Ultrasonographic findings of pregnancy losses after treatment for recurrent pregnancy loss: intravenous immunoglobulin versus placebo

Immunotherapy for recurrent miscarriage

BACKGROUND

Because immunological aberrations might be the cause of miscarriage in some women, several immunotherapies have been used to treat women with otherwise unexplained recurrent pregnancy loss.

OBJECTIVES

The objective of this review was to assess the effects of any immunotherapy, including paternal leukocyte immunization and intravenous immunoglobulin on the live birth rate in women with previous unexplained recurrent miscarriages.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 February 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomized trials of immunotherapies used to treat women with three or more prior miscarriages and no more than one live birth after, in whom all recognized non-immunologic causes of recurrent miscarriage had been ruled out and no simultaneous treatment was given.

DATA COLLECTION AND ANALYSIS

The review author and the two co-authors independently extracted data and assessed study quality for all studies considered for this review.

MAIN RESULTS

Twenty trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunization (12 trials, 641 women), Peto odds ratio (Peto OR) 1.23, 95% confidence interval (CI) 0.89 to 1.70; third-party donor cell immunization (three trials, 156 women), Peto OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (one trial, 37 women), Peto OR 0.40, 95% CI 0.11 to 1.45; or intravenous immunoglobulin, (eight trials, 303 women), Peto OR 0.98, 95% CI 0.61 to 1.58.

AUTHORS' CONCLUSIONS

Paternal cell immunization, third-party donor leukocytes, trophoblast membranes, and intravenous immunoglobulin provide no significant beneficial effect over placebo in improving the live birth rate.

Use of intravenous immunoglobulin for treatment of recurrent miscarriage: a systematic review

BACKGROUND

Intravenous immunoglobulin (IVIG) is a fractionated blood product whose off-label use for treating a variety of conditions, including spontaneous recurrent miscarriage, has continued to grow in recent years. Its high costs and short supply necessitate improved guidance on its appropriate applications.

OBJECTIVE

We conducted a systematic review of randomised controlled trials evaluating IVIG for treatment of spontaneous recurrent miscarriage.

SEARCH STRATEGY

A systematic search strategy was applied to Medline (1966 to June 2005) and the Cochrane Register of Controlled Trials (June 2005).

SELECTION CRITERIA

We included all randomised controlled trials comparing all dosages of IVIG to placebo or an active control.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data using a standardised data collection form. Measures of effect were derived for each trial independently, and studies were pooled based on clinical and methodologic appropriateness.

MAIN RESULTS

We identified eight trials involving 442 women that evaluated IVIG therapy used to treat recurrent miscarriage. Overall, IVIG did not significantly increase the odds ratio (OR) of live birth when compared with placebo for treatment of recurrent miscarriage (OR 1.28, 95% CI 0.78-2.10). There was, however, a significant increase in live births following IVIG use in women with secondary recurrent miscarriage (OR 2.71, 95% CI 1.09-6.73), while those with primary miscarriage did not experience the same benefit (OR 0.66, 95% CI 0.35-1.26).

AUTHOR'S CONCLUSIONS

IVIG increased the rates of live birth in secondary recurrent miscarriage, but there was insufficient evidence for its use in primary recurrent miscarriage.

Immunotherapy for recurrent miscarriage

BACKGROUND

Because immunological aberrations might be the cause of miscarriage in some women, several immunotherapies have been used to treat women with otherwise unexplained recurrent pregnancy loss.

OBJECTIVES

The objective of this review was to assess the effects of any immunotherapy, including paternal leukocyte immunization and intravenous immune globulin on the live birth rate in women with previous unexplained recurrent miscarriages.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2004, Issue 3), MEDLINE (1966 to September 2004) and EMBASE (1980 to September 2004).

SELECTION CRITERIA

Randomized trials of immunotherapies used to treat women with three or more prior miscarriages and no more than one live birth after, in whom all recognised non-immunologic causes of recurrent miscarriage had been ruled out and no simultaneous treatment was given.

DATA COLLECTION AND ANALYSIS

The review author and the two co-authors independently extracted data and assessed study quality for all studies considered for this review.

MAIN RESULTS

Twenty trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunization (12 trials, 641 women), Peto odds ratio (Peto OR) 1.23, 95% confidence interval (CI) 0.89 to 1.70; third party donor cell immunization (three trials, 156 women), Peto OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (one trial, 37 women), Peto OR 0.40, 95% CI 0.11 to 1.45; intravenous immune globulin, Peto OR 0.98, 95% CI 0.61 to 1.58.

AUTHORS' CONCLUSIONS

Paternal cell immunization, third party donor leukocytes, trophoblast membranes, and intravenous immune globulin provide no significant beneficial effect over placebo in improving the live birth rate.

Hysteroscopic Metroplasty Improves Gestational Outcome in Women with Recurrent Spontaneous Abortion

STUDY OBJECTIVE

To compare the reproductive outcome in women with recurrent spontaneous abortion (RSA) associated with septate uterus after hysteroscopic metroplasty compared with patients who did not undergo surgery.

DESIGN

Longitudinal evaluation (Canadian Task Force classification II-2).

SETTING

University of Rome, Tor Vergata-affiliated endoscopic unit.

PATIENTS

Forty-eight consecutive women with septate uterus and RSA were enrolled in the study.

INTERVENTIONS

Hysteroscopic metroplasty.

MEASUREMENTS AND MAIN RESULTS

Reproductive outcome in terms of term pregnancy was significantly improved after hysteroscopic metroplasty compared with controls (76% vs. 20%). No differences were found in the prevalence of preterm delivery between groups (4% vs. 5%).

CONCLUSION

Our data suggest that hysteroscopic septum incision can improve pregnancy outcome in patients with RSA associated with septate uterus.

Immunotherapy for recurrent miscarriage

BACKGROUND

Immunologic aberrations might be the cause of recurrent early pregnancy loss in some women.

OBJECTIVES

The objective of this review was to assess the effects of leukocyte immunisation or other immunologic treatments such as intravenous immune globulin (IVIG) on the live birth rate in women with previous unexplained recurrent miscarriages.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched (September 2002). Individual patient data were obtained from the American Society for Reproductive Immunology.

SELECTION CRITERIA

Randomised trials of immunotherapy in women with three or more prior miscarriages and no more than one live birth; all recognised non-immunologic causes ruled out and no simultaneous treatment intervention.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer.

MAIN RESULTS

Nineteen trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunisation (11 trials, 596 women), odds ratio (OR) 1.05, 95% confidence intervals (CI) 0.75 to 1.47; third party donor cell immunization (3 trials, 156 women), OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (1 trial, 37 women), OR 0.40, 95% CI 0.11 to 1.45; intravenous immune globulin (IVIG), OR 0.98, 95% CI 0.61 to 1.58.

REVIEWER'S CONCLUSIONS

Paternal cell immunization, third party donor leukocytes, trophoblast membranes, and intravenous immune globulin provide no significant beneficial effect over placebo in preventing further miscarriages.

Hysteroscopic findings in 344 women with recurrent spontaneous abortion

STUDY OBJECTIVE

To evaluate the prevalence of different anatomic factors in women with recurrent spontaneous abortion (RSA).

DESIGN

Retrospective analysis over 9 years (Canadian Task Force classification II-2).

SETTING

University hospital-affiliated endoscopic unit.

PATIENTS

Three hundred forty-four consecutive patients with RSA and 922 controls referred for abnormal uterine bleeding.

INTERVENTION

Diagnostic hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Major and minor uterine mullerian abnormalities (septate, unicornuate uteri) were found significantly more often in women with RSA than in controls (32% vs 6%, p <0.001). The frequency of acquired uterine anomalies (submucous myomas, polyps) was significantly higher in controls (32% vs 9%, p <0.001). No significant differences were observed between groups in frequency of adhesions (4% vs 2%).

CONCLUSION

Major mullerian uterine abnormalities are associated with RSA, and minor uterine anomalies may be correlated with an increased risk of recurrent miscarriage.

Human intravenous immunoglobulin therapy

Human intravenous immunoglobulin (hIVIG) is a preparation of normal polyspecific IgG obtained from the plasma of healthy blood donors. Although purified immunoglobulins were initially developed for treatment of primary immunodeficiency syndromes, they have since been documented to be effective in the treatment of some immune-mediated diseases such as immune-mediated thrombocytopenia purpura and autoimmune hemolytic anemia. Blockade of Fc receptors on mononuclear phagocytic cells has been proposed as the most likely mechanism for the rapid early response to hIVIG treatment. Human IVIG has been used to treat canine immune-mediated hemolytic anemia (IMHA), anemia with myelofibrosis, and immune-mediated thrombocytopenia. Doses from 0.5 to 1.5 g/kg may be effective, although most studies have used a dose of 1 g/kg. Human IVIG is administered as an intravenous infusion over 6 to 12 hours, and dogs should be carefully monitored for adverse reactions during administration. The possibility of a increased risk of thromboembolism should be considered when undertaking hIVIG treatment. The safety of multiple treatments of hIVIG has not been established. In most dogs with IMHA, benefit may be limited to short-term improvement in hematocrit, which may allow time for other treatment modalities to become effective. Dogs with nonregenerative anemia and associated myelofibrosis may have longer-term responses to hIVIG treatment.

Immunosuppressive properties of monoclonal antibodies and human polyclonal alloantibodies to the R80K protein of trophoblast

PROBLEM

The R80K protein on human trophoblast is antigenically polymorphic, and in all placentae of successful pregnancies, the protein is covered by maternal alloantibody. Alloantibody eluted from human placenta has been shown to inhibit killing by human NK cells. Do those antibodies to R80K that inhibit NK killing also affect the murine abortion models?

METHODS

We made three murine monoclonal antibodies to conserved epitopes, on human R80K, all of which also reacted with the homologous murine molecule. One antibody only, BA11, suppressed NK cytotoxicity to K562 and of mouse spleen NK cells to murine trophoblast. All three were tested in mouse models of abortion: the CBA x DBA/2 model with a high resorption rate of F1 embryos compared with the parental strains, an endotoxin induced abortion/resorption model and a third model in which the pregnant mouse is subject to sonic stress.

CONCLUSION

Those IgG antibodies eluted from microvesicles which bound to K562, and one of the three monoclonals, BA11, inhibited NK killing. The antibodies react with the murine molecule, and BA11 inhibited abortion in all three mouse abortion models. This reinforces the thesis that interference with NK killing can influence abortion/resorption in mice, and the BA11 antibody may effect similar results in analogous human situations.

Antiphospholipid antibody-associated recurrent pregnancy loss: treatment with heparin and low-dose aspirin is superior to low-dose aspirin alone

OBJECTIVE

The purpose of this study was to compare the use of low-dose aspirin alone with heparin and low-dose aspirin in the treatment of the antiphospholipid antibody syndrome.

STUDY DESIGN

A prospective, single-center trial included 50 patients who were alternately assigned to treatment. Each patient had at least three consecutive spontaneous pregnancy losses, positive antiphospholipid antibodies on two occasions, and a complete evaluation. Data were compared by chi(2) analysis and Fisher's exact test.

RESULTS

Viable infants were delivered of 11 of 25 (44%) women treated with aspirin and 20 of 25 (80%) women treated with heparin and aspirin (p < 0.05). There were no significant differences between the low-dose aspirin and the heparin plus low-dose aspirin groups with respect to gestational age at delivery (37.8 +/- 2.1 vs 37.2 +/- 3.4 weeks), number of cesarean sections (18% vs 20%), or complications.

CONCLUSION

Heparin plus low-dose aspirin provides a significantly better pregnancy outcome than low-dose aspirin alone does for antiphospholipid antibody-associated recurrent pregnancy loss.

A clinical trial for the treatment of antiphospholipid antibody-associated recurrent pregnancy loss with lower dose heparin and aspirin

This study was conducted to determine if lower dose heparin (LD Heparin) combined with aspirin is as efficacious as higher dose heparin (HD Heparin) for the treatment of the antiphospholipid antibody syndrome in women seeking pregnancy. The method of the study was a prospective, single center trial including 50 patients who were consecutively assigned to treatment. Each patient had at least three consecutive, spontaneous pregnancy losses, positive antiphospholipid antibodies on two occasions, and a complete evaluation. Data were compared using Fisher's exact test. Viable infants were delivered from 20/25 (80%) women treated with higher dose heparin vs. 19/25 (76%) of women treated with lower dose heparin. There were no significant differences between groups with respect to gestational age at the time of delivery (37.2 +/- 3.4 versus 37.7 +/- 1.6 weeks), maternal complications, or fetal complications. A lower dose of heparin plus aspirin was as effective as higher dose heparin for the treatment of antiphospholipid antibody-associated recurrent pregnancy loss.

Frequency of abnormal karyotypes among abortuses from women with and without a history of recurrent spontaneous abortion

OBJECTIVE

To compare the frequency of chromosomal abnormalities in products of conception from women with and without a history of recurrent spontaneous abortion.

DESIGN

Retrospective analysis of prospectively collected material.

SETTING

Private practice at the Genetics and IVF Institute, Fairfax, Virginia and Grupo de Reproducción AGY Asociados, México City, México.

PATIENTS

Women with (n = 94) and without (n = 130) a history of recurrent spontaneous abortion who had a spontaneous abortion between January 1, 1992 and November 1, 1994.

INTERVENTION

Chromosomal analysis performed on products of conception using standard G-banding technique.

MAIN OUTCOME MEASURE

The percentage of chromosomal abnormalities among products of conception from women with and without recurrent spontaneous abortion was compared.

RESULTS

Among products of conception from women with recurrent spontaneous abortion, 57% (54/94) had abnormal and 43% (40/94) had normal chromosome analyses. Products of conception from women without recurrent spontaneous abortion had abnormal chromosome analyses in 57% (74/130) and normal results in 43% (56/130).

CONCLUSIONS

No differences in frequency of abnormal karyotype were observed in products of conception from women with recurrent spontaneous abortion compared with women without recurrent spontaneous abortion.

Intravenous immunoglobulin for treatment of recurrent pregnancy loss

PROBLEM

Efficacy of immunotherapy for treatment of recurrent spontaneous abortion (SA) has been controversial. The low treatment effect of white blood cell immunization lead to investigations of alternative treatments including intravenous (i.v.) immunoglobulin (Ig). To evaluate the efficacy of IVIg for treatment of recurrent SA, a prospective, randomized, double blinded, placebo-controlled trial was performed.

METHODS

Ninety-five women experiencing two or more consecutive spontaneous abortions, with no known cause were randomized and received either IVIg 500 mg/kg/month or placebo (albumin).

RESULTS

Of 95 women participating in the study, 47 received IVIg and 48 received placebo. Medication was discontinued in 34 women who failed to conceive within four cycles. The remaining 61 women achieved pregnancy. Pregnancy outcomes included 29 deliveries and 32 recurrent SA. Among women delivering live births 18 (62%) received IVIg and 11 (38%) received placebo. By contrast, 21 (66%) women experiencing recurrent SAs received placebo and 11 (34%) received IVIg. Among 61 women who conceived, 29 received IVIg and 32 received placebo. Of the 29 women who conceived and received IVIg, 18 (62%) delivered live births and 11 (38%) experienced recurrent SA. Of 32 women who conceived and received placebo 11 (34%) delivered live births and 21 (66%) had recurrent SA. The difference in live birth rates between women receiving IVIg and placebo was significant (P = 0.04, odds ratio 3.1).

CONCLUSION

IVIg is effective in enhancing the percentage of live births among women experiencing unexplained recurrent SA.

Interaction of heparin with antiphospholipid antibodies (APA) from the sera of women with recurrent pregnancy loss (RPL)

PROBLEM

To determine if heparin may act directly with antiphospholipid antibodies (APA) to prevent recurrent pregnancy loss (RPL).

METHOD

Patients were seen at the University of Texas Southwestern Medical Center. Twenty women with a history of RPL (> or = 3 miscarriages), positive APA, and an otherwise normal evaluation were treated with heparin in two daily subcutaneous dosages during a successful pregnancy. APA levels were obtained prior to conception and again at 6, 20, and 30 weeks.

RESULTS

Heparin reduced APA binding to cardiolipin and phosphatidylserine in a dose-dependent fashion in ELISA. Heparin affinity chromatography absorbed over 80% of the IgG anticardiolipin antibody in serum from women with high levels of APA. Women treated with increasing dosages of heparin during pregnancy had inversely decreasing levels of IgG anticardiolipin antibody.

CONCLUSION

Heparin may act by directly binding APA in vivo, thereby decreasing the adverse effects of APA in women with APA associated RPL.

Systemic CD56+ cells can predict pregnancy outcome

PROBLEM

To evaluate differences in circulating CD56+ cells between successful and unsuccessful pregnancies, 114 pregnant women were studied prospectively.

METHOD

Seventy women had a history of infertility (INF) and 44 had two or more previous spontaneous abortions (RSA). Among the infertile women, 12 were donor egg recipients (DER) and 15 underwent intracytoplasmic sperm injection (ICSI) for treatment of male factor infertility. Nineteen women were carrying multiple gestations (MG) and 55 had singleton gestations (SG). Thirteen additional women were receiving intravenous immunoglobulin (IVIg).

RESULTS

The percentage of CD56+ cells was determined in 310 blood samples from 114 pregnant women by flow cytometry. The prevalence of women with persistent elevation of percent of 56+ cells (> 12%) was 58% among DER, 73% among ICSI, 37% among MG, 22% among SG, 18% among RSA, and 39% among INF. Thirteen women with SG received IVIG, 10 had CD56+ cells greater than 12% and all 13 experienced live births. Women with percentage CD56+ cells persistently greater than 12% who were not DER, not ICSI, not receiving IVIg, and not carrying MG had a live birth rate of 11%. Women with greater than 12% CD56+ cells had normal karyotype in 78% of concepti studied in contrast to women less than 12% CD56+ cells who had 68% abnormal karyotypes (P = 0.04).

CONCLUSION

Elevated CD56+ cells in pregnant women who are not DER, not ICSI, not receiving IVIg, and not carrying MG predicts loss of a karyotypically normal conceptus with a specificity of 87% and positive predictive value of 78%. While the specificity value of this test is high in both infertile and RSA populations, the sensitivity is 86% in RSA and only 54% in INF suggesting this test does not identify all losses among INF. It may identify a subset of pregnancies at risk for loss of a karyotypically normal embryo that may respond to treatment with IVIg.

Immunotherapy with intravenous immunoglobulin for treatment of recurrent pregnancy loss: American experience

PROBLEM

Recurrent spontaneous abortion (RSA) is the cause of childlessness in 2-5% of reproducing couples. Immunological mechanisms have been proposed as an etiology in some cases of RSA. Various forms of immunotherapy have been attempted in individuals thought to have an immunologic mechanism associated with RSA. Intravenous immunoglobulin (IVIG) has been used in a pilot study to successfully treat women with RSA.

METHOD

To evaluate the efficacy of IVIG in the prevention of RSA as prospective randomized, placebo-controlled clinical trial was undertaken. Women experiencing two or more consecutive RSAs receive either IVIG 500 mg/kg/month or placebo (albumin).

RESULTS

To date 92 women have been enrolled in the study and 58 pregnancies have been achieved. The outcome of the 58 pregnancies include 20 deliveries, 9 ongoing pregnancies and 29 losses. Fourteen (49%) of the 29 pregnancy losses were blighted ova (empty gestational sacs) and 15 (51%) were intrauterine fetal deaths (IUFD's) occurring in the first trimester of pregnancy. Of 14 blighted ova, 8 were in women receiving IVIG and 6 were receiving placebo. Fifteen IUFD's occurred: 3 (20%) in women receiving IVIG and 12 (80%) placebo. Of 11 pregnancy losses occurring in women receiving IVIG, 8 (73%) were blighted ova and 3 (27%) were IUFD's. Eighteen losses occurred in women receiving placebo: 6 (33%) were blighted ova and 12 (67%) were IUFD's.

CONCLUSIONS

These preliminary data suggest IVIG may be effective treatment for RSA. Analysis of data from the completed randomized placebo-controlled trial will test this suggestion.