Chromosome analysis of aborted conceptuses of recurrent aborters positive for anticardiolipin antibody

Uterine CD56dim and CD16+ Cells in Refractory Antiphospholipid Antibody-Related Pregnancy Loss and Chromosomally Intact Abortuses: A Case-Control Study

AIM

To evaluate the role of uterine natural killer (uNK) CD56^dim and CD16⁺ cells in patients with refractory antiphospholipid, antibody-mediated, recurrent, pregnancy loss.

SETTINGS AND DESIGN

A case-control study was conducted between 2012 and 2015 at a university hospital.

PATIENTS AND METHODS

A group of 118 women with a history of antiphospholipid antibody syndrome experiencing fetal loss in spite of low dose aspirin (LDA) and low molecular weight heparin (LMWH) treatment in the current pregnancy were included in this study. A group of 32 patients undergoing an elective termination of viable pregnancies before 20 weeks were taken as controls. Suction evacuation was performed to collect abortus specimens, and uterine wall curettage was performed to collect decidua specimens, which were then stained using monoclonal antibodies specific to CD56 and CD16.

STATISTICS

Statistical analyses were performed using the Statistical Package for the Social Sciences version 18 software. Chi-square and Fisher exact tests were used for making comparison between the groups.

RESULTS

Abnormal fetal karyotype was found in nine (9/97) cases of the study group, which means that abnormal karyotype accounts for only 9.3% of the causes of failure of treatment. Abnormal karyotype was found in four cases of the control group. Only cases with normal karyotyping were subjected to decidual uNK cells analysis. We found that CD56^dim and CD16⁺ were found in the decidua of 79 cases (79/97), which means that aberrant natural killer cells expression might account for 81.4% of the cases of refractory antiphospholipid antibody (APA)-mediated recurrent pregnancy loss.

CONCLUSION

CD56^dim and CD16⁺ uNK cells might be correlated with refractory APA-mediated recurrent pregnancy loss.

Fetal gender ratio in recurrent miscarriages

Background:

The purpose of this study was to evaluate the gender ratio and incidence of chromosomal anomalies in the products of conception (POC) from recurrent miscarriages.

Methods:

We determined the karyotypes of POC from patients with recurrent spontaneous miscarriages between 1999 and 2009.

Results:

In total, 313 specimens were successfully karyotyped, with a median gestational age of 10 weeks at miscarriage (interquartile range 8–13); 199 (64%) were females and 114 (36%) were males. In total, 121 (39%) had abnormal karyotypes, the most prevalent of which were chromosome 21 and 16 trisomies, triploidy, and monosomy X.

Conclusion:

Our findings suggest that female POC might be more susceptible to recurrent miscarriages than male ones during embryogenesis, implantation, and initial fetal development.

Sairei-to therapy on alloimmune recurrent spontaneous abortions and alloimmune-, autoimmune complicated recurrent spontaneous abortions

Alloimmune recurrent spontaneous abortion (RSA) cases that could not be treated with lymphocyte transfusion due to medical and social reasons were treated with Sairei-to therapy as an emergency measure and all four cases resulted in live births. This may show that Sairei-to treatment is effective in preventing alloimmune RSA. The efficacy of Sojyutsu-Sairei-to and Byakujyutsu-Sairei-to on autoimmune RSA has already been proven. When they were used in the treatment of alloimmune-, autoimmune complicated RSA, the abortion prevention rates were 65.4% and 82.3% respectively. These results indicate that Sairei-to is effective in the treatment of alloimmune RSA and alloimmune-, autoimmune complicated RSA.

Heparin treatment in antiphospholipid syndrome with recurrent pregnancy loss: a systematic review and meta-analysis

OBJECTIVE

To estimate the effect of combined heparin and aspirin compared with aspirin monotherapy in pregnant women with antiphospholipid syndrome and recurrent pregnancy loss.

DATA SOURCES

We searched the PubMed database up to December 2009 for English-language studies using the key words "aspirin AND (heparin OR low molecular weight heparin), (antiphospholipid OR anticardiolipin OR aPL) AND pregnancy."

METHODS OF STUDY SELECTION

Two hundred ninety- two studies were initially screened. Randomized controlled trials comparing the effect of heparin (unfractionated heparin or low molecular weight heparin) plus aspirin compared with aspirin alone on the live-birth rate in women with a history of at least two miscarriages and antiphospholipid antibodies were eligible.

TABULATION, INTEGRATION, AND RESULTS

The pooled effect of unfractionated heparin and low molecular weight heparin was evaluable in three and two randomized controlled studies, respectively, with regard to live births, which was the major outcome. Overall, treatment effects were in favor of heparin against first-trimester losses (odd ratio [OR] 0.39, 95% confidence interval [CI] 0.24-0.65, number needed to treat 6). More specifically, unfractionated heparin displayed a significant effect (OR 0.26, 95% CI 0.14-0.48, number needed to treat 4), while the pooled effect of low molecular weight heparin was insignificant (OR 0.70, 95% CI 0.34-1.45). Combination therapy of either unfractionated heparin or low molecular weight heparin with aspirin failed to display any significant effect in the prevention of late-pregnancy losses. No significant differences were observed between treatment and control groups for any other outcomes.

CONCLUSION

The combination of unfractionated heparin and aspirin confers a significant benefit in live births. However, the efficacy of low molecular weight heparin plus aspirin remains unproven, highlighting the urgent need for large controlled trials.

Sixth meeting of the European Forum on antiphospholipid antibodies. How to improve the understanding of the antiphospholipid syndrome?

The main objective of these meetings is to promote international collaboration in various clinical and research projects. This paper is the summary of the 2007 Ljubljana meeting, and offers an overview of the proposed projects. The technical and methodological details of the projects will be published on the forum’s web site (http://www.med.ub.es/MIMMUN/FORUM/STUDIES.HTM).

Thrombophilia and Recurrent Pregnancy Loss

Many unanswered questions regarding thrombophilia and recurrent pregnancy loss exist. For example, does a true association exist? Are thrombotic mechanisms relevant? Is a second messenger necessary to cause the manifestation of thrombosis? At present it seems that thrombophilia are associated with and may even cause some cases of pregnancy loss. The role of treatment remains to be determined. Although the aim of physicians working in this field is entirely laudable, to allow childless couples to have children, it is necessary to have good evidence of effect before treatment is given to all patients. A serious ethical dilemma remains, however, namely should treatment that may be effective be denied to patients who have prior pregnancy losses? Denial of treatment is extremely distressing for the patient and the physician. The author's own practice is to offer treatment after a full explanation, particularly because treatment is generally prescribed in the antiphospholipid syndrome and justified in hereditary thrombophilias according to the report of Carp and colleagues, showing a 25% improvement in live birth rates in treated patients. When treatment fails, however, the embryo should be karyotyped to exclude chromosomal aberrations.

Thrombophilias and recurrent pregnancy loss: a critical appraisal of the literature

Thrombophilias are suggested to play a role in recurrent miscarriage. The aim of this study was to evaluate the literature of the past 10 years regarding the association between thrombophilias and recurrent miscarriage. We concluded that there is a large variety in applied study methodology. Therefore, we defined criteria for an adequate study on the relationship of thrombophilias on recurrent pregnancy loss: (i) no exclusion criteria for patients or at least the same criteria for patients and controls; (ii) a clear definition of the gestational age at previous losses; (iii) a well-described control group; (iv) clear description of the test methods and moment of testing; and (v) a clear description of the (non) significant differences or odds ratio between cases and controls. Eleven out of 69 studies fulfilled these criteria. Their results show significant higher serum homocysteine levels among women with a history of recurrent miscarriage. No relation was found between recurrent miscarriage and the methylenetetrahydrofolate reductase C667T mutation. No relation was observed for the levels of antithrombin, protein C and protein S. Seven studies on the association of factor V Leiden (FVL) and/or pathologic activated protein C ratio (pAPCR) showed that FVL may play a role in second trimester losses, as do antiphospholipid antibodies. Studies on the prothrombin gene mutation yielded conflicting results. Consequently, large prospective studies according to the aforementioned criteria are needed to establish if there is a relationship between thrombophilias and recurrent miscarriage at all. At present, there is only justification for testing for homocysteine levels, antiphospholipid antibodies and FVL in women with a history of recurrent miscarriage.

Antiphospholipid syndrome in pregnancy

PURPOSE OF REVIEW

Antiphospholipid syndrome is widely recognized as a risk factor for numerous obstetric complications including miscarriage, intrauterine growth restriction, preeclampsia, fetal death and preterm labour. The many recent changes in concept regarding this syndrome, the role of the relevant antibodies, mechanism of action, diagnosis and treatment are assessed in this review.

RECENT FINDINGS

In recent years, our understanding of antiphospholipid syndrome has grown. The antigen has become better defined and is now thought to be beta2 glycoprotein 1. The 'classical' antibodies, lupus anticoagulant and anticardiolipin antibody are known to be pathogenic even when passively transferred to animal hosts. It seems, however, that the pathogenic antibodies are those directed towards beta2 glycoprotein 1, and that those which are directed to phospholipids without binding to beta2 glycoprotein 1 may not be pathogenic, but merely epiphenomena. The treatment of this condition has also been changed due to the influence of randomized trials in which heparin or low molecular weight heparin has replaced the use of steroids.

SUMMARY

There are numerous pitfalls in managing this condition. As beta2 glycoprotein 1 antibodies are not usually tested, the condition may be over diagnosed or misdiagnosed. Similarly, the results of treatment are not usually corrected for confounding factors such as fetal chromosomal aberrations. In the absence of other confounding factors low molecular weight heparins are probably the treatment of choice.

Poor prognosis of recurrent aborters with either maternal or paternal reciprocal translocations

OBJECTIVE

To determine whether the miscarriage rate in recurrent miscarriage patients with an abnormal karyotype, especially reciprocal translocations, in either partner is worse than without an abnormal karyotype.

DESIGN

Retrospectively analyzed prospectively obtained database.

SETTING

Nagoya City University Hospital.

PATIENT(S)

One thousand and two hundred eighty-four couples with a history of 2 or more (2 to 12) consecutive first-trimester miscarriages.

INTERVENTION(S)

Patients with antiphospholipid antibodies were treated with low-dose aspirin and combined therapy.

MAIN OUTCOME MEASURE(S)

Subsequent miscarriages were compared for cases with and without an abnormal karyotype in either partner. A karyotype analysis was also conducted for each aborted conceptus and offspring of 95 pregnancies of 47 patients with reciprocal translocations.

RESULT(S)

Of the total of 1,284 couples, 58 (4.5%) had translocations, 11 being Robertsonian translocations. Eleven of the 18 cases (61.1%) where the husband had a reciprocal translocation suffered further miscarriage; this also was the case for 21 of the 29 cases (72.4%) where the wives had a reciprocal translocation. Those with reciprocal translocations in either partner miscarried significantly more frequently than those without an abnormal karyotype. Only one infant with an unbalanced translocation was found in 34 cases of successful pregnancy following habitual abortion.

CONCLUSION(S)

The pregnancy prognosis with either maternal or paternal reciprocal translocations is poorer than without them. The presence of a reciprocal translocation is thus a risk factor in couples who have recurrent miscarriages.

Sex differences of abortuses and neonates in women with allo-immune recurrent abortions

To investigate the possible association of recurrent spontaneous abortions (RSA) of immune aetiologies with neonatal sex differences, karyotyping of abortuses from allo-immune RSA and epidemiological studies on the sex differences of neonates from sporadic aborters was carried out. Allo-immune disorders, as diagnosed by an increased number of shared HLA class II loci and reduced blocking activity of the woman's serum in mixed lymphocyte reaction, were found almost twice (54.9%) as often as auto-immune disorders (29.9%) among a total of 244 women with RSA. Of 33 abortuses karyotyped from women with RSA, 69.7% showed normal female karyotypes, while only 6.1% had normal male karyotypes, indicating that female fetuses are more prone to abort than males. Epidemiological studies revealed that boys were born at a significantly greater incidence of 58.1% in 221 women with a history of sporadic abortion than 47.6% in 893 women with no history of abortion. Moreover, the proportion of women giving birth to boys only was consistently and significantly higher, regardless of repeated deliveries, in sporadic aborters (36.7%) than in women with no history of abortion (19.6%), showing that more boys were born than girls to women with sporadic abortion. It is concluded that male fetuses are more likely to survive than females in allo-immune RSA due to allo-immune reproductive wastage of chromosomally normal female concept in early human pregnancy, and that allo-immune RSA makes up the highest proportion of unexplained RSA.

Antiphospholipid syndrome and recurrent miscarriages

Sixty percent of recurrent spontaneous abortions are unexplained. Antiphospholipid syndrome is a multisystem disease with the predominant features of venous and arterial thrombosis, recurrent pregnancy loss, foetal death and the presence of antiphospholipid antibodies. Many epidemiological studies focus on antiphospholipid autoantibodies syndrome (APS) as a cause of recurrent spontaneous abortion (RSA). It is found that 7-25% of RSA would have APS as the main risk factor. 'Association not being synonymous with cause', the proportion of abortions due to the APS is difficult to estimate for several reasons: definition of recurrent abortion is variable, the assays for antiphospholipid antibodies are not well standardised, inclusion of patients in the study group according to the antibodies titre is author dependent. Recent studies suggest association of antiphospholipid antibodies syndrome not only with recurrent abortions but also with infertility. New mechanisms are described by which antiphospholipid antibodies could cause placental thrombosis and infarction, acting directly on the surface anticoagulant expressed on trophoblastic cells. Only lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) assays are sufficiently standardised to be usable in routine. Testing for other antiphospholipid antibodies (aPLs) should remain investigational. Several treatments have been proposed: low doses of aspirin, low or immunosuppressive doses of corticosteroids, and preventive or effective dose of heparin, intravenous immunoglobulin.

Embryonic karyotype of abortuses in relation to the number of previous miscarriages

OBJECTIVE

To examine the frequency of chromosomal abnormalities in products of conception from patients with recurrent miscarriages in relation to the number of previous miscarriages.

DESIGN

Retrospective analysis.

SETTING

Nagoya City University Medical Hospital.

PATIENT(S)

A total of 1,309 women with a history of 2-20 consecutive first-trimester abortions.

INTERVENTION(S)

Chromosomal analysis performed on products of conception with use of a standard G-banding technique.

MAIN OUTCOME MEASURE(S)

The frequencies of abnormal and normal embryonic karyotypes for each number of previous abortions were studied. The subsequent pregnancy outcome of patients whose previous miscarriages were karyotyped were studied along with the predictive value of karyotyping of previous miscarriages for subsequent miscarriages.

RESULT(S)

The miscarriage rate increased with the number of previous spontaneous abortions. The frequency of abnormal embryonic karyotypes significantly decreased and that of normal embryonic karyotypes significantly increased with the number of previous abortions. Among 71 patients whose embryonic karyotypes were normal, 44 aborted subsequently, and 23 of 60 patients whose embryonic karyotypes were abnormal aborted subsequently. Patients with a previous normal embryonic karyotype aborted more frequently than those with an abnormal karyotype.

CONCLUSION(S)

The frequency of normal embryonic karyotypes significantly increases with the number of previous abortions, and a normal karyotype in a previous pregnancy is a predictor of subsequent miscarriage.

Anti-cardiolipin antibody and anti-cardiolipin beta-2-glycoprotein I antibody in patients with recurrent fetal miscarriage

To elucidate the association between anticardiolipin antibody (aCL-Ab) or anti-cardiolipin beta-2-glycoprotein I-antibody (aCL-beta-2-GP I-Ab) and recurrent fetal miscarriage, the positive rates of aCL-Ab were assessed in 667 patients with recurrent fetal miscarriages and those of aCL-beta-2-GP I-Ab were assessed in 208 patients. The rates were then compared with the control group. The positive rate of aCL-Ab in the patients group (17.4%) was significantly higher than that in the control group (4.0%). The rate of aCL-Ab was especially high in patients who had experienced two or more fetal miscarriages including at least one or more intrauterine fetal deaths during the second or third trimester (41.3%). The positive rate of aCL-beta-2-GP I-Ab in patients with recurrent fetal miscarriage (3/208 cases, 1.4%) was not significantly different from the control group (0/100 cases, 0%). However, the rate of aCL-beta-2-GP I-Ab was significantly higher in patients who had experienced two or more fetal miscarriages including at least one or more intrauterine fetal deaths during the second or third trimester (8.3%) compared with the control group. In conclusion, the implication of aCL-Ab in the genesis of recurrent fetal miscarriage was confirmed. It was suggested that aCL-beta-2-GP I-Ab was associated with the generation of intrauterine fetal death, although it had little association with the genesis of recurrent fetal miscarriage during the first trimester.

Human leukocyte antigen class II genotype in patients with recurrent fetal miscarriage who are positive for anticardiolipin antibody

OBJECTIVE

To elucidate the relationship between human leukocyte antigen (HLA) class II genotypes and patients with recurrent fetal miscarriage who are positive for anticardiolipin antibody.

DESIGN

Prospective clinical study.

SETTING

Institutional practice at the outpatient clinic for infertility, Niigata University Medical Hospital.

PATIENT(S)

Patients with recurrent fetal miscarriage who were positive for anticardiolipin antibody and normal fertile women.

INTERVENTION(S)

Genomic DNA was extracted from peripheral mononuclear cells.

MAIN OUTCOME MEASURE(S)

Human leukocyte antigen class II genotype was determined using a polymerase chain reaction restriction fragment length polymorphism method.

RESULT(S)

The frequencies of DRB1*0403 and DRB1*0410 were significantly higher in the patient group than in the control group. The frequency of DRB1*04 also was significantly higher in the patient group. As for HLA-DQ genotype, the frequency of HLA-DQB1*0501 was significantly lower in the patient group.

CONCLUSION

Human leukocyte antigen systems appear to be involved in the genesis of antiphospholipid syndrome.

Lack of association between antiphospholipid antibodies and first-trimester spontaneous abortion: prospective study of pregnancies detected within 21 days of conception

OBJECTIVE

To determine the role of antiphospholipid antibodies and anticardiolipin antibodies in first-trimester losses, addressing experimental pitfalls that preclude excluding the possibility that these antibodies reflect merely the selection bias of studying couples only after they have already experienced losses.

DESIGN

Given that retrospective studies cannot exclude the possibility that such antibodies arise as a result of the fetal death, blood samples were obtained either before pregnancy or very early in pregnancy. Sera were obtained within 21 days of conception.

SETTING

Multicenter university-based hospitals (National Institute of Child Health and Human Development collaborative study).

PATIENT(S)

Subjects for the current study were 93 women who later experienced pregnancy loss (48 diabetic; 45 nondiabetic), matched 2:1 with 190 controls (93 diabetic and 97 nondiabetic) who subsequently had normal live-born offspring.

INTERVENTION(S)

Sera from these 283 women were analyzed for antiphospholipid antibodies by enzyme immunoassay. In 260 of the 283 women (87 with pregnancy losses; 173 with live-born infants), sera were also available to perform assays for anticardiolipin antibodies by enzyme immunoassay.

MAIN OUTCOME MEASURE(S)

Pregnancy losses.

RESULT(S)

No association was observed between pregnancy loss and the presence of antiphospholipid antibodies or anticardiolipin antibodies. Levels of antiphospholipid antibodies were 6-19 PL/mL in 62.4% of the pregnancies that ended in losses and > or = 20 PL/mL in 5.4%; among pregnancies resulting in live-born infants, the percentages were 56.8% and 6.8%, respectively. Of the pregnancies that ended in a loss, 5.7% had anticardiolipin antibodies > or = 16 GPL/mL, compared with 5.2% of those ending in a live birth.

CONCLUSION(S)

This prospective study suggests that anticardiolipin antibodies and antiphospholipid antibodies are not associated with an increased risk for first-trimester pregnancy loss.