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature and obstetrical complications. Pregnancy complications in obstetric APS (OAPS) include unexplained recurrent early pregnancy loss, fetal death, or premature birth due to severe preeclampsia, eclampsia, intrauterine growth restriction or other consequences of placental insufficiency. Careful, well monitored obstetric care with the use of aspirin and heparin has likely improved the pregnancy outcome in obstetric APS and currently approximately 70-80% of pregnant women with APS have a successful pregnancy outcome. However, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. Other treatments options are currently being explored and retrospective studies suggest that trials with hydroxychloroquine and possibly pravastatin are warranted in pregnant women with aPL. In this review will focus on the current treatment of OAPS.
Collapse
Affiliation(s)
- Karen Schreiber
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK; Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Beverley J Hunt
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK.
| |
Collapse
|
31
|
Manukyan G, Martirosyan A, Slavik L, Margaryan S, Ulehlova J, Mikulkova Z, Hlusi A, Papajik T, Kriegova E. Anti-domain 1 β2 glycoprotein antibodies increase expression of tissue factor on monocytes and activate NK Cells and CD8+ cells in vitro. AUTOIMMUNITY HIGHLIGHTS 2020; 11:5. [PMID: 32127041 PMCID: PMC7065342 DOI: 10.1186/s13317-020-00128-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/19/2020] [Indexed: 02/08/2023]
Abstract
Background β2-Glycoprotein I (β2GPI) represents the major antigenic target for antiphospholipid antibodies (aPL), with domain 1 (D1) being identified as a risk factor for thrombosis and pregnancy complications in APS. We aimed to analyse the ability of aPL, and particularly anti-D1 β2GPI, to stimulate prothrombotic and proinflammatory activity of immune cells in vitro. Methods Peripheral blood mononuclear cells (PBMCs) from 11 healthy individuals were incubated with: (1) “anti-D1(+)”—pooled plasma derived from patients suspected of having APS contained anticardiolipin antibodies (aCL), lupus anticoagulant (LA), anti-β2GPI and anti-D1 β2GPI; (2) “anti-D1(−)”—pooled plasma from patients suspected of having APS contained aCL, LA, anti-β2GPI, and negative for anti-D1 β2GPI; (3) “seronegative”—negative for aPL. Results The presence of anti-D1(+) and anti-D1(−) plasma resulted in increased HLA-DR and CD11b on monocytes. While only anti-D1(+) plasma markedly increased the percentage and median fluorescence intensity (MFI) of CD142 (tissue factor, TF) on monocytes in comparison with those cultured with anti-D1(−) and seronegative plasma. Anti-D1(+) plasma resulted in increased percentage and MFI of activation marker CD69 on NK and T cytotoxic cells. Expression of IgG receptor FcγRIII(CD16) on monocytes and NK cells was down-regulated by the anti-D1(+) plasma. Conclusions Taking together, our study shows the ability of patient-derived aPL to induce immune cell activation and TF expression on monocytes. For the first time, we demonstrated the influence of anti-D1 β2GPI on the activation status of monocytes, NK and cytotoxic T cells. Our findings further support a crucial role of D1 epitope in the promotion of thrombosis and obstetrical complications in APS.
Collapse
Affiliation(s)
- Gayane Manukyan
- Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology NAS RA, 7 Hasratyan St., 0014, Yerevan, Armenia. .,Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic.
| | - Anush Martirosyan
- Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology NAS RA, 7 Hasratyan St., 0014, Yerevan, Armenia
| | - Ludek Slavik
- Department of Hemato-oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Sona Margaryan
- Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology NAS RA, 7 Hasratyan St., 0014, Yerevan, Armenia.,Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Jana Ulehlova
- Department of Hemato-oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Zuzana Mikulkova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Antonin Hlusi
- Department of Hemato-oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Tomas Papajik
- Department of Hemato-oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and Faculty Hospital, Olomouc, Czech Republic
| |
Collapse
|
32
|
D'Ippolito S, Ticconi C, Tersigni C, Garofalo S, Martino C, Lanzone A, Scambia G, Di Simone N. The pathogenic role of autoantibodies in recurrent pregnancy loss. Am J Reprod Immunol 2019; 83:e13200. [PMID: 31633847 DOI: 10.1111/aji.13200] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 12/20/2022] Open
Abstract
In the present manuscript, we review the recent research investigating the pathogenic association between most studied autoantibodies and recurrent pregnancy loss. Pregnancy loss represents a common obstetric complication occurring in about 15%-25% of all clinically recognized pregnancies. The recurrence of pregnancy loss identifies a distinct clinical entity, that is recurrent pregnancy loss (RPL), affecting about 2%-4% of couples. Several factors, including age, chromosomal abnormalities, uterine anomalies, thrombophilic disorders, endocrinopathies, hormonal and metabolic disorders, infections, sperm quality, and lifestyle issues, are involved in RPL. The role of autoantibodies in RPL is only partially determined. In some cases (antiphospholipid antibodies [aPL]), their involvement is well established. In other cases (anti-thyroid autoantibodies, antinuclear, anti-transglutaminase, and anti-endomysial antibodies), it is still debated, despite multiple, although not fully conclusive, evidences strongly suggest a possible involvement in RPL. Further extensive research is needed to definitively confirm or exclude their actual role.
Collapse
Affiliation(s)
- Silvia D'Ippolito
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Ticconi
- Section of Gynecology and Obstetrics, Department of Surgical Sciences, University Tor Vergata, Rome, Italy
| | - Chiara Tersigni
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Serafina Garofalo
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmelinda Martino
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Lanzone
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nicoletta Di Simone
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, U.O.C. di Ostetricia e Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
33
|
Bruno V, Nuccetelli M, Ticconi C, Bruno A, Martelli F, Capogna MV, Bernardini S, Piccione E, Pietropolli A. Amniotic fluid antiphospholipid antibodies: potential role in antiphospholipid syndrome-independent aberrant implantation process. Reprod Biol Endocrinol 2019; 17:79. [PMID: 31615575 PMCID: PMC6794730 DOI: 10.1186/s12958-019-0527-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 09/30/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The direct role of antiphospholipid antibodies (aPL) at maternal-fetal interface has not been fully investigated, especially whether they are involved in physiological and pathological implantation conditions, in an antiphospholipid syndrome (APS)-independent manner. In fact, trophoblast cells and placental endothelial cells at the implantation site express potential aPL targeted-phospholipid antigens (PL Ags); thus, the local production and presence of their specific antibodies, not related to APS (characterized by aPL presence in the peripheral blood), could be a potential marker of aberrant invasion, implantation and fetal-maternal immune tolerance processes. METHODS Anti-Beta2glycoprotein I (anti-β2GPI) and anticardiolipin (aCL Ab) antibodies (the most clinically relevant aPL) were detected by immunoenzymatic assay (ELISA), in the amniotic fluid (AF) of 167 women with physiological and complicated common pregnancy conditions, sharing an aberrant implantation process, such as recurrent pregnancy loss (RPL), autoimmune hypothyroidism (ahT) and smoking. All women included in the study were negative to peripheral blood aPL. RESULTS aCL and anti-β2GPI antibodies were detectable in all the AF samples. RPL, ahT and smoking patients had higher level of anti-β2GPI Abs (IgM) compared to women with physiological pregnancies (p < 0.0001). Since IgM cannot cross the placenta, their local production in response to maternal-fetal interface stimuli, could be hypothesized. CONCLUSIONS The presence of aPL in the AF (not related to APS) could reveal a potential clinical significance at maternal-fetal interface in selected pregnancy complications, in which an aberrant implantation process, and in turn an impaired fetal-maternal immune tolerance cross-talk, could occur.
Collapse
Affiliation(s)
- Valentina Bruno
- Academic Department of Biomedicine and Prevention, Section of Gynecology, University of Rome "Tor Vergata", Rome, Italy.
| | - Marzia Nuccetelli
- Department of Experimental Medicine and Surgery, Tor Vergata University Hospital, Tor Vergata University, Rome, Italy
| | - Carlo Ticconi
- Academic Department of Surgical Sciences, Section of Gynecology, Tor Vergata University Hospital, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Antonella Bruno
- Academic Department of Surgical Sciences, Section of Gynecology, Tor Vergata University Hospital, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Federica Martelli
- Academic Department of Biomedicine and Prevention, Section of Gynecology, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Vittoria Capogna
- Academic Department of Surgical Sciences, Section of Gynecology, Tor Vergata University Hospital, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Sergio Bernardini
- Department of Experimental Medicine and Surgery, Tor Vergata University Hospital, Tor Vergata University, Rome, Italy
| | - Emilio Piccione
- Academic Department of Surgical Sciences, Section of Gynecology, Tor Vergata University Hospital, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Adalgisa Pietropolli
- Academic Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Surgical Sciences, Section of Gynecology, Tor Vergata University Hospital, Rome, Italy
| |
Collapse
|
34
|
Lu H, Hu R. The role of immunity in the pathogenesis and development of pre‐eclampsia. Scand J Immunol 2019; 90:e12756. [PMID: 30739345 DOI: 10.1111/sji.12756] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/25/2019] [Accepted: 02/05/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Hui‐Qing Lu
- Hospital of Obstetrics and Gynecology Fudan University Shanghai China
| | - Rong Hu
- Hospital of Obstetrics and Gynecology Fudan University Shanghai China
| |
Collapse
|
35
|
Chaturvedi S, Brodsky RA, McCrae KR. Complement in the Pathophysiology of the Antiphospholipid Syndrome. Front Immunol 2019; 10:449. [PMID: 30923524 PMCID: PMC6426753 DOI: 10.3389/fimmu.2019.00449] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/19/2019] [Indexed: 12/16/2022] Open
Abstract
The antiphospholipid syndrome (APS) is characterized by thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). Complement is a system of enzymes and regulatory proteins of the innate immune system that plays a key role in the inflammatory response to pathogenic stimuli. The complement and coagulation pathways are closely linked, and expanding data indicate that complement may be activated in patients with aPL and function as a cofactor in the pathogenesis of aPL-associated clinical events. Complement activation by aPL generates C5a, which induces neutrophil tissue factor-dependent procoagulant activity. Beta-2-glycoprotein I, the primary antigen for pathogenic aPL, has complement regulatory effects in vitro. Moreover, aPL induce fetal loss in wild-type mice but not in mice deficient in specific complement components (C3, C5). Antiphospholipid antibodies also induce thrombosis in wild type mice and this effect is attenuated in C3 or C6 deficient mice, or in the presence of a C5 inhibitor. Increased levels of complement activation products have been demonstrated in sera of patients with aPL, though the association with clinical events remains unclear. Eculizumab, a terminal complement inhibitor, has successfully been used to treat catastrophic APS and prevent APS-related thrombotic microangiopathy in the setting of renal transplant. However, the mechanisms of complement activation in APS, its role in the pathogenesis of aPL related complications in humans, and the potential of complement inhibition as a therapeutic target in APS require further study.
Collapse
Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Keith R McCrae
- Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland, OH, United States.,Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH, United States
| |
Collapse
|
36
|
Khalife D, Ghazeeri G, Kutteh W. Review of current guidelines for recurrent pregnancy loss: new strategies for optimal evaluation of women who may be superfertile. Semin Perinatol 2019; 43:105-115. [PMID: 30642578 DOI: 10.1053/j.semperi.2018.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The current evidence-based guidelines for the evaluation of recurrent pregnancy loss recommended by the American Society for Reproductive Medicine and by the European Society of Human Reproduction and Embryology are compared and contrasted in this review. The clinical use of either of these guidelines will result in a probable diagnosis for only half of the affected patients. New strategies for a full evaluation of recurrent pregnancy loss incorporating 24- chromosome microarary on the products of conception offer more explanations for patients and caregivers. This new algorithm should decrease the use of empiric, unproven treatments. Combining the results of genetic testing on the miscarriage tissue with the conventional diagnostic tests has made it possible to explain the etiology of pregnancy loss in more than 90% of the cases. This cost-saving strategy can decrease the emotional distress and frustration for both couples and physicians when it comes to management of recurrent pregnancy loss.
Collapse
Affiliation(s)
- Dalia Khalife
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynecology, American University of Beirut Medical Center P.O. Box: 113-6044. Beirut, Lebanon
| | - Ghina Ghazeeri
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynecology, American University of Beirut Medical Center P.O. Box: 113-6044. Beirut, Lebanon
| | - William Kutteh
- Clinical Professor of Reproductive Endocrinology Vanderbilt University School of Medicine; Consulting Gynecologist, Department of Surgery Director of Fertility Preservation St. Jude Children's Research Hospital; Managing Partner, Director of Recurrent Pregnancy Loss Center Fertility Associates of Memphis 80 Humphreys Center, Suite 307 Memphis, TN 38120-2363 Phone: 901-747-2229 FAX: 901-747-4446.
| |
Collapse
|
37
|
Khizroeva J, Makatsariya A, Bitsadze V, Makatsariya N, Khamani N. In vitro fertilization outcomes in women with antiphospholipid antibodies circulation. J Matern Fetal Neonatal Med 2018; 33:1988-1993. [PMID: 30309273 DOI: 10.1080/14767058.2018.1535586] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Antiphospholipid antibodies (aPL) have a multifaceted effect on the hemostatic system, damaging all its protective links.Aim: To study the effect of APA on outcomes of assisted reproductive technologies (ART).Study design: We examined 267 women with infertility, who planned pregnancy using ART. They included 178 women with IVF failure (I group) and 89 women with pregnancy after the IVF program (II group). The comparison group consisted of 80 pregnant women after IVF (male factor); a control group included 80 pregnant women with physiological pregnancy. Results of study demonstrated a high frequency of aPL circulation in a group of women with IVF failures. Overall, the proportion of aPL among all 267 women who planned pregnancy with ART was 32.6%. Elevated levels of aPL in the structure of causes of IVF failures (group I) were observed in 42.1% of them. Among women whose pregnancy occurred with ART (II group) the rate of APA was 19.1%. In the comparison group, in 6.3% of cases, aPL circulation was observed. In the control group, the rate was 3.4%.Conclusion: Considering the high percentage of aPL circulation in the case of IVF failures, authors think that high titers of aPL are a temporary contraindication for IVF. Patients with a history of aPL circulation are required to receive anticoagulant therapy from the first days of the hormonal protocol. The drug of choice is a group of low molecular weight heparins (LMWH). An individual approach is extremely important with the possible identification of causes of IVF failures and selective therapy, which leads to a significant improvement in the outcomes of the IVF program.
Collapse
Affiliation(s)
- Jamilya Khizroeva
- Obstetrics and Gynecology Department #2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander Makatsariya
- Obstetrics and Gynecology Department #2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Viktoriya Bitsadze
- Obstetrics and Gynecology Department #2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Natalya Makatsariya
- Obstetrics and Gynecology Department #2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Nadin Khamani
- Obstetrics and Gynecology Department #2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| |
Collapse
|
38
|
Antovic A, Sennström M, Bremme K, Svenungsson E. Obstetric antiphospholipid syndrome. Lupus Sci Med 2018; 5:e000197. [PMID: 30364418 PMCID: PMC6195166 DOI: 10.1136/lupus-2016-000197] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Abstract
The present clinical and laboratory classification criteria for antiphospholipid syndrome (APS) were established in Sydney, Australia, in 2006. In this review, we focus on the obstetric subset of APS (OAPS), defined by persistent positivity for antiphospholipid antibodies together with either early recurrent pregnancy loss, early fetal death, stillbirth or premature birth <34 gestational weeks due to pre-eclampsia, eclampsia and placental insufficiency. It is important to diagnose these cases since most women suffering from OAPS can, when given appropriate treatment, have successful pregnancies. Furthermore, patients with OAPS may, depending on the antibody profile, be at enhanced risk of thrombotic events later in life. We present an update on the present knowledge of possible underlying pathogenesis, risk factors and risk estimations for adverse pregnancy outcomes before and during pregnancy, current treatment concepts, and long-term outcomes for women with OAPS and their children.
Collapse
Affiliation(s)
- Aleksandra Antovic
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Maria Sennström
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Bremme
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is defined as the association of thrombotic events and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies (aPL). In this review, we will highlight the most important clinical presentations of APS with a focus on the obstetric morbidity, the current management strategies and the outlook for the future. RECENT FINDINGS The use of aspirin and heparin has improved the pregnancy outcome in obstetric APS and approximately 70% of pregnant women with APS have a successful pregnancy outcome. Unfortunately, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. This therefore highlights the need for alternative treatments to improve obstetrical outcome. Other treatment options are currently explored and retrospective studies show that pravastatin for example is beneficial in women with aPL-related early preeclampsia. Moreover, the immunmodulator hydroxychloroquine may play a beneficial role in the prevention of aPL-related pregnancy complications. SUMMARY APS is among the most frequent acquired risk factors for a treatable cause of recurrent pregnancy loss and increases the risk of conditions associated with ischaemic placental dysfunction, such as fetal growth restriction, preeclampsia, premature birth and intrauterine death. Current treatment is mainly based on aspirin and heparin. Studies to inform on alternative treatment options are urgently needed.
Collapse
|
40
|
Turrent-Carriles A, Herrera-Félix JP, Amigo MC. Renal Involvement in Antiphospholipid Syndrome. Front Immunol 2018; 9:1008. [PMID: 29867982 PMCID: PMC5966534 DOI: 10.3389/fimmu.2018.01008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/23/2018] [Indexed: 12/13/2022] Open
Abstract
Antiphospholipid syndrome is a complex autoimmune disease, characterized by the presence of vascular thrombosis, obstetric, hematologic, cutaneous, and cardiac manifestations. Renal disease in patients with antiphospholipid syndrome was not recognized in the first descriptions of the disease, but later on, the renal manifestations of the syndrome have been investigated widely. Renal manifestations of antiphospholipid syndrome conform a wide spectrum of diverse renal syndromes. Hypertension is one of the most frequent, but less commonly recognized renal alteration. It can be difficult to control as its origin is renovascular. Renal vascular thrombosis can be arterial or venous. Other alterations are renal infarction and vascular thrombosis in arterial territories. Venous thrombosis can be present in primary and secondary antiphospholipid syndrome; it presents with worsening of previous proteinuria or de novo nephrotic syndrome, hypertension and renal failure. Antiphospholipid syndrome nephropathy is a vascular disease that affects glomerular tuft, interstitial vessels, and peritubular vessels; histopathology characterizes the renal lesions as acute or chronic, the classic finding is thrombotic microangiopathy, that leads to fibrosis, tubule thyroidization, focal cortical atrophy, and glomerular sclerosis. Antiphospholipid syndrome nephropathy can also complicate patients with systemic lupus erythematosus, and there is vast information supporting the worse renal prognosis in this group of patients with the classic histopathologic lesions. Treatment consists of anticoagulation, as for other thrombotic manifestations of antiphospholipid syndrome. There is some evidence of glomerulonephritis as an isolated lesion in patients with antiphospholipid syndrome. The most frequently reported glomerulonephritis is membranous; with some reports suggesting that immunosuppressive treatment may be effective. Patients with end stage renal disease commonly are positive for antiphospholipid antibodies, but it is not clear what is the role of aPL in this setting. Patients with vascular access may have complications in the presence of antibodies so that anticoagulation is recommended. Patients ongoing renal transplant with persistent antiphospholipid antibody positivity may have early and late graft failure.
Collapse
Affiliation(s)
| | | | - Mary-Carmen Amigo
- Internal Medicine Rheumatology Service, Centro Médico ABC, Mexico City, Mexico
| |
Collapse
|
41
|
Bolnick AD, Bolnick JM, Kohan-Ghadr HR, Kilburn BA, Pasalodos OJ, Singhal PK, Dai J, Diamond MP, Armant DR, Drewlo S. Enhancement of trophoblast differentiation and survival by low molecular weight heparin requires heparin-binding EGF-like growth factor. Hum Reprod 2018; 32:1218-1229. [PMID: 28402449 DOI: 10.1093/humrep/dex069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 02/09/2017] [Indexed: 02/07/2023] Open
Abstract
STUDY QUESTION Does low molecular weight heparin (LMWH) require heparin-binding epidermal growth factor (EGF)-like growth factor (HBEGF) signaling to induce extravillous trophoblast differentiation and decrease apoptosis during oxidative stress? SUMMARY ANSWER LMWH increased HBEGF expression and secretion, and HBEGF signaling was required to stimulate trophoblast extravillous differentiation, increase invasion in vitro and reduce trophoblast apoptosis during oxidative stress. WHAT IS KNOWN ALREADY Abnormal trophoblast differentiation and survival contribute to placental insufficiency syndromes, including preeclampsia and intrauterine growth restriction. Preeclampsia often manifests as a pro-thrombotic state, with unsuccessful transformation of the spiral arteries that reduces oxygen supply and can produce placental infarction. LMWH improves placental function by increasing blood flow. Recent data suggest that the actions of LMWH transcend its anti-coagulative properties, but the molecular mechanism is unknown. There is evidence that LMWH alters the expression of human HBEGF in trophoblast cells, which regulates human trophoblast pathophysiology. HBEGF, itself, is capable of increasing trophoblast survival and invasiveness. STUDY DESIGN, SIZE, DURATION First-trimester placental explants and the HTR-8/SVneo cell line, established using extravillous trophoblast outgrowths from first-trimester villous explants, were treated in vitro with LMWH to examine the effects on HBEGF signaling and trophoblast function under normal physiological and pathological conditions. A highly specific antagonist of HBEGF and other inhibitors of HBEGF downstream signaling were used to determine the relationship between LMWH treatment and HBEGF. PARTICIPANTS/MATERIALS, SETTING, METHODS Placental tissues (n = 5) were obtained with IRB approval and patient consent from first-trimester terminations. Placental explants and HTR-8/SVneo cells were cultured on plastic or Matrigel™ and treated with a therapeutic dose of LMWH (Enoxaparin; 10 IU/ml), with or without CRM197, pan Erb-B2 Receptor Tyrosine Kinase (ERBB) inhibitor, anti-ERBB1 or ERBB4 blocking antibodies, or pretreatment of cells with heparitinase I. Extravillous differentiation was assessed by immunocytochemistry to determine the relative levels of integrins α6β4 and α1β1. Trophoblast invasiveness was assessed in villous explants by measuring outgrowth from villous tips cultured on Matrigel, and by invasion assays with HTR-8/SVneo cells cultured on Matrigel-coated transwell insert. Placental explants and HTR-8/SVneo cells were exposed to oxidative stress in a hypoxia-reoxygenation (H-R) model, measuring cell death by TUNEL assay, caspase 3 cleavage, and BCL-2α expression. MAIN RESULTS AND THE ROLE OF CHANCE LMWH induced extravillous differentiation, according to trophoblast invasion assays and integrin (α6β4-α1β1) switching. Treatment with LMWH rescued cytotrophoblasts and HTR-8/SVneo cells from apoptosis during exposure to reoxygenation injury, based on TUNEL, caspase 3 cleavage and BCL-2α expression. Experiments using CRM197, ERBB1 and ERBB4 blocking antibodies, pan-ERBB inhibitor and removal of cell surface heparin demonstrated that the effects of LMWH on trophoblast invasion and survival were dependent upon HBEGF signaling. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION The primary limitation of this study was the use of only in vitro experiments. Patient demographics from elective terminations were not available. WIDER IMPLICATIONS OF THE FINDINGS These data provide new insights into the non-coagulation-related aspects of perinatal LMWH treatment in the management of placental insufficiency disorders. STUDY FUNDING/COMPETING INTEREST(S) This research was supported by grants from the National Institutes of Health (HD071408 and HL128628), the March of Dimes, and the W. K. Kellogg Foundation. There were no conflicts or competing interests.
Collapse
Affiliation(s)
- Alan D Bolnick
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Jay M Bolnick
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | | | - Brian A Kilburn
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Omar J Pasalodos
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Pankaj K Singhal
- Department of Obstetrics and Gynecology, Good Samaritan Hospital Medical Center, West Islip, NY, USA
| | - Jing Dai
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA
| | - D Randall Armant
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA.,Department of Anatomy and Cell Biology, Wayne State University, Detroit, MI, USA
| | - Sascha Drewlo
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| |
Collapse
|
42
|
Dobrowolski C, Erkan D. Treatment of antiphospholipid syndrome beyond anticoagulation. Clin Immunol 2018; 206:53-62. [PMID: 29510235 DOI: 10.1016/j.clim.2018.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder marked by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). At the present time, treatment is primarily focused on anticoagulation. However, there is increasing awareness of the mechanisms involved in APS pathogenesis, which has led to the trial of novel therapies targeting those mechanisms. Following a brief review of the etiopathogenesis of and current management strategies in APS, this paper focuses on the evidence for these potential, targeted APS treatments, e.g., hydroxychloroquine, statins, rituximab, belimumab, eculizumab, defibrotide, sirolimus, and peptide therapy.
Collapse
Affiliation(s)
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
| |
Collapse
|
43
|
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein 1 antibodies. APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature as well as obstetrical complications. The pathophysiological hallmark is thrombosis, but other factors such as complement activation might be important. Prevention of thrombotic manifestations associated with APS includes lifestyle changes and, in individuals at high risk, low-dose aspirin. Prevention and treatment of thrombotic events are dependent mainly on the use of vitamin K antagonists. Immunosuppression and anticomplement therapy have been used anecdotally but have not been adequately tested. Pregnancy morbidity includes unexplained recurrent early miscarriage, fetal death and late obstetrical manifestation such as pre-eclampsia, premature birth or fetal growth restriction associated with placental insufficiency. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low-molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.
Collapse
|
44
|
Immunoglobulins from sera of APS patients bind HTR-8/SVneo trophoblast cell line and reduce additional mediators of cell invasion. Reprod Biol 2017; 17:389-395. [PMID: 29102762 DOI: 10.1016/j.repbio.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/18/2017] [Accepted: 10/27/2017] [Indexed: 12/20/2022]
Abstract
Immunoglobulins from sera of patients with antiphospholipid syndrome (APS) decrease trophoblast cell invasion in vitro. This study aimed to extend understanding of cellular effects of immunoglobulins from APS (aPL+) in HTR-8/SVneo cells. aPL+ IgG induced change in effector molecules important for cell invasion was investigated further. After 1h of culture 21% cells bound aPL+ IgG, as opposed to 6% in control (aPL-). This was accompanied by increase in phospho-p38 at 30min. After 24h treatment aPL+IgG decreased protein levels of integrin subunits α1 (78% of control; p<0.01), α4 (65% of control, p<0.01), α5 (76% of control; p<0.01) and β1 (80% of control; p<0.01), and secreted gal-1 (68% of control; p<0.05). ProMMP-9 was reduced to 70% of control (p<0.001). Treatment with inhibitor of p38 MAPK signaling SB202190 reversed inhibition in integrin β1 and secreted gal-1. Involvement of p38 MAPK signaling and decrease in integrin subunit α4, proMMP-9, and secreted gal-1 in HTR-8/SVneo cells are novel and extend the list of mediators of trophoblast invasion affected by aPL.
Collapse
|
45
|
Spinillo A, Beneventi F, Caporali R, Ramoni V, Montecucco C. Undifferentiated connective tissue diseases and adverse pregnancy outcomes. An undervalued association? Am J Reprod Immunol 2017; 78. [PMID: 28921728 DOI: 10.1111/aji.12762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022] Open
Abstract
Undifferentiated connective tissue diseases (UCTDs) are a heterogeneous group of disorders characterized by symptoms and signs suggestive of systemic autoimmune rheumatic disease (ARD), but which do not fulfill all the established criteria for definite diagnosis of a condition. Although a third of UCTDs can progress to a definite ARD within months or years, most UCTDs can remain stable for years with minimal disease activity. The annual incidence of UCTD in the general population ranges from 14 to 140 per 100 000 people. UCTDs are associated with the persistence of several circulating autoantibodies including antinuclear, antiphospholipid or antithyroid antibodies. Immunological evaluation of subjects with UCTDs suggests a proinflammatory state and dysregulation of the Th1/Th2 balance. Autoantibodies have well-known deleterious effects on placentation and have been associated with an increased risk of prematurity, fetal growth restriction (FGR), preeclampsia, and congenital atrioventricular heart block. Although epidemiological and biological data suggest a potential negative impact on reproductive outcomes, the relationship between UCTD and pregnancy outcomes has not been adequately studied. While awaiting definitive data from large studies, obstetricians should be aware that rheumatic disorders in their early, incomplete, or undifferentiated phases can adversely affect pregnancy outcomes, increasing the likelihood of pregnancy loss, FGR, preeclampsia, and prematurity.
Collapse
Affiliation(s)
- Arsenio Spinillo
- Division of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Fausta Beneventi
- Division of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Veronique Ramoni
- Division of Rheumatology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Carlomaurizio Montecucco
- Division of Rheumatology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
46
|
Velayuthaprabhu S, Chinnathambi A, Alharbi SA, Matsubayashi H, Archunan G. Relationship Between Fetal Loss and Serum Gonadal Hormones Level in Experimental Antiphospholipid Syndrome Mouse. Indian J Clin Biochem 2017; 32:347-352. [PMID: 28811696 PMCID: PMC5539012 DOI: 10.1007/s12291-016-0618-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
Abstract
To investigate the effects of antiphospholipid antibodies on establishment of pregnancy and changes in hormones such as estradiol-17ß (E2) and progesterone (P) levels in circulation. Hence, mice were immunized with human β2-Glycoprotein I (β2GPI) and the effect of these antibodies on fetuses weight, placental obsrvation, Serum levels of P and E2 in pregnant mice, hematological were observed. Immunization of mice with human β2-GPI resulted in elevated levels of antiphospholipid antibodies. The experimentally induced antiphospholipid syndrome mouse showed higher rate of fetal resorption, low number of viable fetuses, and "placental abnormalities". In these animals, serum E2 and P levels were reduced significantly. In addition, the blood cell variation among APS induced and control mice were determined. No significant variations were observed in number of Red Blood Cell count, White Blood Cell count and Hemoglobin content, while platelet number was significantly reduced as compared to control. These results clearly demonstrate that human β2-GPI might be involved in causing gestational failure in APS by exerting their effect on serum hormones.
Collapse
Affiliation(s)
- Shanmugam Velayuthaprabhu
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu India
| | - Arunachalam Chinnathambi
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, 11451 Kingdom of Saudi Arabia
| | - Sulaiman Ali Alharbi
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, 11451 Kingdom of Saudi Arabia
| | - Hidehiko Matsubayashi
- Reproduction Clinic Osaka, Board Certified by Japan Society for Reproductive Medicine, Kita, Osaka, 530-0011 Japan
| | - Govindaraju Archunan
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu India
| |
Collapse
|
47
|
El Hachem H, Crepaux V, May-Panloup P, Descamps P, Legendre G, Bouet PE. Recurrent pregnancy loss: current perspectives. Int J Womens Health 2017; 9:331-345. [PMID: 28553146 PMCID: PMC5440030 DOI: 10.2147/ijwh.s100817] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.
Collapse
Affiliation(s)
- Hady El Hachem
- Department of Reproductive Medicine, Ovo Clinic, Montréal, QC, Canada.,Department of Obstetrics and Gynecology, University of Montreal, Montréal, QC, Canada
| | - Vincent Crepaux
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Biology, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | | |
Collapse
|
48
|
Alvarez AM, Balcázar N, San Martín S, Markert UR, Cadavid AP. Modulation of antiphospholipid antibodies-induced trophoblast damage by different drugs used to prevent pregnancy morbidity associated with antiphospholipid syndrome. Am J Reprod Immunol 2017; 77. [PMID: 28132398 DOI: 10.1111/aji.12634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/02/2017] [Indexed: 12/28/2022] Open
Abstract
PROBLEM Women with antiphospholipid antibodies (aPLs) present a risk of pregnancy morbidity (PM), vascular thrombosis (VT), or both (PM/VT). aPLs affect trophoblast function, and the aim of this study was to determine the modulation of this aPL-induced damage by different drugs. METHOD OF STUDY IgG was obtained from women with PM and PM/VT positive to aPLs. Binding of IgG to trophoblastic cells, proliferation, mitochondrial membrane integrity, and trophoblast invasion were assessed. The effect of enoxaparin, aspirin, and aspirin-triggered lipoxin (ATL) were evaluated as well as signal transducer and activator of transcription 3 (STAT3) phosphorylation. RESULTS IgG from women with aPLs strongly binds to trophoblastic cells. Integrity of mitochondrial membrane was reduced, and proliferation was increased by IgG-PM/VT. Both IgG-PM and IgG-PM/VT decreased trophoblast invasion, which was restored by enoxaparin, aspirin, and ATL. IgG-PM triggered reduction in STAT3 phosphorylation. CONCLUSION Some drugs used to prevent aPL-induced PM modulated the alteration of trophoblast function.
Collapse
Affiliation(s)
- Angela M Alvarez
- Reproduction Group, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Norman Balcázar
- Physiology and Biochemistry Department, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | | | - Udo R Markert
- Placenta Laboratory, Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - Angela P Cadavid
- Reproduction Group, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
49
|
Pelusa HF, Pezzarini E, Basiglio CL, Musuruana J, Bearzotti M, Svetaz MJ, Daniele SM, Bottai H, Arriaga SM. Antiphospholipid and antioangiogenic activity in females with recurrent miscarriage and antiphospholipid syndrome. Ann Clin Biochem 2016; 54:577-583. [PMID: 27638930 DOI: 10.1177/0004563216672248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Antiphospholipid syndrome is an autoimmune disease characterized by thrombosis, fetal losses and thrombocytopenia associated to antiphospholipid antibodies. They are directed to phospholipids, such as cardiolipins (anticardiolipin) and lupus anticoagulant or to complexes formed by phospholipids and protein cofactors, such as β2 glycoprotein 1 (a-β2GP1) and annexin V (a-annexin V). These auto-antibodies may be considered as a family of antibodies involved in thrombotic events and antiphospholipid activity. On the other hand, some proangiogenic factors are involved in the normal development of placental vasculature, such as the vascular endothelial growth factor. Overexpression of vascular endothelial growth factor receptor in its soluble form (sVEGFR-1) has been associated to a higher antiangiogenic activity. Our aim was to analyse the association between anticardiolipin, lupus anticoagulant, a-β2GP1, a-annexin V and sVEGFR-1 with recurrent miscarriage before week 10 of gestation in females with antiphospholipid syndrome. Methods We studied 24 females (primary or secondary antiphospholipid syndrome), who were divided into two groups: females with recurrent miscarriage before week 10 of gestation (M; n = 12) and females with no history of fetal loss (NM; n = 12). Anticardiolipin, a-β2GP1, a-annexin V and sVEGF-R1 concentrations were assessed by ELISA, while lupus anticoagulant was assessed by screening and confirmatory tests. Results A significant association was observed between the number of positive biomarkers and the belonging group ( P < 0.05). Besides, a positive result for lupus anticoagulant and a-β2GP1 was found to be significantly associated to the M group ( P < 0.05). Conclusions Lupus anticoagulant and a-β2GP1 may be implicated in pregnancies complicated by recurrent miscarriage in females with antiphospholipid syndrome.
Collapse
Affiliation(s)
- Hector F Pelusa
- 1 Área Bioquímica Clínica, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Eleonora Pezzarini
- 1 Área Bioquímica Clínica, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Cecilia L Basiglio
- 1 Área Bioquímica Clínica, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina.,2 Instituto de Fisiología Experimental (IFISE-CONICET), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Jorge Musuruana
- 3 Servicio de Reumatología y Enfermedades Autoinmunes Sistémicas, Hospital J. B. Iturraspe, Santa Fe, República Argentina
| | - Mariela Bearzotti
- 4 Laboratorio Central, Departamento Bioquímica Clínica con sede en el Hospital Provincial del Centenario, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - María J Svetaz
- 4 Laboratorio Central, Departamento Bioquímica Clínica con sede en el Hospital Provincial del Centenario, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Stella M Daniele
- 1 Área Bioquímica Clínica, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Hebe Bottai
- 5 Área Estadística y Procesamiento de Datos, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| | - Sandra Mm Arriaga
- 1 Área Bioquímica Clínica, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Santa Fe, República Argentina
| |
Collapse
|
50
|
Tincani A, Bompane D, Danieli E, Doria A. Pregnancy, lupus and antiphospholipid syndrome (Hughes syndrome). Lupus 2016; 15:156-60. [PMID: 16634369 DOI: 10.1191/0961203306lu2279rr] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Autoimmune diseases (AD) occur frequently in women during their childbearing years and may influence pregnancy outcome and neonatal health. Patients with systemic lupus erythematosus (SLE) can experience a disease flare-up during pregnancy with potential negative effects on the product of conceptus, especially if the disease is active. Recurrent pregnancy loss is now considered as a treatable clinical condition associated with the presence of circulating antiphospholipid antibodies (aPL). The neonatal lupus syndromes (NLS), caused by the transplacental passage of maternal IgG anti-Ro/SS-A and anti-La/SS-B antibodies to the fetus, carry significant morbidity and mortality in case of cardiac manifestations. Immunosuppressive agents are often administered during pregnancy in order to control maternal disease and to ensure a better pregnancy outcome. Nowadays, owing to our increasing knowledge of the disease pathophysiological mechanisms and the development of combined medical-obstetric clinics, pregnancy outcome in patients with AD has notably improved.
Collapse
Affiliation(s)
- A Tincani
- Rheumatology and Clinical Immunology, Brescia Hospital and University, Italy.
| | | | | | | |
Collapse
|