Lupus anticoagulant and pregnancy management

Association of genetic variants of PD1 with recurrent pregnancy loss

Purpose

Programmed cell death 1 (PD1) and PD ligand 1 (PDL1) are speculated to have an important role in maintaining a normal pregnancy and there are also a few reports of an association between the single-nucleotide polymorphisms (SNPs) of PD1 or PDL1 and diseases in humans. The association was examined between the polymorphisms of PD1,PDL1,CTLA4 and recurrent pregnancy loss (RPL).

Methods

The study group consisted of 243 women with two or more pregnancy losses and 176 parous women. The frequency of three SNPs of PD1, two of PDL1, and four of CTLA4 were compared between the patients and controls. Next, the subsequent live birth rates in the patients with RPL with and without risk alleles were examined.

Results

Two SNPs (rs36084323 and rs3481962) of PD1 were found to occur at significantly higher frequencies in the patient group than in the control group. The subsequent live birth rate of the patients with vs. without the risk alleles of rs36084323 and rs3481962 were 83.3% vs. 83.3% and 81.6% vs. 84.0%, respectively.

Conclusion

Variations of the PD1 gene were identified as risk factors for RPL. However, the presence or absence of the PD1 risk alleles had no predictive effect on the subsequent pregnancy outcome.

Determination of clinically significant tests for antiphospholipid antibodies and cutoff levels for obstetric antiphospholipid syndrome

Objective

The objective of this paper is to determine which kinds of assays for antiphospholipid antibodies (aPL) should be tested for clinical practice for patients with recurrent pregnancy loss (RPL).

Materials and methods

We studied 560 patients with a history of RPL prospectively. We determined the obstetric significance of 11 commercially available tested assays for lupus anticoagulant (LA)-aPTT StaClot, phosphatidylserine-dependent antiprothrombin (aPS/PT) IgG, IgM, classical cardiolipin (CL) IgG, IgM, CL IgG, IgM, IgA, and β2glycoprotein I (β2GPI) IgG, IgM, IgA Phadia. Obstetric significance was defined as the potential for anticoagulant therapy to improve the subsequent live birth rate, or a difference in the live birth rate between positive and negative untreated cases.

Results

The LA-aPTT StaClot assay and aPS/PT IgG assay, but not CL IgG, were found to have obstetric significance. Our conventional tests covered positive cases with the aPS/PT IgM and classical CL IgG assays. The results of the LA-aPTT StaClot, LA-aPTT and LA-RVVT assays showed different distributions, although strong or moderate correlation was observed.

Conclusion

LA-aPTT StaClot and aPS/PT IgG might be suitable for use in routine practice for patients with RPL. Each test for aPL should be ascertained for obstetric significance, because similar assays may have different outcomes.

Preimplantation Genetic Diagnosis and Natural Conception: A Comparison of Live Birth Rates in Patients with Recurrent Pregnancy Loss Associated with Translocation

BACKGROUND

Established causes of recurrent pregnancy loss (RPL) include antiphospholipid syndrome, uterine anomalies, parental chromosomal abnormalities, particularly translocations, and abnormal embryonic karyotypes. The number of centers performing preimplantation genetic diagnosis (PGD) for patients with translocations has steadily increased worldwide. The live birth rate with PGD was reported to be 27-54%. The live birth rate with natural conception was reported to be 37-63% on the first trial and 65-83% cumulatively. To date, however, there has been no cohort study comparing age and the number of previous miscarriages in matched patients undergoing or not undergoing PGD. Thus, we compared the live birth rate of patients with RPL associated with a translocation undergoing PGD with that of patients who chose natural conception.

METHODS AND FINDINGS

After genetic counseling, 52 patients who desired natural conception and 37 patients who chose PGD were matched for age and number of previous miscarriages and these comprised the subjects of our study. PGD was performed by means of fluorescence in situ hybridization analysis. The live birth rates on the first PGD trial and the first natural pregnancy after ascertainment of the carrier status were 37.8% and 53.8%, respectively (odds ratio 0.52, 95% confidence interval 0.22-1.23). Cumulative live birth rates were 67.6% and 65.4%, respectively, in the groups undergoing and not undergoing PGD. The time required to become pregnancy was similar in both groups. PGD was found to reduce the miscarriage rate significantly. The prevalence of twin pregnancies was significantly higher in the PGD group. The cost of PGD was $7,956 U.S. per patient.

CONCLUSIONS

While PGD significantly prevented further miscarriages, there was no difference in the live birth rate. Couples should be fully informed of the similarity in the live birth rate, the similarity in time to become pregnancy, the advantages of PGD, such as the reduction in the miscarriage rate, as well as its disadvantages, such as the higher cost, and the advantages of a natural pregnancy, such as the avoidance of IVF failure. The findings presented here should be incorporated into the genetic counseling of patients with RPL and carrying a translocation.

Management of recurrent miscarriage

Recurrent miscarriage is classically defined as three or more consecutive pregnancy losses. Many researchers have now revised this definition to two or more pregnancy losses because of the recent increase in the prevalence of childless couples. Established causes of recurrent miscarriage are antiphospholipid antibodies, uterine anomalies and abnormal chromosomes in either partner, particularly translocations. Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. However, it is not yet established as to what kind of testing should be conducted in patients with recurrent pregnancy loss. Standardization of tests for antiphospholipid antibodies is needed. On the other hand, embryonic aneuploidy is the most frequent cause of recurrent miscarriage. Chromosome analysis of the embryo is important, because it has good predictive value for subsequent live birth. It is not necessary to give any medications for unexplained cases of recurrent miscarriage, and provision of psychological support may be the most important to encourage the couples to continue to conceive until a live birth results.

Real-world practice of obstetricians in respect of assays for antiphospholipid antibodies

OBJECTIVE

The international classification criteria (CC) for definite antiphospholipid syndrome (APS) recommend confirmation of the sustained presence, for at least 12 weeks, of both lupus anticoagulant (LA), as determined by aPTT and RVVT, and anti β2glycoprotein I (β2GPI) or anticardiolipin (aCL) IgG and/or IgM. However, it remains unclear whether obstetricians comply with the aforementioned CC for the diagnosis of APS in daily clinical practice. We performed a nationwide survey to examine the attitudes of Japanese obstetricians toward the use of assays for antiphospholipid antibodies (aPLs).

METHODS

A questionnaire was sent to 2,700 obstetric facilities where maternity checkups are carried out. The types of assays conducted for aPLs, ascertainment of persistence of the antibodies for at least 12 weeks, and the cutoff points used for the assays were examined.

RESULTS

Of the facilities surveyed, 61.5% carried out the assay(s) only once. In regard to the type of assay performed, 97.1% carried out the assay for aCL IgG and/or β2GPI-dependent aCL, while 67.9% performed the LA-aPTT and/or LA-RVVT assay. Only 8.8% carried out assays for both LA. As for the cutoff points used, 98% of the facilities used lower cutoff points described in the manufacturers' manuals rather than the cutoff values recommended in the CC.

CONCLUSION

Thus, only a limited number of facilities adhered precisely to the CC for the diagnosis of APS. Inappropriate treatment and unnecessary expense are potentially major concerns when facilities overdiagnose APS using lower cutoff points or without ascertaining the persistence of the antibodies for at least 12 weeks. On the other hand, some patients miss the opportunity to be treated for APS because of the absence of testing for LA.

Genotyping analysis for the 46 C/T polymorphism of coagulation factor XII and the involvement of factor XII activity in patients with recurrent pregnancy loss

Background

Established causes of recurrent pregnancy loss (RPL) include antiphospholipid syndrome, uterine anomalies, parental chromosomal abnormalities, particularly translocations and abnormal embryonic karyotype. A systematic review concluded that coagulation factor XII (FXII) deficiency was associated with RPL. However, it could not be established whether the 46 C/T SNP of FXII or low activity of FXII was a risk factor for RPL, because of the small sample size.

Methods and Findings

We conducted a cross-sectional and cohort study in 279 patients with two or more unexplained consecutive pregnancy losses and 100 fertile women. The association between the lupus anticoagulant (LA) activity and FXII activity was examined. The frequency of the CC, CT and TT genotypes and the FXII activity were also compared between the patients and controls. Subsequent miscarriage rates among the CC, CT, TT genotypes and according to the FXII activity was examined. LA was associated with reduced FXII activity. The CT, but not the TT, genotype was confirmed to be a risk factor for RPL in the cross-sectional study using multivariate logistic regression analysis (OR, 2.8; 95% CI, 1.37–5.85). The plasma FXII activity in the patients was similar to that in the controls. Neither low FXII activity nor the CT genotype predicted the subsequent pregnancy outcome in the cohort study. On the other hand, and intermediate FXII activity level of 85–101% was predictive of subsequent miscarriage.

Conclusions

Low FXII activity was not associated with RPL. The FXII gene was found to be one of the significant susceptibility genes for RPL, similar to the FV Leiden mutation. However, the clinical influence of the CT genotype might be relatively small, because the presence/absence of this genotype did not have any predictive value for the subsequent pregnancy outcome. This was the first study indicating the influence of FXII 46C/T on further pregnancy outcomes.

Does surgery improve live birth rates in patients with recurrent miscarriage caused by uterine anomalies?

We found that congenital uterine anomalies have a negative impact on reproductive outcome in recurrent-miscarriage couples, being associated with further miscarriage with a normal embryonic karyotype. There has been no study comparing live birth rates between patients with and without surgery. We conducted a prospective study to prove that surgery for a bicornuate or septate uterus might improve the live birth rate. A total of 170 patients with congenital uterine anomalies suffering two or more miscarriages were examined. The live birth rate after ascertainment of anomalies, cumulative live birth rate and infertility rate, were compared between patients with and without surgery. In patients with a septate uterus, the live birth rate (81.3%) at the first pregnancy after ascertainment of anomalies with surgery tended to be higher than that (61.5%) in those without surgery. The infertility rates were similar in both groups, while the cumulative live birth rate (76.1%) tended to be higher than without surgery (60.0%). Surgery showed no benefit in patients with a bicornuate uterus for having a baby, but tended to decrease the preterm birth rate and the low birth weight. The possibility that surgery has benefits for having a baby in patients with a septate uterus suffering recurrent miscarriage could not be excluded.

Peripheral natural killer cell activity as a predictor of recurrent pregnancy loss: a large cohort study

OBJECTIVE

To determine the predictive value of preconceptional peripheral blood natural killer (pNK) cell activity in patients with recurrent pregnancy loss (RPL).

DESIGN

Cohort study.

SETTING

University department.

PATIENT(S)

A total of 552 patients with a history of two to six consecutive miscarriages.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The predictive value of preconceptional pNK cell activity for subsequent miscarriage was analyzed using multivariable logistic regression analysis, with age, number of previous miscarriages, and presence/absence of previous live births and bed rest as covariates.

RESULT(S)

Age and number of previous miscarriages, but not high pNK cell activity, were found to be independent risk factors for a subsequent miscarriage. No effect of bed rest and previous live birth on the likelihood of live birth was observed (odds ratios 1.28 [95% confidence interval 0.81-2.02] and 0.91 [0.52-1.59], respectively).

CONCLUSION(S)

Elevated pNK cell activity was found to not be an independent risk factor for subsequent miscarriage. Clinicians should not measure the plasma NK activity as a systematic recurrent pregnancy loss examination, because its clinical significance is yet to be established.

Diagnosis and treatment methods for recurrent miscarriage cases

Recurrent miscarriage is classically defined as three or more consecutive pregnancy losses. Established causes of recurrent miscarriage are antiphospholipid antibodies, uterine anomalies and abnormal chromosomes in either partner, particularly translocations. Embryonic aneuploidy is the most important cause of miscarriage before 10 weeks' gestation. It can be speculated that about 51% of patients with a history of three miscarriages experienced these because of abnormal embryonic karyotypes. It is not necessary to give any medication for such cases caused by an abnormal embryonic karyotype. Psychological tender loving care might be the most important requirement to continue conceiving till live birth results.

Aspirin in pregnancy

Aspirin, acetylsalicylic acid, is the most frequently consumed drug in pregnancy, taken mostly without a prescription because of headache or a minor ailment. Numerous preparations containing acetylsalicylic acid are freely available over the counter under a variety of proprietary names, and in many cases pregnant women and their doctors may be unaware that aspirin is being taken.

Uterine Cervical Inflammatory Cytokines, Interleukin-6 and -8, as Predictors of Miscarriage in Recurrent Cases

PROBLEM

Inflammatory changes frequently occur in cases of second trimester miscarriage or pre-term delivery, but little attention has been paid to this association with recurrent miscarriage. As interleukin-6 and interleukin-8 are inflammatory cytokines reported to be associated with bacterial vaginosis, intrauterine infections, and pre-term delivery, we here investigated whether they might have predictive value for spontaneous abortion in recurrent cases.

METHOD OF STUDY

Cervical mucus and sera were collected at 4-5 weeks' gestation from a total of 59 patients with a history of two or more unexplained consecutive first trimester miscarriages, and examined by enzyme-linked immunosorbent assay. Patients then were followed up without medication and their pregnancy outcomes were compared with the test results.

RESULTS

Of a total of 59 patients, 13 (22%) miscarried subsequently. Both IL-6 and IL-8 in cervical mucus were significantly higher in patients who miscarried subsequently than in those who had a live birth. In addition, there was no correlation between cervical mucus and serum concentrations of IL-6 and IL-8 take at the same time, and there was no relation with serum IL-6 and IL-8 levels between the two groups.

CONCLUSION

Cervical IL-6 and IL-8 might have predictive value for cases of recurrent miscarriage.

Serum TNF-alpha, IL-6, lupus anticoagulant and anticardiolipin antibody in women with and without a past history of recurrent miscarriage

OBJECTIVE

The aim of the this study was to investigate Lupus Anticoagulan (LA), Anticardiolipin Antibody (ACA), Tumor Necrosis Factor-alpha (TNF-alpha) and Interleukin-6 (IL-6) serum levels in 40 pregnant and 20 nonpregnant.

MATERIALS AND METHODS

The women were divided into three groups. The first group consisted of 20 pregnant women of less than 20 gestational weeks and a past history of habitual abortion . The second group consisted of 20 non pregnant patients with a past history of habitual abortion. The third group consisted of 20 healthy non pregnant women.

RESULT

LA was found in only one patient in the Group 2. ACA Ig G positivity were found 1 patient in the Group 1, 3 patients Group 2 and 1 patient in Group 3. Mean ACA IgG was highest in the Group 2. High serum TNF-alpha levels were found in the 12 (60%), 6(30%) and 2 (10%) women in the Groups 1, 2, and 3, respectively. Significant difference were found for TNF-alpha among the groups (P<0.05). The highest level of TNF-alpha was found in the Group 1 and the lowest in the Group 3. There were statistically significant differences for IL-6 among the three groups (P>0.05).

CONCLUSION

We propose that cytokines especially TNF-alpha was found to be related to the pregnancy loss.

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

Factor XII but not protein C, protein S, antithrombin III, or factor XIII is a predictor of recurrent miscarriage

OBJECTIVE

To investigate whether a decrease in the values of protein C (PC), protein S (PS), antithrombin III (ATIII), factor XII (FXII), or factor XIII (FXIII) has predictive value for subsequent miscarriages.

DESIGN

Prospective study.

SETTING

Nagoya City University Medical School.

PATIENT(S)

A total of 536 patients with a history of two or more first-trimester miscarriages.

INTERVENTION(S)

One hundred and twelve patients treated with low-dose aspirin were excluded from the analysis.

MAIN OUTCOME MEASURE(S)

The subsequent pregnancy outcome of 424 patients was compared for abnormal and normal levels of each parameter.

RESULT(S)

There were no differences in the subsequent miscarriage rates between abnormal and normal values of PC, PS, ATIII, and FXIII. However, the rate with abnormal FXII is significantly higher than that with normal FXII.

CONCLUSION(S)

A decrease in FXII (but not in PC, PS, ATIII, or FXIII) predicts subsequent miscarriage in patients with a history of first-trimester recurrent miscarriages.

Prevalence of autoantibodies in patients with recurrent miscarriages

PROBLEM

It is well known that the prevalence of several autoantibodies is higher in patients with recurrent miscarriages than in normal women. However, links between individual autoantibodies are unclear. The present study focuses on the possible association between beta 2-glycoprotein I (beta 2-GPI)-dependent anticardiolipin antibody (aCL), lupus anticoagulant (LA), and antinuclear antibody (ANA) in patients with recurrent miscarriages.

METHOD OF STUDY

Three hundred and one patients, with a history of two or more unexplained miscarriages, were studied. The titers of beta 2-GPI-dependent aCL and LA were then compared between single-antibody-positive and three-antibody-positive groups.

RESULTS

The prevalences of beta 2-GPI-dependent aCL, LA, and ANA were 3.3, 10.0, and 25.2%, respectively. Four of the 301 patients had all three antibodies. The LA titers in patients with positive values for three antibodies was significantly higher than in cases with only LA.

CONCLUSION

beta 2-GPI-dependent aCL, LA, and ANA define three distinct, but partly related populations in patients with recurrent miscarriage. We should test at least two kinds of autoantibodies in recurrent aborters, because it has been found that, e.g., beta 2-GPI-dependent aCL and LA are predictors for miscarriages.

Activated partial thromboplastin time is a predictive parameter for further miscarriages in cases of recurrent fetal loss

OBJECTIVE

To determine whether clinically routine clotting tests such as activated partial thromboplastin time (aPTT), prothrombin time (PT), or fibrinogen can be used to predict further miscarriages.

DESIGN

Prospective study.

SETTING

Nagoya City University Hospital, Nagoya, Japan.

PATIENT(S)

A total of 261 patients with a history of two consecutive first-trimester spontaneous abortions who had no antiphospholipid antibodies or other autoimmune diseases and no anatomic anomalies were examined for aPTT, PT, and fibrinogen before becoming pregnant again.

INTERVENTION(S)

Blood tests were performed before pregnancy. Patients then were followed up during subsequent pregnancy and their outcomes were compared with their previous blood test results.

MAIN OUTCOME MEASURE(S)

Activated partial thromboplastin time, PT, and fibrinogen were measured by coagulation time methods.

RESULT(S)

Fifty-eight of 261 patients (22.2%) had a subsequent miscarriage. Mean (+/-SD) values for preconception aPTT in individuals whose subsequent pregnancies ended in success and failure were 88.2%+/-23.4% and 99.3%+/-26.4%, respectively. The difference was statistically significant. Respective values were 106.8%+/-22.8% and 106.3%+/-21.4% for PT and 245+/-61.1 mg/dL and 259.1+/-57 mg/dL for fibrinogen. These findings were not significantly different.

CONCLUSION(S)

A shortened aPTT before conception is associated with further miscarriages in patients with a history of recurrent spontaneous abortions who have no antiphospholipid antibodies.

A prospective study on pregnancy risk of antiphospholipid antibodies in association with systemic lupus erythematosus

This prospective study is an attempt to address the issues of whether or not antiphospholipid antibodies (aPL) constitute a significant risk factor for pregnancy in individuals with systemic lupus erythematosus (SLE) and whether or not combination therapy of high-dose prednisolone (PSL) and low-dose acetylsalicylic acid (ASA) offers efficient control. Antibodies against six phospholipids were measured in sera of patients with stable SLE who had no severe complications before pregnancy, and were followed up during subsequent pregnancies. Four of 12 patients with SLE demonstrated aPL-positivity. Six of 8 patients without aPL had appropriate-for-date (AFD) live babies, the remaining two suffering intrauterine fetal death (IUFD) in the first trimester, one having a chromosome abnormality. Two aPL-positive patients treated only with 5-15 mg/day PSL during pregnancy ended in IUFD in the second trimester. In contrast, the other two patients treated with high-dose PSL and low-dose ASA each had AFD live babies at 38 weeks gestation. The results suggest that APL is a crucial risk factor in pregnancy with stable SLE. Combination therapy of high-dose PSL and low-dose ASA may enable aPL-positive patients with SLE to have AFD live babies.

The prevalence of lupus anticoagulant and anticardiolipin antibodies in women with a history of first trimester miscarriages

OBJECTIVE

To determine the prevalence of lupus anticoagulant and raised anticardiolipin antibodies in women with a history of two or more miscarriages in the first trimester of pregnancy.

DESIGN

A prospective study of lupus anticoagulant and anticardiolipin antibody levels in unselected women with a history of two or more first trimester miscarriages.

SETTING

The prepregnancy clinic and miscarriage antenatal clinic in a tertiary referral centre.

SUBJECTS

Two hundred and forty-three women, of whom 113 (47%) had a past history of two miscarriages, and 130 (53%) had three or more miscarriages.

MAIN OUTCOME MEASURES

Quantitative detection of lupus anticoagulant and anticardiolipin antibodies; number of miscarriages in women in the normal and the abnormal groups.

RESULTS

Of the 243 women tested, 41 (16.8%) had an abnormality of lupus anticoagulant or anticardiolipin antibodies. This was significantly different from the normal population as previously reported. Sixteen women (6.6%) were positive for lupus anticoagulant, 20 (8.2%) had elevated anticardiolipin antibodies, and five (2%) had both abnormalities. The most frequently positive test for lupus anticoagulant was the dilute Russel viper venom time, and IgG was the most frequently elevated anticardiolipin antibody. Of the women with a history of only two miscarriages, 15% had an abnormality of lupus anticoagulant or anticardiolipin antibodies, compared with 18.5% of those with a history of three or more miscarriages. This did not reach statistical significance. There were 117 (48%) primary miscarriers and 126 (52%) secondary miscarriers. Of the primary miscarriers, 17% had an abnormality, compared to 18% of the secondary miscarriers.

CONCLUSIONS

These findings provide further evidence of an association between lupus anticoagulant and anticardiolipin antibodies and early pregnancy loss. It is not known if these are the cause of miscarriage, markers for miscarriage, or if antiphospholipid antibodies develop as a result of a noncontinuing pregnancy. Further studies comparing various treatments are required before women with these antibodies can be optimally managed.

Anticardiolipin and antinuclear antibodies in patients with unexplained recurrent abortions

In a controlled study on a resident population in Kuwait, 103 patients with unexplained recurrent spontaneous abortions were investigated for the frequency of positive tests for anticardiolipin antiobodies (ACA) and antinuclear antibodies (ANA). The frequency of ACA was significantly (P<0.001) higher in patients (32.0%) than in controls (7.1%). Only four patients (3.8%) were positive for both IgG and IgM ACA. The frequency of positive tests for ANA was also significantly (P<0.001) higher in patients (13.6%) than in controls (1.2%). No difference was found between first and second trimester aborters in the frequency of positive tests for either ACA or ANA. Primary aborters did not differ from secondary aborters in the frequency of ACA. However, secondary aborters had significantly higher frequency of ANA. There was no concordance between ACA and ANAN positive tests. These results suggest that ACA may be associated with some cases of unexplained recurrent abortions and that tests for both IgG and IgM isotypes should be carried out in the investigations of these patients.

Lupus anticoagulant and monocyte procoagulant activity in polyabortive women

Monocyte stimulation may be induced by various agents. Monocytes generate procoagulant activity (PCA) in response to stimulation; they widely interact with the hemostatic system and participate in thrombin formation. Extensive placental thrombotic infarction has been implicated in fetal death in polyabortive patients with lupus anticoagulant (LA). We investigated 38 polyabortive women: 17 LA negative (LA-) and 18 LA positive (LA+). We compared the results with 25 clinically normal women. After four hours of incubation, the mean value of monocyte PCA in the LA+ women was significantly higher than in either the LA- or the control group (p < 0.0001). The monocyte PCA was out of the range of the controls in 9 of the 18 LA+ women. No correlation was observed between the levels of LA and monocyte PCA (r = 0.02; p = 0.94). No differences were found in monocyte PCA increase when induced by LA-, LA+ or control plasma; in all cases the increase was about five-six fold. Our results indicate that an increased monocyte PCA is present in some LA+ polyabortive women, thus suggesting that monocyte activation might be involved in the formation of thrombotic placental infarction and the consequent fetal loss in some patients. It might also suggest that these patients, in particular, could benefit from corticosteroid treatment, which is known to inhibit the formation of monocyte PCA.

Reproductive outcome in women with recurrent spontaneous abortions of alloimmune and autoimmune causes: preconception versus postconception treatment

OBJECTIVES

The null hypothesis is that treatment of women with recurrent spontaneous abortions with anticoagulation and immunosuppression will not increase the reproductive outcome if it is started preconceptionally.

STUDY DESIGN

Ninety-four women with recurrent spontaneous abortion with autoimmune abnormalities comprised the study group. Group I began autoimmune therapy 48 hours after ovulation: heparin 5000 U twice daily, aspirin 80 mg daily, and prednisone 5 mg twice daily, with an increase to 10 mg twice daily when pregnant. Group II started the same medication after a positive pregnancy test. Group III received no medication. Controls were 19 women with no autoimmune abnormalities. The frequency of reproductive outcome was subject to multiple comparison by the Duncan test.

RESULTS

The percentages of live-born children in groups I, II, and III were 74%, 44%, and 11%, respectively.

CONCLUSIONS

Preconception diagnostic work-up and treatment of autoimmune abnormalities in women with histories of recurrent spontaneous abortion is advocated.

Functional protein S in women with lupus anticoagulant inhibitor

Protein C (PC) and protein S (PS) are components of a potent, natural anticoagulant system. A deficiency of one of these two inhibitors is associated with thrombotic events in young people. A significant reduction in functional PS activity has been observed during normal pregnancy, and recurrent fetal loss may occur in women with lupus anticoagulant (LA) inhibitor. We measured functional PS activity and free PS antigen in 16 non pregnant patients with LA inhibitor and in 17 normal women as controls. A significant difference was observed between patients and controls in functional PS activity (65 +/- 23% vs 87 +/- 15%, p = 0.02) but not in free PS antigen (88 +/- 17% vs 93 +/- 17%). Functional PS activity decreased only in six patients (37%). Removal of IgG from plasma reduced the difference in functional PS activity between patients and controls. Immunologic IgG levels did not correlate with anti-phospholipid antibodies (APA) activities, activated partial thromboplastin time/kaolin clotting time (aPTT/KCT) data or functional PS activity.

Prevention of miscarriage in antiphospholipid syndrome

Recurrent adverse pregnancy outcome may be the final result of different causes, including autoimmune diseases, as the Antiphospholipid Syndrome. Antiphospholipid antibodies (lupus anticoagulant and/or anticardiolipin antibodies) were found in 16% of 197 patients with prior unexplained recurrent miscarriages. During our study 22 out of 32 antiphospholipid antibodies positive women became pregnant again. To prevent abortion relapses, 16 of them were treated with acetylsalicylic acid (50 mg x 2/day) and/or fluocortolone (20 mg/day for 5 days/week). Such therapy started as soon as pregnancy was diagnosed in 14 patients. Two patients began the therapeutic regimen during the third month of gestation. Six patients, who didn't accept this therapeutic approach, represent our control group. All the 14 early treated patients ended pregnancy with success. The 2 women that began the therapy later presented abortion relapses. Among the 6 not treated patients, 5 presented spontaneous abortion and only one gave birth to a baby. No side effect was observed neither in treated mothers nor in their babies. In conclusion, even if further studies would be necessary to standardise a therapeutic protocol, our results encourage the clinical care of patients with antiphospholipid antibodies and adverse pregnancy outcomes.

Different clinical presentations of a lupus anticoagulant in the same family

A young man who had suffered several episodes of deep-vein thrombosis of the legs since the age of 20 had a myocardial infarction at the age of 33, at which time both a prolonged partial thromboplastin time (PTT), compatible with a lupus anticoagulant (LA), and decreased fibrinolytic capacity (FC) were found. His sister presented with deep-vein thrombosis of a leg and subsequent pulmonary embolism when she was 18 years old. She had a miscarriage three years later and developed a hemolytic-uremic syndrome at the age of 35. The PT and FC were normal. Laboratory investigations of the parents revealed positive antinuclear antibodies in the mother's serum but no anomaly in the father. This study suggests a familial tendency to develop autoimmune disorders associated with LA and thromboembolic complications related to decreased FC.

Immunology and clinical importance of antiphospholipid antibodies

Having reviewed the literature on the association of aPL antibodies with clinical manifestations, it is clear that this group of autoantibodies are of considerable importance. The presence of aPL antibodies in some but not all individuals confers a risk of a clinical syndrome characterized by recurrent arterial or venous thrombosis, thrombocytopenia, hemolytic anemia, or positive Coombs' test, and in females, recurrent idiopathic fetal loss. In SLE, the risk is approximately 40%, compared with a risk of 15% in the absence of aPL antibodies. However, only one half of persons possessing these antibodies have SLE, and overall the risk is around 30%. In some circumstances, such as in chlorpromazine or infection-associated aPL antibodies, there appears to be no increased risk. At the other end of the spectrum are seen patients whose only clinical manifestations comprise features of this clinical syndrome, and this entity has been designated the primary antiphospholipid syndrome (PAPS). aPL antibodies are also important because they are not uncommon. They have been found frequently in women with idiopathic recurrent fetal loss (30%), in non-autoimmune patients with ischemic heart disease (20%), or venous thrombosis (up to 30%), or stroke (4-47%), and in chronic immune thrombocytopenia (30%). These autoantibodies can be detected using sensitive solid-phase immunoassays employing the CL antigen, or in appropriate coagulation tests to detect LA activity. These assays are simple to perform but require care in selection of the best test and in interpretation of results. Current tests do not distinguish between those persons at risk of the clinical events and those not at risk. Detection of specific isotypes (especially IgG) and antibody level may aid in such a designation. Treatment of aPL antibody-associated syndromes remains a controversial subject. Since thromboses are associated with significant morbidity and potential mortality, there is a good argument for long-term preventive antithrombotic therapy, at least for as long as the antibodies are detectable, in those patients in whom clinical complications have previously occurred. It is not generally recommended that this treatment be offered to individuals in whom aPL antibodies are detected but who have not suffered previous thromboses, since the risk of such events does not appear to be equal within a group of aPL antibody-positive persons. This particularly applies to pregnant women, since live births and uncomplicated pregnancies are observed regularly in the presence of aPL antibodies without specific treatment. A previous history of at least one unexplained, late fetal loss is considered a prerequisite before intervention in subsequent pregnancies.(ABSTRACT TRUNCATED AT 400 WORDS)

Recurrent adverse pregnancy outcome and antiphospholipid antibodies

Antiphospholipid antibodies, which include lupus-like anticoagulant and anticardiolipin antibody, have been linked to a number of adverse pregnancy outcomes, although their exact pathogenic mechanisms remain poorly defined. The relative risk of complications such as intrauterine growth retardation, spontaneous abortions, and stillbirth in patients with antiphospholipid antibodies also remains undetermined. Heightened attention has been focused on the association, leading to investigations into the pathogenesis. Uncontrolled studies have also explored therapeutic regimens such as aspirin, steroids, and heparin, and clinical trials have used various treatment protocols. Although knowledge into the association of antiphospholipid antibodies and recurrent adverse pregnancy outcome is limited and continues to evolve, this association provides new insights into the disease and offers promise for pharmacologic prophylaxis. In this article, current concepts on pathogenesis, diagnosis, and therapy are reviewed and recommendations are made for clinical care of these patients.

Immunoglobulin G fractions from patients with antiphospholipid antibodies cause fetal death in BALB/c mice: a model for autoimmune fetal loss

We determined whether purified immunoglobulin G from patients with antiphospholipid antibodies causes fetal loss in pregnant mice. Sera were obtained from nonpregnant parous women (group 1) and nonpregnant women with antiphospholipid antibodies and a history of fetal loss (group 2). Pregnant BALB/c mice were given an intraperitoneal injection of 15 mg of IgG on day 8 of pregnancy. Typically, mice treated with IgG from antiphospholipid antibodies aborted within 48 hours. When animals were sacrificed on days 9 to 15, the uterus of each animal was inspected for the presence of live, dead, or resorbing fetuses. In contrast to mice injected with control IgG or saline solution, each mouse injected with IgG from antiphospholipid antibodies aborted and no live fetuses were found (p less than 0.05). Histologic examination of the uteroplacental interface showed decidual necrosis in the mice treated with IgG containing antiphospholipid antibodies, and immunofluorescent studies also showed prominent intravascular decidual IgG and fibrin deposition. We conclude that IgG from antiphospholipid antibodies of women with fetal loss causes fetal loss in BALB/c mice. It appears that the fetal loss is mediated by IgG binding in the maternal decidual vasculature.

Antiphospholipid antibodies and reproduction

Antiphospholipid antibodies (APAs) may be identified in the laboratory by using either coagulation studies or solid-phase immunologic assays (ELISA; RIA). These methodologies do not necessarily evaluate the same antibody; consequently, it is appropriate to screen a patient's plasma by utilizing both assays. APAs have been associated with a variety of obstetrical complications including recurrent spontaneous abortion, intrauterine fetal death, early onset preeclampsia, deep vein thrombosis, and postpartum serositis syndrome. The Kaolin Clotting Time appears to be the most sensitive coagulation test for identifying the lupus anticoagulant. However, preliminary studies would suggest the presence of anticardiolipin antibodies as detected by solid-phase assays are more sensitive and predictive of the clinical course. Although there are no prospective trials to analyze treatment of patients with APA, preliminary data suggest the use of prednisone in combination with aspirin significantly improves the probability of delivery of a viable infant. In addition, heparin, intravenous gammaglobulin, and exchange plasmaphoresis have all been tried with varying degrees of success in individual patients in small series.

Fetal loss treatment in patients with antiphospholipid antibodies

A group of seven young women with antiphospholipid antibodies, histories of recurrent fetal loss, and no live births is reported. Two patients had systemic lupus erythematosus, and the other five fulfilled criteria for the primary antiphospholipid syndrome. A false Venereal Disease Research Laboratory (VDRL) test was present in four of the patients, three had a previous episode of arterial or venous thrombosis, or both, and two had thrombocytopenia. Prednisone and acetylsalicylic acid were given, and monthly controls of lupus anticoagulant activity were carried out. The dose of acetylsalicylic acid was fixed while the dose of steroids was adjusted according to the degree of lupus anticoagulant activity. A fetal survival was obtained in 7/9 (78%) of the pregnancies. Three of the newborn infants had transitory lupus anticoagulant activity. A search for antiphospholipid antibodies should be carried out in patients with otherwise unexplained fetal losses, falsely positive VDRL tests, thrombosis, or thrombocytopenia as the treatment of such patients with prednisone and acetylsalicylic acid is highly effective.

Antiphospholipid antibodies and recurrent pregnancy loss

Antiphospholipid antibodies (APA) have recently been linked to a variety of clinical findings including arterial and venous thrombosis, recurrent spontaneous abortions and fetal loss, as well as thrombocytopenia. These observations have stimulated multidisciplinary interest in the laboratory identification of APA and the clinical management of patients with positive tests for APA.

The use of warfarin in pregnancy complicated by circulating lupus anticoagulant; a technique for monitoring

A case is described in which a pregnancy, preceded by two mid-trimester fetal losses, was complicated by deep-vein thrombosis due to the presence of circulating lupus anticoagulant. Warfarin was used as anticoagulant therapy concurrently with high-dose prednisolone. It is suggested that warfarin may have advantages over heparin in managing pregnancies in women with circulating lupus anticoagulant. A technique is described which allowed the monitoring of levels of lupus anticoagulant in the circulation while warfarin is being administered.h3.