Lupus anticoagulant and anticardiolipin antibodies in pregnancy: a review. II. Diagnosis and management

The prevalence of positive anticardiolipin antibody in Jamaican women with spontaneous abortion and the correlation with past clinical history

One hundred and thirty-eight (138) pregnant women who had spontaneous abortions were screened for immunoglobulin G (IgG) antibodies to cardiolipin (aCL) by enzyme immunoassay (EIA). A total of 85 (61.6%) tested negative, while 53 (38.4%) had positive aCL test results. A review of the patients' hospital notes was conducted and comparisons were made between patients with moderate/high positive (21/138, 15.2%), those with low positive (32/138, 23.1%) and those with negative aCL results (85/138, 61.6%). The variables examined were a history of previous abortions, the number of previous fetal deaths and a past history of medical problems such as thrombosis or high blood pressure. No significant differences were found between the patients with moderate/high positive aCL; low positive aCL; and those with negative aCL test results for any of the clinical variables examined. In conclusion, the prevalence of positive IgG aCL tests was high in this cohort of patients with spontaneous abortion. However, intervention is not necessary in many of these patients who have only a positive aCL test, but none of the clinical conditions of the antiphospholipid syndrome.

Immunodiagnostic evaluation in women with reproductive failure

PROBLEM

Several immunological factors have been associated with diagnostic subpopulations of reproductive failure. It is important to determine a trend of immunological abnormalities among these subpopulations. The purpose of this study is to assist in the selection of treatment for patients suspected of having specific diagnoses of reproductive failure.

METHOD OF STUDY

Blood samples from 591 patients were evaluated for the presence of antiphospholipid (APA), antinuclear (ANA), and antithyroid (ATA) antibodies, as well as for lupus anticoagulant (LA), embryotoxic factors (ETF), and elevated levels of natural killer (NK) (CD56+) cells, and all tests were performed as a panel. The patients were grouped into the following diagnostic categories: recurrent pregnancy loss (n = 302), IVF/ET failure (IVFf, n = 122), unexplained infertility (n = 97), ovarian dysfunction (n = 47), and endometriosis (n = 23). The thresholds for positivity and the prevalence of the tested factors among normal healthy populations have been established by testing 100 or more healthy male and female individuals with each one of the tests used (general population control). All tests as panel were performed on 20 normal fertile female individuals as controls (fertile female controls).

RESULTS

Of all patients with reproductive failure, 75.6% had at least one abnormal test. The most frequent abnormal result was found to be the elevation of NK (CD56+) cells (37%), followed by ANA (34%), APA (24%), ATA (19%), and ETF (11%). Of the recurrent pregnancy loss patients, 74.2% had at least one positive abnormal result from all of the tests performed: overall, 70% of women with IVF failure had at least one abnormal test; of patients diagnosed with unexplained infertility, approximately 81% had at least one abnormal result; 74.4% of the patients with ovarian dysfunction and 52% of the patients with endometriosis had at least one abnormal result. From normal fertile controls, 10% showed at least one abnormal test result.

CONCLUSION

APA, ANA, ATA, ETF, and elevated NK (CD56 ) cells are significantly more prevalent among women experiencing reproductive failure than among the control group and normal healthy individuals.

Antiphospholipid antibodies: a threat throughout pregnancy

Antiphospholipid syndrome (APS) has been associated with recurrent pregnancy loss. The exact pathophysiologic mechanism in unclear but may be associated with an imbalance in the prostacyclin/ thromboxane ratio, which results in vasoconstriction and platelet aggregation. Antiphospholipid syndrome is diagnosed through laboratory tests and clinical assessment. Various regimens are used to treat women who have APS. The purpose of this article is to review this disorder and discuss indications for testing, diagnosis and treatment, and nursing implications.

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.

The use of intravenous gammaglobulin, heparin and aspirin in the maintenance of pregnancy of freeze thawed embryo in a patient with lupus-type anticoagulant

A case of lupus anticoagulant and repeated fetal loss with a successful delivery of a healthy baby after transfer of thawed frozen embryos and intravenous immunoglobulin administration is described. The repeated fetal loss was due to vascular disturbances caused by lupus anticoagulants. Early implantation was not affected. Anticoagulants and/or steroids did not help in further establishing pregnancy. Intravenous immunoglobulin combined with heparin and aspirin led to term pregnancy and the birth of a healthy child.

Prevention of anticardiolipin antibody-related pregnancy losses with prednisone and aspirin

PURPOSE

Prevention and treatment of pregnancy loss associated with the antiphospholipid syndrome (APS) are controversial. Successful pregnancies have been reported with prednisone and low-dose aspirin in patients with lupus anticoagulant and anticardiolipin antibodies (aCL), but failure has also been reported. The purpose of this prospective study was to define the efficacy of such combination therapy in the prevention of pregnancy loss related to aCL.

PATIENTS AND METHODS

Consecutive pregnant patients with a minimum of one pregnancy loss and at least two positive aCL determinations more than 3 months apart, and in whom other causes of pregnancy loss were ruled out, were included in the study. aCL concentrations were determined by enzyme-linked immunosorbent assay before and during therapy. Patients received prednisone, at a dosage of 40 mg/d, for 4 weeks. The dose was then tapered down 10 mg every 4 weeks, and then to a maintenance dose of 5 mg/d. They also received aspirin, 81 mg/d, throughout the pregnancy. Babies were evaluated during the pregnancy by measurement of fetal heart rate and ultrasonography, and after the delivery by measurement of weight and Apgar scores, and, in some cases, by arterial gasometry.

RESULTS

Eleven patients with a mean (+/- SD) age of 33.2 +/- 5.01 years were included. Prior to therapy, the rate of live-born babies was 15.6% (32 previous fetal losses and 5 live-born babies), and, after therapy, it was 100% (12 pregnancies and 12 live-born babies). There were no significant adverse effects to either mothers or babies. All the patients had positive aCL determinations. Nine patients had positive IgG aCL. The levels of the antibodies decreased during treatment in these nine patients. IgM aCL determinations were positive in nine patients. The levels of this isotype decreased in eight patients (90%) during treatment.

CONCLUSIONS

Treatment with prednisone and aspirin appears to be efficacious, safe, and economic in the prevention of pregnancy loss and fetal growth retardation in patients with aCL.

The perinatal autopsy: a contemporary approach

As autopsy rates in general hospitals decline, interest in the perinatal autopsy continues to rise, reflecting the emergence of a vigorous specialty growing in parallel with fetal medicine, prenatal diagnosis and clinical genetics. Perinatal autopsies are best carried out in tertiary centres which provide these services. Meticulous documentation, flexibility of technique, intelligent use of laboratory tests and wide systematic histopathologic sampling are emphasized. Microbiologic examination is of particular value when carried out by a laboratory having a special interest in genital tract and perinatal pathogens. Karyotyping must be selective if resources are to be conserved and is most productive when there are multiple malformations. Perinatal autopsy is not complete without examination of the placenta and significant lesions should be clearly distinguished from curiosities and from changes secondary to fetal death. The pathologist's wider contribution to perinatal medicine includes providing high quality data to epidemiology units and auditing committees, contributing to the multidisciplinary management of prenatally diagnosed fetal abnormalities, monitoring iatrogenic disease patterns and supporting the process of perinatal grief management. Special problems and diagnostic challenges are to be found when investigating sudden, unexplained intrauterine fetal death, hydrops, bone dysplasias and complicated multiple pregnancies.