Antiphospholipid syndrome and recurrent miscarriages

TORCH, Anti-cardiolepin, and Anti-phospholipids in Women with Repeated Miscarriage in Mosul City

  Abstract   Background and Objective: The present study aimed to identify a connection between common viral infections and women who had repeatedly miscarriages. Material and Methods: This study is a retrospective study which has been carried out on 2010 records in Mosul city/Iraq, and the patients were all women of child-bearing age (20-35 years old). All of the women had suffered from an abortion at least once before. The target viruses in charge for this study include; Toxoplasma gundi, Cytomegalovirus, Rubella virus, and Herpes virus. Results and Conclusion: The analysis is based on the detection of the anti-bodies which confirmed a negative correlation between antibodies level and active viral infection, together with no clear association between the presence of active infectious status and miscarriage. Additionally, only few positive cases for each individual patient were positive for viral infection.  Hence, the outcome confirmed no clear association between presence of infectious agent and repeated miscarriage. Nonetheless, rubella and cytomegalovirus have shown the highest contribution in this regard.

Patterns of Recurrent Thrombosis in Primary Antiphospholipid Syndrome-Multicenter, Real-Life Long-Term Follow-Up

Background

Antiphospholipid syndrome (APS) is an acquired hypercoagulable condition associated with antiphospholipid antibody (aPL) presence. Data on re-thrombosis following APS-diagnosis are limited.

Methods

This is a retrospective analysis of new thrombotic events among primary APS (pAPS) patients followed for up to 15 years in three medical centers in Israel.

Results

Among 312 primary-APS patients, 143 (46%) had new thrombotic event classified to three patterns: (1) Arterial—associated with heart valve disease (OR 7.24, 95% C.I. 2.26–24.6), hypertension (OR 3, 95% C.I. 1.44–6.25), elevated anti-B2-GPI IgM (OR 1.04, 95% C.I. 0.996–1.08), arterial thrombosis at presentation (OR 1.74 95% C.I. 0.992–3.26), and older age (41 vs. 34 years, p < 0.001). (2) Venous—linked with venous thrombosis at presentation (OR 12.9, 95% C.I. 5.27–31.6, p < 0.001), heart valve disease (OR 9.81 95% C.I. 1.82–52.9, p = 0.018), aGAPSS (OR 1.15 95% C.I. 1.02–1.29), and younger age (31 vs. 36.5 years, p = 0.001); and (3) Combined pattern—associated with heart valve disease (OR 40.5 95% C.I. 7.7–212) and pulmonary embolism (OR 7.47 95% C.I. 1.96–28.5). A 4th variant “the Breakthrough pattern” defined by re-thrombosis despite prophylactic therapy was observed in 100/143 (70%) patients and linked with heart valve disease (OR 8. 95% C.I. 2.43–26.3), venous thrombosis at presentation (OR 2.61 95% C.I. 1.47–4.66), leg ulcers (OR 12.2, 95% C.I. 1.4–107), hypertension (OR 1.99, 95% C.I. 0.92–4.34), and higher aGAPSS (OR 1.08, 95% C.I. 0.99–1.18).

Conclusion

In this real-life observation, re-thrombosis was common among pAPS patients including in those recommended to receive prophylactic therapy. Different patterns of recurrence were identified and linked with presenting symptoms, specific serological markers, APS manifestations, and comorbidities. Studies that will address interventions to prevent recurrences of APS-related events are needed.

Chronic Inflammatory Placental Disorders Associated With Recurrent Adverse Pregnancy Outcome

Chronic inflammatory placental disorders are a group of rare but devastating gestational syndromes associated with adverse pregnancy outcome. This review focuses on three related conditions: villitis of unknown etiology (VUE), chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The hallmark of these disorders is infiltration of the placental architecture by maternal immune cells and disruption of the intervillous space, where gas exchange between the mother and fetus occurs. Currently, they can only be detected through histopathological examination of the placenta after a pregnancy has ended. All three are associated with a significant risk of recurrence in subsequent pregnancies. Villitis of unknown etiology is characterised by a destructive infiltrate of maternal CD8+ T lymphocytes invading into the chorionic villi, combined with activation of fetal villous macrophages. The diagnosis can only be made when an infectious aetiology has been excluded. VUE becomes more common as pregnancy progresses and is frequently seen with normal pregnancy outcome. However, severe early-onset villitis is usually associated with fetal growth restriction and recurrent pregnancy loss. Chronic histiocytic intervillositis is characterised by excessive accumulation of maternal CD68+ histiocytes in the intervillous space. It is associated with a wide spectrum of adverse pregnancy outcomes including high rates of first-trimester miscarriage, severe fetal growth restriction and late intrauterine fetal death. Intervillous histiocytes can also accumulate due to infection, including SARS-CoV-2, although this infection-induced intervillositis does not appear to recur. As with VUE, the diagnosis of CHI requires exclusion of an infectious cause. Women with recurrent CHI and their families are predisposed to autoimmune diseases, suggesting CHI may have an alloimmune pathology. This observation has driven attempts to prevent CHI with a wide range of maternal immunosuppression. Massive perivillous fibrin deposition is diagnosed when >25% of the intervillous space is occupied by fibrin, and is associated with fetal growth restriction and late intrauterine fetal death. Although not an inflammatory disorder per se, MPFD is frequently seen in association with both VUE and CHI. This review summarises current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology and potential prophylaxis against recurrence in these three chronic inflammatory placental syndromes.

Long Term Follow up of Patients With Primary Obstetric Antiphospholipid Syndrome

Introduction: Primary obstetric antiphospholipid syndrome (OAPS) is defined by specific morbidities and/or losses of pregnancy in the presence of persistent antiphospholipid antibodies (aPL). This variant of APS is usually treated during pregnancy and the post-partum period. Data on occurrence of thrombotic event during long term follow-up of OAPS patients is limited.

Methods: A multi-centre retrospectively cohort of female patients with primary APS (pAPS) was assembled during 2004–2019. Patients were grouped according to disease presentation as pure OAPS or thrombotic APS (tAPS) for those presenting with thrombosis. Clinical and serological data were compared between groups.

Results: Of 219 pAPS female patients 67 (30.6%) were diagnosed with OAPS and 152 (69.4%) with tAPS. During >10 years of follow-up 24/67 (35.8%) OAPS and 71/152 (50%) tAPS suffered a new thrombotic event (p = 0.06), while obstetric morbidity was more likely in the OAPS group (31.3 vs. 10.5%, p < 0.001) respectively. Among patients with OAPS at presentation heart valve disease and the presence of ANA were related to thrombosis following diagnosis (25 vs. 4.7%, p = 0.02; and 45.8 vs. 20.8%, p = 0.04 respectively).

Conclusion: Thrombotic event following diagnosis were common among female patients with pAPS regardless of disease presentation. Heart valve disease and ANA positivity may be risk factors for thrombosis during follow-up of patients presenting with pure OAPS.

Prognostic analysis of antibody typing and treatment for antiphospholipid syndrome-related recurrent spontaneous abortion

OBJECTIVE

To determine the efficacy of antibody typing and treatment on live birth rate in Chinese patients with antiphospholipid syndrome (APS)-related recurrent spontaneous abortion (RSA).

METHODS

A retrospective study analyzed 4542 Chinese patients who experienced spontaneous abortion, of whom 314 had APS (272 primary and 42 secondary). Type of antibodies was tested. Anticoagulant and anti-inflammatory treatments were adopted according to the titer and type of antibodies. The incidence of repeated abortion and placental dysfunction, gestational age, and mean weight of the fetuses were recorded.

RESULTS

Among the patients with APS-related RSA, primary APS accounted for the largest proportion. The proportion of antibody classification was as follows: β2-glycoprotein 1 (β2GP1)-IgM (151, 48.08%), lupus anticoagulant (LAC) (36, 11.46%), anticardiolipin (aCL)-IgM (32, 10.19%), β2GP1-IgM and aCL-IgM (29, 9.23%), and aCL-IgG (16, 5.09%). After treatment, the negative conversion of antibody, including β2GP1-IgM and LAC, significantly improved pregnancy outcomes. There was no significant difference in pregnancy outcomes between the other antibody titers.

CONCLUSION

The combination of anticoagulant and anti-inflammatory treatment led to a higher live birth rate in the treatment of APS-related RSA, highlighting the potential of antibody typing in providing clinical guidance for the treatment of APS-related RSA.

Aspirin and heparin in the treatment of recurrent spontaneous abortion associated with antiphospholipid antibody syndrome: A systematic review and meta-analysis

The present study aimed to review relevant, randomized, controlled trials in order to determine the effects of aspirin and heparin treatment on recurrent spontaneous abortion (RSA) in women with antiphospholipid syndrome (APS). Previous relevant studies were identified using PubMed, Cochrane, Embase, CNKI, VANFUN and VIP by retrieving appropriate key words. Additionally, key relevant sources in the literature were reviewed and articles published before May 2019 were included. The 22 selected studies included 1,515 patients in the treatment group and 1,531 patients in the control group. These previous studies showed that heparin and aspirin significantly improved live birth rate when compared with treatments using intravenous immunoglobulin, aspirin alone or aspirin combined with prednisone. Moreover, heparin and aspirin greatly increased the birth weight compared with placebo and improved vaginal delivery relative to intravenous immunoglobulin. The gestational age at birth was significantly higher in the heparin and aspirin group compared with the placebo group and the incidence of intrauterine growth restriction was lower in the heparin and aspirin group compared with the placebo group. Furthermore, heparin and aspirin markedly reduced the incidence of miscarriage compared with the aspirin group and the placebo group, and the incidence of pre-eclampsia was lower in the heparin and aspirin group than the placebo group. Thus, heparin and aspirin could be further examined for the treatment of RSA in women with APS.

Regulatory B Cells: Dark Horse in Pregnancy Immunotherapy?

There are many unanswered questions surrounding the function of immune cells and how they interact with the reproductive system to support successful pregnancy or contribute to pregnancy pathologies. While the role of immune cells such as uterine natural killer and dendritic cells, and more recently regulatory T cells has been established, the role of another major immune cell population, the B cell, and particularly the regulatory B cells, is relatively poorly understood. This review outlines what is known about B-cell subsets in the context of pregnancy, what constitutes a regulatory B cell and what role they may play, particularly during early pregnancy. Lastly, we discuss why immunotherapies for the treatment of pregnancy disorders is not widely progressed clinically and speculate on the potential of functional regulatory B cells as the basis of novel immunotherapeutic approaches for the treatment of immune-based pregnancy pathologies.

Revisiting the complement system in systemic lupus erythematosus

Introduction: Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease, characterized by the production of autoantibodies. Numerous mechanisms contribute to the pathogenesis and autoimmunity in SLE. One of the most important mechanisms is the defective function of the early complement components that are involved in clearing the immune-complexes and apoptotic debris. Major evidence supporting this hypothesis is the development of severe lupus in individuals with monogenic defects in any one of the early complement components such as C1q, C1 s, C1 r, C2, or C4.Areas covered: In this review, we discuss hereditary defects in classical complement components and their clinical manifestations, acquired defects of complements in lupus, the role of complements in the pathogenesis of antiphospholipid antibody syndrome and lupus nephritis, and laboratory assessment of complement components and their functions. Articles from the last 20 years were retrieved from PubMed for this purpose.Expert opinion: Complements have a dual role in the pathogenesis of SLE. On one hand, deficiency of complement components predisposes to lupus, while, on the other, excess complement activation plays a role in the organ damage. Understanding the intricacies of the role of complements in SLE can pave way for the development of targeted therapies.

Anti-phospholipid antibody prevalence and association with subclinical atherosclerosis and atherothrombosis in the general population

BACKGROUND

There is no agreement on the prevalence of anti-phospholipid antibodies (aPLs) and the correlation with atherosclerosis and cardiovascular (CV) events in the general population.

METHODS

We performed a cross-sectional study on 1712 randomly enrolled subjects from a Northern Italian city to investigate the presence of aPLs and the association with subclinical atherosclerosis (using the carotid artery intima media thickness measured as inter-adventitia common carotid artery diameters - ICCAD) and retrospectively collected CV factors and events (i.e. acute myocardial infarction, stroke, and peripheral obliterans arterial vasculopathy) using physician-assisted questionnaires. We tested serum IgG, IgM, and IgA anti-cardiolipin, anti-beta2glycoprotein I (aGPI), and anti-phosphatidylserine-prothrombin antibodies.

RESULTS

Positive aPLs were found in 15.1% of the subjects, with no differences between sex but with higher rates in older subjects. Carotid subclinical atherosclerosis was more frequent in aPL positive subjects; more specifically, aGPI IgA were associated with higher ICCAD average (adjusted beta 0.51, 95% confidence interval (CI)0.17-0.84; p = 0.003). A positive history of CV events was also more frequent in aPL positive subjects (odds ratio (OR) 1.67, 95%CI 1.08-2.54; p = 0.012), particularly peripheral obliterans arterial vasculopathy (OR 2.02; 95%CI 1.14-3.57; p = 0.015). Among subjects with a Framingham risk score >20, and/or diabetes, and/or body mass index >35 kg/m², aPL positivity was associated to the highest risk of CV events (OR 2.52, 95%CI 1.24-5.11; p = 0.011).

CONCLUSIONS

APL prevalence in the general population is higher than previously reported. CV events and subclinical atherosclerosis are more frequent in the presence of aPL, particularly when a high CV risk coexists.

Investigation of the association between C677T polymorphism of the MTHFR gene and plasma homocysteine level in recurrent fetal miscarriage

AIM

The aim of this study is to determine the association between C677T polymorphism in MTHFR gene and plasma homocysteine concentration in recurrent fetal miscarriages.

METHODS

Overall, 100 women were included in the research, the case group comprised of 50 women who had a history of spontaneously recurrent miscarriage with unspecified cause, and 50 of whom had experienced at least two successful pregnancy, as controls. Methods used in the study included PCR-RFLP with limited effective HinfI enzyme in order to investigate MTHFR polymorphism and enzyme-linked immunosorbent assay analysis to investigate plasma homocysteine concentration.

RESULTS

There was a significant increase in the prevalence of mutant TT genotype among women with miscarriage history. Also, the mean homocysteine level in the case group was significantly higher than that in the control group (P = 0.002) and higher level of homocysteine was found in the carriers of T allele.

CONCLUSION

Our data suggest that C677TT genotype may be a risk factor for miscarriage and CC wild type genotype supposed to have protective effect on hyperhomocysteinemia.

Efficacy of Different Treatment Regimens for Antiphospholipid Syndrome-related Recurrent Spontaneous Abortion

Background:

Antiphospholipid syndrome (APS)-related immune factors are considered as an important cause of recurrent spontaneous abortion (RSA). Anticoagulant and anti-inflammatory treatments are believed to effectively improve adverse pregnancy outcomes by affecting the abnormal autoimmune response of the maternal-fetal interface. The aim of this study was to observe the clinical characteristics and treatment outcomes of anticoagulant regimens and anti-inflammatory plus anticoagulation regimens for APS-related RSA.

Methods:

APS-related RSA cases from September 2011 to September 2016 at Peking University Third Hospital were retrospectively analyzed. The patients were assigned to study group (anti-inflammation plus anticoagulation) and control group (simple anticoagulation). The incidence of repeat abortion, the incidence of placental dysfunction, the gestational weeks of pregnancy, and the mean weight of the fetus were observed.

Results:

The pregnancy and neonatal outcome indicators of the repeat pregnancy loss rate (11.11% vs. 22.70%), placental dysfunction-related diseases (6.35% vs. 15.60%), the mean birth weight of infants born after 24 weeks gestation (3152.41 ± 844.67 g vs. 2765.76 ± 816.40 g), full-term delivery weight (3456.28 ± 419.79 g vs. 3076.18 ± 518.79 g), the proportions of low birth weight infants (12.70% vs. 21.98%), and small for gestational age (6.35% vs. 14.18%) differed significantly between the study and control groups (all P < 0.05). The incidence of preterm delivery, term delivery, and stillbirth was not significantly different between the two groups, and there was no significant difference between the study and control groups in gestational age at birth (37.6 ± 3.3 weeks vs. 36.9 ± 3.2 weeks; P > 0.05).

Conclusion:

The anti-inflammatory and anticoagulation regimen is more effective than the simple anticoagulation regimen in the treatment of APS recurrent abortion.

Effect and mechanism of the aβ2‑GP I/rhβ2‑GP I complex on JEG‑3 cell proliferation, migration and invasion

Antiphospholipid antibody (aPL)-mediated antiphospholipid syndrome (APS) is an autoimmune disease. Upon binding to aPL, the primary antigen of aPL, β2-glycoprotein I (β2-GP I), induces abnormal immune function, which further activates downstream signaling pathways in the cell and eventually leads to APS. The present study aimed to determine whether β2-GP I antigen and anti-β2-glycoprotein I antibody (aβ2-GP I), which belong to the aPL class of antibodies, may affect human chorionic epithelium cell (JEG-3) proliferation, migration and invasion. Recombinant human (rh)β2-GP I protein was expressed using a prokaryotic expression system and aβ2-GP I antibody was purified from the blood serum of 10 patients with recurrent pregnancy loss. JEG-3 cells were stimulated with rhβ2-GP I and aβ2-GP I separately or simultaneously, and serum immunoglobulin G of normal pregnant women was used as negative control. Using cell counting kit-8, cell cycle and transwell assays in addition to EdU staining, it was determined that aβ2-GP I/rhβ2-GP I complex markedly increased JEG-3 cell proliferation, migration and invasion. The results revealed that mRNA levels of inhibitor of nuclear factor (NF)-κB kinase subunit (IKKβ), myeloid differentiation primary response protein MyD88 (MyD88), NF-κB and NF-κB inhibitor α (IκBα), as well as the protein levels of MyD88, IκBα and phospho(p)-IκBα in JEG-3 cells increased following incubation with the aβ2-GP I/rhβ2-GP I complex. The observed upregulation of p-IκBα protein suggested that IκBα-mediated inhibition of NF-κB was weakened. Furthermore, JEG-3 cells were transfected with PGMLV-NF-κB-Lu vector. Luciferase activity in JEG-3-NFκB-Luc1 and JEG-3-NFκB-Luc2 cells was enhanced following treatment with aβ2-GP I/rhβ2-GP I complex. The present study demonstrated that aβ2-GP I/rhβ2-GP I complex activates NF-κB through MyD88 signal transduction pathway, which further enhances JEG-3 cell proliferation, migration and invasion.

Efficacy evaluation of low-dose aspirin in IVF/ICSI patients evidence from 13 RCTs: A systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis of existing literature to evaluate the different outcomes of low-dose aspirin on patients undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), including clinical pregnancy rate, implantation rate, live birth rate, miscarriage rate, fertilization rate, number of oocytes retrieved, and so forth.

METHODS

Electronic databases including PubMed, MEDLINE, and Embase were searched between 1997 and March 2016 to identity eligible studies. The following comparisons between treatment groups were included: aspirin versus placebo; aspirin versus control group; aspirin versus aspirin + prednisolone + control.

RESULTS

Thirteen randomized controlled trials which included 3104 participants were selected. There were no significant differences in implantation rate (RR = 1.15; 95% CI = 0.78-1.70), live birth rate (RR = 1.06; 95% CI = 0.93-1.21), miscarriage rate (RR = 1.28; 95% CI = 0.93-1.77), fertilization rate (RR = 0.91; 95% CI = 0.75-1.11), and endometrial thickness (WMD = 0.15; 95% CI = -0.38-0.67). But the research showed that aspirin treatment may improve the clinical pregnancy rate (RR = 1.16; 95% CI = 1.04-1.28) compared to placebo or no treatment, and reduce the number of oocytes retrieved (WMD = -0.68; 95% CI = -0.91-0.46).

CONCLUSIONS

Our findings suggest that low-dose aspirin may improve the pregnancy rate in IVF/ICSI, with the recommended clinical use dose of 100 mg/day. Considering the limitation of included studies, further well-designed large-scaled RCTs are necessary to clarify whether aspirin may improve assisted reproduction outcomes in IVF/ICSI patients.

The Prevalence of Thrombophilia in Women With Recurrent Fetal Loss and Outcome of Anticoagulation Therapy for the Prevention of Miscarriages

OBJECTIVE

To estimate the prevalence of thrombophilia in women with recurrent miscarriages and to assess the effect of antithrombotic therapy.

DESIGN

A retrospective cohort study between the years 2004 and 2010.

SETTING

A hypercoagulation community clinic in northern Israel.

PATIENTS

Four hundred ninety pregnant women referred for thrombophilia screening.

MAIN OUTCOME MEASURES

Screening results for thrombophilia and antithrombotic treatment with enoxaparin, aspirin, or both and pregnancy outcomes.

RESULTS

The most common thrombophilia in our study group was factor V Leiden mutation with a prevalence of 20.9% followed by protein S deficiency with a prevalence of 19%. Live birth rate was higher in the group of women who received enoxaparin regardless of whether a specific thrombophilia could be found. This finding was more pronounced in women who had ≥4 miscarriages.

CONCLUSION

The prevalence of thrombophilia was higher in our study group than in the general population. Furthermore, treatment with enoxaparin might improve the rate of live births in women with or without evidence of thrombophilia, especially in women with ≥4 miscarriages.

The management of pregnant patients with antiphospholipid syndrome

Recurrent pregnancy loss is now considered a treatable clinical condition associated with antiphospholipid antibodies. The management of pregnant patients with antiphospholipid syndrome is mainly based on the use of antiaggregant/anticoagulant agents (with aspirin and heparin) to prevent thrombosis in the uteroplacental circulation. Interventions with these drug therapies and monitored pregnancy have increased fetal survival.

The prevalence of positive serum anticardiolipin antibodies and asymptomatic bacteriuria in women with recurrent abortions

OBJECTIVE

The asymptomatic colonization of the urinary tract in pregnant women may result in severe medical and obstetric complications. The aim of this study was to study the prevalence of asymptomatic bacteriuria in cases of elevated levels of the anticardiolipin antibody in women who experience spontaneous abortions.

MATERIALS AND METHODS

A total of 12 women were enrolled in this case control study, including 60 patients with a history of three or more abortions and 60 healthy pregnant women. All participants were screened for ACL (IgG) and with a urine culture.

RESULTS

Overall, 19 (31.7%) patients and seven (11.7%) healthy pregnant women were positive for ACL. The mean concentrations were 67.1±27.2 IU/mL in the patients and 17.41±6.12 IU/mL in the healthy controls (p≤0.05). In the 60 patients, only 17 (28.3%) had significant bacteriuria, whereas 5 (8.3%) women in the control group had significant bacteriuria. The statistical analysis revealed a highly significant difference. Of the 19 patients with a positive elevation of ACL, 11 (57.9%) had significant bacteriuria, and eight (42.1%) had non-significant bacteriuria. Six patients had ACL-negative results associated with significant bacteriuria. The statistical analysis revealed a highly significant difference.

CONCLUSION

A high serum anticardiolipin level was prevalent in women who experienced recurrent abortions associated with asymptomatic bacteriuria.

Thromboembolism risk following recurrent miscarriage

Normal pregnancy is associated with extensive changes in hemostasis such that the procoagulant effect becomes dominant. The evolutionary advantage of this hypercoagulability may be to counteract the inherent instability associated with hemochorial placentation, which is unique to human beings. However, overall, there is a four- to 10-fold increased thrombotic risk throughout gestation and the postpartum period. Certain inherited or acquired thrombophilic factors may predispose to arterial and/or venous thrombosis and have a possible association with pregnancy complications, including recurrent miscarriage (RM), which affects up to 5% of couples with childbearing desire. A subgroup of women with RM has been demonstrated to be in a prothombotic state before and after pregnancy. The long-term health implications of this hypercoagulability may imply an increased risk of ischemic heart disease. Moreover, the presence of antiphospholipid antibodies rather than thrombophilic genetic defects (i.e., factor V Leiden or prothrombin G202010A mutation) in patients with RM is a determinant of thrombotic events later in life, especially among those patients having also cardiovascular risk factors. This article highlights the thromboembolic risk in nonpregnant RM patients in different thrombophilic settings and the need for thromboprophylaxis among these patients.

The haplotype M2 of the ANXA5 gene is not associated with antitrophoblast antibodies

PURPOSE

The M2 haplotype in ANXA5 as well as antitrophoblast antibodies predispose to recurrent pregnancy loss (RPL). Since M2/ANXA5 can be a factor for development of antiphospholipid antibodies (aPL), this study aimed to trace a possible association of M2 with antitrophoblast antibodies.

METHODS

One hundred patients with two or more consecutive, idiopathic RPLs were divided in two subgroups, JEG-3(+) (n = 42) and JEG-3(-) (n = 58), according to the anti-JEG-3 reactivity measured in subjects' sera. Both subgroups were genotyped for ANXA5 promoter haplotypes and genetic frequencies were compared to available fertile and control populations, as well as within the subgroups.

RESULTS

M2/ANXA5 was generally enriched in the JEG-3 screened cohort of RPL patients in comparison to fertile and population controls. Despite the relatively higher abundance of the haplotype in the JEG-3(-) sample as compared to JEG-3(+) patients and in the JEG-3(-) primary RPL subset in particular, compared to the rest of patients, there was no statistically significant difference between both, JEG-3(-) and JEG-3(+) subgroups.

CONCLUSION

It appears that the haplotype M2/ANXA5 is not associated with the presence of anti-trophoblast antibodies. Our finding indicates that anti-trophoblast antibodies are a class of molecules that differ from aPL and from anti-b2-GPI antibodies, apparently not directed to same or similar epitopes that aPL and anti-b2-GPI would recognize.

Adaptive immune responses during pregnancy

It has long been believed that there is no immune interaction between mother and conceptus during pregnancy. This concept changed after evidence was provided that the maternal immune system is aware of the semiallogeneic conceptus and develops strategies to tolerate it. Since then, finely regulated mechanisms of active tolerance toward the fetus have been described. This Special Issue of the American Journal of Reproductive Immunology deals with these mechanisms. It begins with the description of minor histocompatibility antigens in the placenta; it further goes through adaptive immune responses toward paternal fetal antigens, mostly concentrating on regulatory T cells and molecules modulating the Th1/Th2 balance. The participation of antibody-producing B cells in normal and pathological pregnancies is also discussed. This introductory chapter resumes the concepts presented throughout the Issue and discusses the clinical applications raised from these concepts.

Lantibiotics as probes for phosphatidylethanolamine

Phosphatidylethanolamine (PE) is a major component in the mammalian plasma membrane. It is present mainly in the inner leaflet of the membrane bilayer in a viable, typical mammalian cell. However, accumulating evidence indicates that a number of biological events involve PE externalization. For instance, PE is concentrated at the surface of cleavage furrow between mitotic daughter cells and is correlated with the dynamics of contractile ring. In apoptotic cells, PE is exposed to the cell surface, thus providing a molecular marker for detection. In addition, PE is a cofactor in the anticoagulant mechanism, and a distinct distribution profile of PE has been documented at the blood-endothelium interface. These recent discoveries were made possible using PE-specific probes derived from duramycin and cinnamycin, which are members of type B lantibiotics. This review provides an account on the features of these PE-specific lantibiotics in the context of molecular probes for the characterization of PE on a cellular and tissue level. According to the existing data, PE is likely a versatile chemical species that plays a role in the regulation of defined biological and physiological activities. The utilities of lantibiotic-based molecular probes will help accelerate the characterization of PE as an abundant, yet elusive membrane component.

Coagulation disorders in pregnancy: acquired and inherited thrombophilias

Both acquired and inherited thrombophilias are associated with an increased risk of pregnancy-related venous thromboembolism (VTE) as well as with adverse pregnancy outcome. However, the extension of attributable risk for each thrombophilia and outcome is still a question of debate. Thrombophilias have been investigated in connection with VTE and pregnancy complications such as: recurrent and nonrecurrent early pregnancy loss, late fetal death, placental abruption, fetal growth restriction, and preeclampsia. This review discusses the evidence of association between thrombophilias and pregnancy outcome together with issues as to clinical management and preventive strategies.

Phosphatidylethanolamine at the luminal endothelial surface--implications for hemostasis and thrombotic autoimmunity

OBJECTIVE

Accumulating evidence suggests that phosphatidylethanolamine (PE) is physically present at the luminal endothelial surface, where it tentatively functions as a critical anticoagulant. The goal of the current investigation was 3-fold: to characterize the distribution profile of PE at the luminal endothelial surface; to examine the immunoreactivity to the vascular endothelium by anti-PE (aPE) sera from patients presenting with thrombosis; and to discuss the potential mechanism of PE upregulation by endothelial cells.

METHODS

The rat aortic arch was selected as major conduit vessel under significant hemodynamic burden. The presence of PE and the antigenic profile of aPE sera at the luminal endothelial surface were examined using duramycin as a PEbinding probe and immunohistochemistry. Phosphatidylethanolamine upregulation at endothelial cell surface was investigated using cultured monolayer subject to laminar shear stress or thrombin treatment.

RESULTS

High levels of PE were detected at the luminal endothelial surface of aortic flow dividers, the ascending aorta, and the outer curvature of the aortic arch. The antigenic profiles of aPE sera, which are highly associated with elevated thrombotic risks in patients, are consistent with PE distribution along the endothelial surface. Finally, PE is upregulated at the surface of cultured endothelial cells in response to luminal shear stress but not thrombin.

CONCLUSIONS

The current data describe the physical distribution of vascular PE at the blood-endothelium interface. The luminal PE presents a vulnerability to anti-PE autoimmunity and is consistent with the association between aPE and elevated risk for idiopathic thrombosis.

Anti-phospholipid antibodies and other immunological causes of recurrent foetal loss--a review of literature of various therapeutic protocols

PROBLEM

An immune-based aetiology is one of the several accepted causes for recurrent foetal loss (RFL). However, most of the immunological theories have not fulfilled the criteria for causality. This is a review of the various immunological causes of RFL and the outcome of different treatment protocols.

METHOD OF STUDY

Both auto- and alloimmune maternal immunological abnormalities have been proposed to account for foetal loss. Among the autoimmune factors, anti-phospholipid antibodies (APAs) have been demonstrated to be the strongest risk factors for foetal loss, the prevalence of which is as high as 40% in women with RFL. Other autoimmune antibodies implicated in RFL are anti-nuclear antibodies (ANAs), anti-thyroid antibodies and anti-endothelial cell antibodies. The alloimmune factors implicated in pregnancy loss of unknown aetiology include abnormal natural killer (NK) cell activity, alteration in T helper 1 (Th1) and T helper 2 (Th2) ratios, presence of alloimmune antibodies like anti-paternal cytotoxic antibodies, anti-idiotypic antibodies, mixed lymphocyte reaction blocking antibodies and abnormal expression of HLA-G molecules. Management of patients with RFL is mainly based on immunomodulatory (prednisolone, intravenous immunoglobulins, plasma exchange, paternal lymphocyte therapy), anti-aggregation (aspirin) or anti-coagulation (unfractionated or low molecular weight heparin) agents.

RESULTS

Low-molecular-weight heparin with low-dose aspirin has been found to be the most effective treatment for women with APAs and RFL. Differences in dosage, timing of treatment, inclusion criteria, outcome assessment parameters etc. are some of the factors which have resulted in discrepancies in various reports.

CONCLUSION

Identification of the immunological mechanisms involved in pregnancy loss and the action of different therapeutic reagents is important so that effective therapies can be designed and investigated.

Explaining "unexplained" perinatal loss: experiences of women with antiphospholipid syndrome

OBJECTIVE

To explore women's experiences of 1 or more perinatal losses associated with antiphospholipid syndrome (APS) and describe their perceptions about losses related to this disorder and its effects on both their outlook and subsequent childbearing.

SUBJECTS

The participants included thirty-eight 18- to 50-year-old women from 5 countries, who were members of general and APS online perinatal support groups and had 1 or more perinatal losses associated with APS.

METHODS

The respondents were recruited from various online perinatal loss support groups, using convenience and snowball sampling. Semistructured e-mail interviews were conducted, using the qualitative technique of phenomenology.

RESULTS

Two major themes that emerged from the data are existence in bewilderment and persistence in the quest for knowledge and information. The first theme has 2 subthemes: delayed diagnosis and living in uncertainty.

CONCLUSION

Women with APS and related perinatal losses perceive the need to persist in seeking scientific knowledge because the information they receive from healthcare providers is limited and unclear. Evidence-based medical and nursing education about antiphospholipid antibody syndrome is necessary to improve clinical practice and thereby the perinatal outcome and the ill effects of this condition for women during and after the childbearing period.

The influence of the environment and other exogenous agents on spontaneous abortion risk

It is estimated that close to 30% of all pregnancies end in spontaneous abortion. Although about 60% of spontaneous abortions are thought to be due to genetic, infectious, hormonal, and immunological factors, the role of the environment remains poorly understood. Pregnancy involves a delicate balance of hormonal and immunological functions, which may be affected by environmental substances. Many toxic substances that are persistent in the environment and accumulate in the fatty tissues may disrupt this equilibrium. This overview addresses known risk factors for spontaneous abortions and examines the role, if any, that environmental factors (chemical and physical) may play in the etiology of this adverse health outcome.

Autoantibodies to plasminogen and tissue plasminogen activator in women with recurrent pregnancy loss

Reduced fibrinolytic activity has been described in primary anti-phospholipid syndrome (PAPS), and may be responsible for thrombotic events. Antibodies to tissue type plasminogen activator (t-PA) or plasminogen (PLG) might contribute to the hypofibrinolytic state in autoimmune diseases, but the clinical significance of these antibodies is still unclear in recurrent pregnancy loss (RPL). The aim of this study is to evaluate the prevalence and clinical significance of anti-PLG and anti-t-PA antibodies in 87 patients with a history of RPL: 54 women with well-defined PAPS (mean age 32.5 years; range 26-38) and 33 women with unexplained RPL (mean age 30 years; range 24-39). IgG anti-PLG antibodies were found in 20 and four patients from the group with RPL/PAPS and unexplained RPL, respectively; IgG anti-t-PA antibodies were found in 11 and two patients from the above two groups, respectively. IgG anti-PLG antibodies were associated with the high risk of RPL (OR 7.2, P = 0.004), especially with RPL/PAPS (OR 11.2, P < 0.001) evaluated by Fisher's exact test, while IgG anti-t-PA were associated with RPL/PAPS (OR 10.0, P = 0.01) but not with RPL (OR 6.8, P = 0.06). A significant inhibition of exogenous fibrinolysis was observed by IgG fractions from patients with anti-PLG or anti-t-PA antibodies on microplates and on the human umbilical vein endothelial cells, compared with those from healthy controls. The prevalence of IgG anti-PLG antibodies was high in RPL patients, especially in RPL/PAPS, while the prevalence of IgG anti-t-PA antibodies was high in RPL/PAPS but not in RPL, and some of them might inhibit fibrinolysis in patients.

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.

Catastrophic antiphospholipid syndrome related to severe ovarian hyperstimulation

Antiphospholipid syndrome (APS) is a cause of infertility and fetal loss. Ovarian stimulation can induce previously unknown APS. Ovarian hyperstimulation syndrome (OHS) is uncommon but potentially life-threatening, as well as catastrophic APS. A woman that simultaneously developed a severe OHS and a catastrophic APS is described in this paper. Both entities produced thrombotic cardiac and brain thrombosis. A peculiar mechanism of cardiac ischemia is also described. In spite of the life-threatening risk of this situation, the indication for preventive anti-aggregation and/or anticoagulation is not clear.

Thrombophilia screening in pregnancy

Thromboembolism in pregnancy is a major contributor to pregnancy morbidity and mortality with potentially serious adverse effects for both mother and fetus. The purposes of this article are to explore the impact of heritable and acquired thrombophilias on pregnancy and to determine the appropriateness of screening for thrombophilias in pregnancy. In determining the appropriateness of screening, attention was given to the changes that occur in the coagulation and fibrinolytic systems during normal pregnancy. The impact of different heritable and acquired thrombophilias on maternal venous thromboembolism, fetal loss, and its impact on certain obstetric conditions are then explored. Guidelines and conclusions are made as to the appropriateness of screening.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the various thrombophilias associate with pregnancy, to describe the impact of thrombophilias on pregnancy, and to outline the appropriate screening guidelines for thrombophilias during pregnancy.

An update in recurrent spontaneous abortion

Recurrent spontaneous abortion (RSA) is defined as three or more consecutive pregnancy losses prior to the 20th week of gestation. The etiology of recurrent spontaneous abortion is often unclear and may be multifactorial, with much controversy regarding diagnosis and treatment. Reasonably accepted etiologic causes include, genetics, anatomical, endocrine, placental anomalies, hormonal problems, infection, smoking and alcohol consumption, exposure to environmental factors, psychological trauma and stressful life event, certain coagulation and immunoregulatory protein defects. Detection of an abnormality in any of these areas may result into specific therapeutic measures, with varying degrees of success. However, the majority of cases of RSA remains unexplained and is found to be associated with certain autoimmune (APA, ANA, ACA, ATA, AECA) and alloimmune (APCA, Ab2, MLR-Bf) antibodies that may play major role in the immunologic failure of pregnancy and may lead to abortion. Alteration in the expression of HLA-G molecules, T-helper-1 (Th-1) pattern of cytokines and natural killer (NK) cells activity may also induce abortion. Various forms of treatment like antithrombotic therapies such as aspirin and heparin, intravenous immunoglobulin (IVIg) therapy, immunotherapy with paternal lymphocytes and vitamin D3 therapy are effective mode of treatment for unexplained cause of fetal loss in women with RSA.

Thrombophilia and pregnancy complications

OBJECTIVE

This systematic review examines the strength of the association between thrombophilia and recurrent pregnancy loss and other serious obstetric complications. Study design Electronic databases and manual bibliography searches were used to identify studies evaluating the association between thrombophilia and pregnancy loss, preeclampsia, fetal growth retardation, and placental abruption.

RESULTS

Thrombophilic disorders are associated with an increased risk of fetal loss in the majority of case control and cohort studies. The risk is increased throughout pregnancy, but may be higher in the second and third trimester. The common pathologic finding of placental infarction suggests unexplained fetal loss may result from uteroplacental insufficiency and thrombosis. Thrombophilic disorders are not consistently associated with preeclampsia, fetal growth retardation, or placental abruption. Preliminary data suggest prophylactic anticoagulation may improve outcome in thrombophilic women with unexplained recurrent fetal loss.

CONCLUSION

Women with thrombophilia have an increased risk of pregnancy loss and possibly other serious obstetric complications, although definition of the magnitude of risk will require prospective longitudinal studies. Preliminary data suggesting prophylactic anticoagulation may improve gestational outcome provide a rationale for prospective randomized trials in thrombophilic women with unexplained recurrent fetal loss.

New fetoproteins, as presumptive antigenic inducers of abortions and congenital anomalies. Temporal forking of immunological abortions. A working hypothesis

In a previous experimental study soluble alloantigens and soluble foreign (not recognized by the dam's immune system) transitory antigens in chick embryo have been detected. When a chick embryo extract was injected in hens and their eggs were incubated, the death or a delay in chick embryo development or congenital anomalies were observed. Based on the foregoing, the following working hypothesis is established: any fetoprotein not coming into contact with the fetal immune system during the central clonal selection period becomes a foreign antigen. If it is a female fetus that becomes pregnant at adult age, then passage to the maternal circulation or to the decidua of the same foreign fetoprotein from her fetus is a candidate to induce a humoral or cell-mediated response. If specific IgG or toxic factors of the different cells activated by cell-mediated immunity in the mother access the inductive antigen (e.g., an enzyme) in the conceptus, there functions may be cancelled or the antigen-carrier cell may undergo lysis. This will result in damage to tissues leading to abortion or to a viable but morphologically or functionally abnormal offspring. This can occurs with some of soluble foreign transitory antigens existents. The soluble alloantigens are foreign for the mother because are coded by paternal genes and act of similar way.

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.

Autoantibody Panel Screening in Recurrent Miscarriages

PROBLEM

Antiphospholipid autoantibodies (aPL), antithyroid antibodies and anti-extractable nuclear antigens (anti-ENA) have all been reported to be associated with recurrent miscarriages (RM) and infertility. However, this association remained controversial.

MATERIALS AND METHODS

Fifty-eight women with impaired fertility (38 women with RM and 20 women with infertility, but no miscarriages) and 28 control parous women were screened for seven autoantibodies [antithyroglobulin (aTG), antithyroid peroxidase (aTPO), anticardiolipin (aCL), antiphosphatidyl-serine (aPS), antiprothrombin antibodies (aPT), anti-beta 2 glycoprotein 1 (abeta2GP1), and anti-ENA]. There was no evidence for autoimmune diseases in the patients or the control. The analysis was also performed with several panels of autoantibodies, each of which contained two or more autoantibodies.

RESULTS

Anti-TPO was the only antibody to be associated with RM (P = 0.01). A significant association was found between RM, and autoantibodies in the 'aTG + aTPO + anti-ENA' or 'aTG + aTPO' panels. The 'aTG + aTPO + anti-ENA' panel was also associated with RM when the analysis was performed only on 17 women who had secondary infertility: 10 from the 38 women with RM, and seven from the 20 women with infertility and no miscarriages. A significant association (P < 0.001) was also apparent between anti-CL and anti-PS and infertility compared with the 28 control women.

CONCLUSIONS

RM was associated with autoantibodies to aTPO and the combined panel of aTPO, aTG and anti-ENA, but not with aPL. aPL were associated with infertility.