Intravenous gamma-globulin, antiphospholipid antibodies, and pregnancy

Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review

Most investigators currently advocate prophylactic-dose heparin plus low-dose aspirin as the preferred treatment of otherwise healthy women with obstetric antiphospholipid syndrome, whilst women with a history of vascular thrombosis alone or associated with pregnancy morbidity are usually treated with therapeutic heparin doses in association with low-dose aspirin in an attempt to prevent both thrombosis and pregnancy morbidity. However, the protocols outlined above fail in about 20 % of pregnant women with antiphospholipid syndrome. Identifying risk factors associated with pregnancy failure when conventional therapies are utilized is an important step in establishing guidelines to manage these high-risk patients. Some clinical and laboratory risk factors have been found to be related to maternal-foetal complications in pregnant women on conventional therapy. However, the most efficacious treatments to administer to high-risk antiphospholipid syndrome women in addition to conventional therapy in order to avoid pregnancy complications are as yet unestablished. This is a comprehensive review on this topic and an invitation to participate in a multicentre study in order to identify the best additional treatments to be used in this subset of antiphospholipid syndrome patients.

The treatment of anti-phospholipid syndrome: A comprehensive clinical approach

Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.

Pathogenesis and management of antiphospholipid syndrome

Antiphospholipid antibodies are a heterogeneous group of autoantibodies that have clear associations with thrombosis and pregnancy morbidity, and which together constitute the 'antiphospholipid syndrome' (APS). However, the pathophysiology of these complications is not well understood and their heterogeneity suggests that more than one pathogenic process may be involved. Diagnosis remains a combination of laboratory analysis and clinical observation but there have been significant advances in identifying specific pathogenic features, such as domain I-specific anti-β2-glycoprotein-I antibodies. This in turn has pointed to endothelial and complement activation as important factors in the pathogenesis of APS. Consequently, although anticoagulation remains the standard treatment for thrombotic APS and during pregnancy, the realisation that these additional pathways are involved in the pathogenesis of APS has significant implications for treatment: agents acting outside the coagulation system, such as hydroxychloroquine for pregnancy complications and sirolimus as an inhibitor of the mammalian target of rapamycin (mTOR) pathway, are now under evaluation and represent a radical change in thinking for haematologists. Conventional anticoagulation is also under challenge from new, direct acting anticoagulants. This review will provide a comprehensive overview of the evolving understanding of APS pathogenesis and how this and novel therapeutics will alter diagnosis and management.

IVIG in APS pregnancy

For more than two decades, the intravenous administration of high doses of IgG pooled from the plasma of healthy donors (immune globulin therapy, also known as ‘IVIG’) has benefited patients with a variety of autoimmune disorders. A potential therapeutic role of IVIG in the prevention of thrombosis and of miscarriages in antiphospholipid syndrome (APS) has been postulated. Multicenter randomized controlled trials attempted to define the role of IVIG in preventing pregnancy complications in APS indicate that simple anticoagulation could not be completely satisfactory, and certain patient subgroups might take advantage of IVIG therapy alone or in combination with heparin.

Intravenous immunoglobulins and antiphospholipid syndrome: How, when and why? A review of the literature

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and arterial thromboses and recurrent fetal losses, frequently accompanied by a moderate thrombocytopenia, in the presence of antiphospholipid antibodies (aPL), namely lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or anti-β2 glycoprotein-I (β2GPI) antibodies. The current mainstay of treatment for thrombotic APS is heparin followed by long-term anticoagulation, while in obstetric APS, the accepted first-line treatment consists in low-dose aspirin (LDA) plus prophylactic unfractionated or low-molecular-weight heparin (LMWH). Recently, new emerging treatment modalities, including intravenous immunoglobulins (IVIG), have been implemented to manage APS refractory to conventional therapy. The objective of this review is to summarize the currently available information on the IVIG therapy in APS, focusing on the use of IVIG in the obstetric form, CAPS and on primary or secondary thromboprophylaxis. We analyzed 35 studies, reporting the effects of IVIG in APS patients, and we discussed their results. IVIG in obstetric APS seem to be very useful in selected situations (patients not responsive to the conventional treatment, concomitant autoimmune manifestations or infections or patients in whom anticoagulation is contraindicated). IVIG treatment represents an important component of the combination therapy of CAPS and they could be useful, in addition to the standard therapy, to prevent recurrent thrombosis in APS patients refractory to conventional anticoagulant treatment. Anyway, in some cases we also found controversial results that claim the need of further well-designed studies to definitely state the efficacy and tolerability of IVIG in CAPS, obstetric and non-APS.

Nephrological and obstetric complications of the antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a disorder of hypercoagulability, characterised by thromboembolic events, repeated miscarriages and thrombocytopenia in association with circulating antiphospholipid antibodies. These antibodies are directed against epitopes on either oxidised phospholipids complexed with a glycoprotein, beta 2-glycoprotein I, or against the glycoprotein itself. Renal manifestations of the APS are varied and depend on the type of renal pathology present. The renal vasculature may be affected by either a small vessel, thrombotic microangiopathy process or by large vessel thrombosis. In patients with end stage renal disease, the prevalence of antiphospholipid antibodies may increase with time on dialysis. Anticardiolipin antibodies have been associated with a high incidence of haemodialysis access clotting, a major source of morbidity and hospitalisation in end stage renal disease patients. In renal transplant recipients, antiphospholipid antibodies may be associated with a higher incidence of primary graft non-function, particularly in patients without a history of pretransplantation haemodialysis. Complications of the APS during pregnancy span all trimesters and include intrauterine growth retardation, placental abruption, pre-eclampsia, preterm labour and recurrent fetal loss. As these women have a high risk of recurrent fetal loss, multiple treatment modalities have been investigated, including aspirin, heparin, prednisone and intravenous immunoglobulin. Various treatment strategies for the APS have been developed and are based on a combination of anticoagulant therapy with either warfarin or heparin, along with antiplatelet therapy with aspirin. Experimental treatments involving immunomodulatory therapy with intravenous immunoglobulin, apheresis and novel antibody therapy are being investigated with hopes of successful clinical applications.

Heparin-induced thrombocytopenia and thrombosis

Heparin remains the most commonly used parenteral medication in hospitalized patients. Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis syndrome or the white clot syndrome are important complications of heparin use. This article provides an in-depth review of the etiopathogenesis, clinical manifestations, diagnosis, and management options in patients with HIT. Clinical problems associated with HIT such as antiphospholipid antibody syndrome and venous gangrene are described. The management options of HIT patients during cardiac interventional procedures and coronary surgery as well as recent advances in therapeutic options are summarized.

[Value of intravenous immunoglobulins during antiphospholipid syndrome]

BACKGROUND

The antiphospholipid syndrome was individualized 12 years ago. Treatment was initially based on steroids, immunosuppressive drugs and intravenous immunoglobulin therapy. More recently, several retrospective studies have established that in most clinical conditions therapeutic doses of oral vitamin K antagonists (INR > or = 3) are sufficient to control the disease.

THE ROLE OF IMMUNOGLOBULIN THERAPY

However, high dose immunoglobulin therapy is still indicated in a few cases, especially in life-threatening immune peripheral thrombocytopenia, and in recurrent foetal loss: in the latter indication, immunoglobulin therapy alone is efficient in 80% of cases.

FUTURE PROSPECTS

Prospective studies are needed to assess the efficacy of intravenous immunoglobulin therapy in neurological complications occurring in spite of anticoagulant therapy, and in the context of repeated foetal losses when antithrombotic therapy with aspirin and subcutaneous heparin has failed.

Utilization of intravenous immunoglobulin therapy to treat recurrent pregnancy loss in the antiphospholipid syndrome: a review

Although experience is still limited, intravenous immunoglobulin therapy for recurrent pregnancy loss in the Antiphospholipid Syndrome (APS) may represent a significant advance. APS was widely recognized only fifteen years ago. Pregnancy loss and thrombosis are the prominent clinical features. Initially, prednisone was used for treatment of pregnancy loss, but matemal and fetal complications stimulated searches for alternative therapy. Subcutaneous heparin and low dose aspirin was next utilized, but although efficacious, there is still a 30% failure rate, and intrauterine growth retardation, prematurity, and pre-eclampsia are relatively frequent. In the late 1980's, there were a number of case reports of successful pregnancy outcomes after treatment with intravenous immunoglobulin (IVIg) but regimens differed. Series from two centers have confirmed these initial findings and treatment regimens have become more consistent. Both centers have reported success with doses of 400 mg/kg/day for 5 days or 1 g/kg/day for two days each month initiated during the first or early second trimester. Success rates of 70-100% have been reported, and complications such as pre-eclampsia, intrauterine growth retardation, and premature births appear reduced, when compared to prednisone and low dose aspirin or heparin and low dose aspirin. Several patients who were treated with IVIg also received heparin, making it uncertain whether heparin may also need to be added to IVIg. Intravenous immunoglobulin is safe, but expensive. Despite its expense, if IVIG is shown to markedly decrease matemal and fetal morbidity, it may be the logical treatment of choice to prevent pregnancy loss in APS.

Clinical uses of intravenous immunoglobulin in pregnancy

Intravenous immunoglobulin was licensed for use in the United States in 1981. Currently, there are only a few Food and Drug Administration-labeled indications for intravenous immunoglobulin, but up to 50 "off-label" uses are reported in the literature. The obstetric literature contains numerous reports on intravenous immunoglobulin therapy during pregnancy. This article reviews the properties, pharmacokinetics, mechanisms of action, and side effects of intravenous immunoglobulin, as well as the reported uses of intravenous immunoglobulin during pregnancy.

Recurrent fetal loss and antiphospholipid antibodies: clinical and therapeutic aspects

Recurrent fetal losses indicate screening for antiphospholipid antibodies, especially after the third consecutive fetal loss, or when they occur after 12 weeks gestation or when the mother presents with thrombosis or other ailments of antiphospholipid syndrome. Fetal loss may be caused by thromboses of placental vasculature. There is no agreement concerning the mechanism of thromboses: protein C pathway and/or annexin V are the best candidates. When fetal loss occurs early during gestation, murine models suggest that antiphospholipid antibodies can also act on trophoblasts by inhibiting syncytia formation. Among the high risk patients with more than two fetal losses, an association of aspirin and heparin given early during gestation is successful in 70–80% of cases.

Intravenous immunoglobulin in rheumatic disease

With the advent of numerous commercial preparations of intravenous immunoglobulin preparations since 1981, it is now possible to administer these preparations in significant quantities to cause elevation of serum immunoglobulin levels both in patients with antibody-deficient states and in those with normal circulating immunoglobulin levels. This led to a report of dramatic improvement of thrombocytopenia in a child with agammaglobulinemia following the use of intravenous immunoglobulin preparations for recurrent infections, and further studies in both children and adults with associated symptoms suggested therapeutic efficacy of intravenous immunoglobulin preparations in controlling autoimmune symptoms.

Intravenous immunoglobulin for treatment of recurrent pregnancy loss

PROBLEM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The antiphospholipid-protein syndrome

The pathogenesis of the antiphospholipid syndrome remains uncertain. Antibodies that react with phospholipids may not be directly responsible for cellular injury, but may be part of the immune network through which autoantibodies with pathogenic potential are generated. The latter may recognize proteins such as beta 2-glycoprotein I that form complexes with phospholipids, proteins whose functions depend upon interaction with phospholipids such as protein C and its cofactors, altered lipoproteins such as oxidized low-density lipoproteins, or other molecules that share only antigenic similarity. Thus, a spectrum of autoantibodies that recognize different lipid-protein complexes may develop in these patients and contribute to the observed clinical heterogeneity of the syndrome. Current techniques do not permit identification of the subset of patients with antiphospholipid antibodies at risk for thrombosis or abortion and there are no prospective, controlled trials addressing the prophylaxis or treatment of affected individuals. Identification of the cellular targets of antibodies to lipid-protein moieties is needed to identify patients at risk for these complications and as a means to monitor therapy.

Intravenous immunoglobulin infusion therapy in women with recurrent spontaneous abortions of immune etiologies

We have investigated clinical effectiveness of intravenous immunoglobulin G infusion (IVIg) on antiphospholipid antibody titers in five women with evidence of antiphospholipid antibody-associated recurrent spontaneous abortions and one with antinuclear antibody who became refractory to conventional autoimmune treatment during pregnancy and experienced pregnancy complications. Three women developed intrauterine growth retardation and three had complicated twin pregnancies with rising autoantibody titers. Antiphospholipid antibody and antinuclear antibody titers were tested pre and 2 weeks after each IVIg infusion. We report that: (i) IgG antiphospholipid antibody titers were significantly suppressed after each IVIg infusion (P < 0.05); (ii) IgM antiphospholipid antibody titers were also significantly suppressed after each IVIg infusion (P < 0.0001); (iii) decreased titers of autoantibodies paralleled increased levels of maternal IgG which lasted for at least 30 days; the autoantibodies showed a definite rise again prior to the next infusion; (iv) antinuclear antibody titers were effectively suppressed; and (v) rising autoantibody titers combined clinical manifestation of intrauterine growth retardation and women with complicated twin pregnancies. We conclude that IVIg infusion effectively suppresses IgM and IgG autoantibodies to phospholipids and antinuclear antibody in autoimmune women with a history of recurrent spontaneous abortions and refractory to conventional anticoagulation or immunosuppressive treatment.

Intravenous immunoglobulin therapy for the antiphospholipid syndrome in pregnancy

OBJECTIVE

Our purpose was to study the influence of intravenous immunoglobulin on pregnancy outcome.

STUDY DESIGN

Pregnancy outcomes were evaluated in five patients with 17 unsuccessful previous pregnancies. Each patient received 400 mg/kg immunoglobulin for 5 days monthly beginning in the first or early second trimester. Four patients with previous thromboembolic events were treated with concomitant heparin prophylaxis. Four patients received 81 mg of aspirin daily.

RESULTS

Short- and long-term decreases of anticardiolipin immunoglobulin G were noted in three patients. Four patients were delivered of healthy infants at term, one at 32 weeks' gestation with a diagnosis of fetal distress. Neither preeclampsia nor fetal intrauterine growth retardation were observed. The immunoglobulin therapy was not associated with major side effects. Significant placental histologic anomalies were not identified.

CONCLUSIONS

The observations suggest that immunoglobulin therapy may improve pregnancy outcomes beyond that observed with heparin and aspirin. A prospective trial is encouraged.

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

PROBLEM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Antiphospholipid antibodies and the antiphospholipid syndrome

The study of aPL antibodies and the APS has appealed to large numbers of investigators over the last decade. This accounts, in part, for the great degree of apparently contradictory data being published. What seems certain is that these antibodies are associated with thrombosis and recurrent pregnancy loss, and animal data suggest a direct role in pathogenesis. In vitro studies demonstrate that these antibodies have a variety of functional effects on the hemostatic system, giving further credence to an antibody role in thrombosis. Further studies will doubtless give better insight into the mechanisms of antibody action and this will provide a more rational basis for treatment.

Immunologically mediated abortion (IMA)

Roughly 20% of all clinical pregnancies evolve into "spontaneous abortions". The causes of spontaneous abortion have been determined in under 60% of the total and comprise genetic, infectious, hormonal and immunological factors. In some cases the immune tolerance mechanism may be impaired and the foetus immunologically rejected (IMA, immunologically mediated abortion). The immunological mechanism implicated depends on the time in which pregnancy loss takes place. During preimplantation and up to the end of implantation (13th day) the cell-mediated immune mechanism (potential alloimmune etiologies) is responsible for early abortion. This mechanism involves immunocompetent decidual cells (eGL, endometrial granulated lymphocytes) already present during pre-decidualization (late luteal phase) and their production of soluble factors or cytokines. Once the implantation process is over, after blastocyst penetration of the stroma and the decidual reaction of uterine tissue, IMA could be caused by cell-mediated and humoral mechanism (anti-paternal cytotoxic antibodies or autoantibody etiology), by the production of paternal anti major histocompatibility complex antibodies, or even by an autoimmune disorder leading to the production of autoantibodies (antiphospholipid antibodies, antinuclear antibodies or polyclonal B cell activation). The diagnostic work-up adopted to select IMA patients is crucial and includes primary (karyotype of both partners, toxo-test, hysterosalpingography, endometrial biopsy, thyroid function tests, serum hprolactin, luteal phase dating) and secondary (full hemochromocytometric test, search for LE cells, lupus anticoagulant, anticardiolipin, antinuclear antibodies, Rheumatoid factor, blood complement VDRL) investigations. Therapeutical approaches vary. If autoimmune disorders are demonstrated therapies with different combinations of corticosteroids, aspirin and heparin or intravenous immunoglobulin are administered. Otherwise, therapy with paternal or donor peripheral blood mononuclear cells should be instituted.

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

OBJECTIVE

To describe the ultrasonographic findings of pregnancies that terminated in repeat abortion in women participating in an ongoing randomized placebo-controlled clinical trial evaluating the efficacy of intravenous (IV) immunoglobulin (Ig) in the treatment of recurrent spontaneous abortion (SA).

DESIGN

A prospective descriptive study of ultrasonographic findings of pregnancies from 27 women experiencing repeated recurrent SAs after entry into a clinical trial.

SETTING

Clinical practice at the Genetics & IVF Institute in Fairfax, Virginia.

PATIENTS

Women experiencing two or more consecutive recurrent SAs received either 500 mg/kg per mo IV Ig or placebo (albumin). To date 90 women have been enrolled in the clinical trial and 52 have achieved pregnancy. The outcome of the 52 pregnancies include 16 deliveries, 9 ongoing pregnancies, and 27 losses.

INTERVENTIONS

Ultrasonographic examinations performed in 27 women experiencing pregnancy loss are the subject of this study.

MAIN OUTCOME MEASURES

The frequency of ultrasonographic findings of empty gestation sac (blighted ovum) and intrauterine fetal demise (IUFD) is compared between patients receiving IV Ig and placebo.

RESULTS

Ultrasonographic findings of the 27 pregnancies losses included 11 blighted ova and 16 IUFDs. Of 11 blighted ova, 8 (73%) were in women receiving IV Ig and 3 (27%) were receiving placebo. Sixteen IUFDs were observed: 3 (19%) in women receiving IV Ig and 13 (81%) in women receiving placebo. Of 11 pregnancy losses occurring in women receiving IV Ig, 8 (73%) were blighted ova, 3 (27%) were IUFDs. Sixteen pregnancy losses occurred in women receiving placebo: 3 (19%) were blighted ova and 13 (81%) were IUFDs. The differences in frequency of blighted ova between IV Ig- and placebo-treated women was significant.

CONCLUSION

IV Ig is not effective in preventing blighted ova and may be effective in preventing IUFDs.

Primary antiphospholipid antibody syndrome and cerebral ischemia: report on acute intervention in two cases and literature review with emphasis on therapeutic options

In two patients with primary antiphospholipid antibody syndrome and acute cerebrovascular ischemic events, local intraarterial fibrinolysis and intravenous heparin therapy, respectively, resulted in a limitation of persisting neurological deficits. On the basis of the 35 case reports available a combination of anticoagulation with warfarin, plus immunosuppression with steroids and/or cyclophosphamide or azathioprine, appears to be the best treatment to prevent further cerebral ischemic events. The therapeutic options are reviewed and discussed.

Pregnancy outcome in women with antiphospholipid antibodies

The association of antiphospholipid antibodies (APA) or lupus anticoagulant (LA) and recurrent fetal loss (RFL) is well established; however, the spectrum of pregnancy outcome in relation to various therapeutic approaches versus placebo is unknown. We studied 49 women with RFL, 14 with immune thrombocytopenia (ITP) 13 of whom without a history of RFL, and 32 controls (all in the first trimester of pregnancy) for the presence of APA. Tests for APA were positive in 15/49 women with RFL (30%), 6/14 ITP (43%) and 2/32 controls (6%). Treatment in the APA positive patients consisted of: no treatment for the 8 patients who had no history of RFL (Group A; all 34 previous pregnancies successful), aspirin alone (Group B, 5 patients; all 30 previous pregnancies unsuccessful), aspirin with prednisolone (Group C, 9 patients; 69/80 previous pregnancies unsuccessful), or aspirin, prednisolone and immunoglobulin G for resistant cases (Group D, 4 patients, previously in Group C). 10/11 (90.9%), 3/7 (43%), 7/13 (53.8%) and 4/7 (57.1%) pregnancies were successful in Group A, B, C and D, respectively. There was a total of 19/45 (42%) failures including 3 pregnancies in one patient who failed to respond to all forms of therapy. This open study with small subgroups of patients draws attention to a wide range of pregnancy outcome in women with APA and to the fact that APA may serve only as a marker for a wide range of pathological conditions with variable degrees of disease severity. More studies are, however, needed to explore the real mechanism of RFL in women with APA and RFL, especially those who are resistant to therapy.

Sneddon's syndrome and phospholipid antibodies

We present a case of Sneddon's syndrome with high titers of antiphospholipid antibodies (APLA), in which the leading symptom was an incapacitating memory defect. MRI revealed vasculitic lesions of the central nervous system (CNS). Therefore immunosuppressive therapy was started with steroids and cyclophosphamide pulses. The transient beneficial effects of such a therapy will be discussed.

Immunoregulation of Autoimmune Disorders: The Role of Intravenous Immunoglobulins

Modified and intact immunoglobulin preparations are available for therapeutic use. The administration of intravenous immunoglobulins (IVI G) gave positive results in Primary Immunodeficiency Syndromes (PIS) (prophylaxis of viral and bacterial diseases), in treatment of secondary immunodeficiencies (hematologic malignancies, bone marrow transplantation), and in some infections. Adverse reactions have been reported during IVIG infusions, but they are rarely serious and do not represent limiting conditions for a short or long term therapy. After the original observation in thrombocytopenic purpura, IVIG have been used as immune modulators in various autoimmune related disorders. Various mechanisms of action are proposed: blockade and down regulation of phagocytic function via Fc receptor, regulation of idiotype-anti idiotype network, suppression of idiotype synthesis, T-B cell interference towards antigen presentation, increase in suppressor lymphocytes, IVIG-cytokine interaction.

The effect of aspirin on recurrent fetal loss in experimental antiphospholipid syndrome

PURPOSE

To evaluate the effect of aspirin treatment upon fetal loss in mice with experimental antiphospholipid syndrome (APLS).

MATERIALS AND METHODS

Experimental APLS was induced in pregnant mice by passive transfer of mouse monoclonal anticardiolipin antibody. The mice were treated with high (100 micrograms/d) or low (10 micrograms/d) dose of aspirin, using vitamin C (100 micrograms/d or 10 micrograms/d) as a control. The mice were assessed for the presence of lupus anticoagulants (prolonged aPTT), thrombocytopenia, degree of fetal resorption rate and mean embryo and placental weights.

RESULTS

The mice with APLS had a higher fetal resorption rate (45.7 +/- 12.2% vs 2.5 +/- 0.4%, P < 0.001), reduced placenta mean weight (104 +/- 8 mg vs 169 +/- 7 mg, P < 0.001), prolonged aPTT (94 +/- 14 sec vs 39 +/- 4 sec, P < 0.001), and reduced mean platelet count (597 +/- 186 x 10(3)/mm3 vs 847 +/- 51 x 10(3)/mm3, P < 0.001). The group of mice with APLS, who were treated with low-dose aspirin, had a lower resorption rate (11.1 +/- 9.3% vs 45.7 +/- 12.2%, P < 0.001), a higher placenta mean weight (178 +/- 8 mg vs 104 +/- 8 mg, P < 0.001), a higher mean embryo weight (1042 +/- 134 mg vs 721 +/- 91 mg, P < 0.001), and a lower aPTT (58 +/- 15 sec vs 94 +/- 14 sec, P < 0.001). Mice who were treated with high-dose aspirin also had a lower resorption rate, although not as much as in the low-dose aspirin group (34.2 +/- 12.7% vs 45.7 +/- 12.2%, P < 0.001).

CONCLUSION

Aspirin, especially in low dose, has a protective effect against obstetrical complications associated with experimental APLS.

What do we really know about autoantibody abnormalities and reproductive failure: a critical review

CONDENSATION

The diagnosis and treatment of autoantibody-associated forms of reproductive failure is critically reviewed.

OBJECTIVE

To critically evaluate the published literature in reference to autoantibody-associated forms of reproductive failure.

LOCATION

Medical School-affiliated private Infertility Center.

MATERIALS

A review of over 200 published papers reflecting on the topic.

RESULTS

Autoantibody associated reproductive failure, characterized by a decrease in fecundity and an increase in the risk of pregnancy loss, appears established. Autoantibody abnormalities, as routinely detected by standard laboratory assays, are, however, neither immunologically nor biologically specific since cross reactivities between autoantibodies are frequent and a specific autoantibody may cause a biological effect in one but not in another affected individual.

CONCLUSIONS

The evaluation of autoantibody abnormalities in all cases of suspected autoimmune-associated reproductive failure is valuable and will improve clinical care of affected patients. Clinicians need, however, to recognize the limitations of autoantibody testing and have to adjust their clinical management to the degree and quality of autoantibody evaluation available to them in their community.

The role of IVIG in the management of patients with antiphospholipid antibodies and recurrent pregnancy losses

Intravenous immune gamma-globulin appears to have a role in the management of some autoimmune-mediated diseases. The exact mechanisms whereby IVIG is beneficial to patients with these diseases are not understood. The antiphospholipid-antibody syndrome is a recently recognized syndrome in which antibodies to negatively charged phospholipids are associated with a thrombotic diathesis, fetal wastage, and thrombocytopenia. The association between these antibodies and the clinical complaints is unknown. Recent evidence has suggested that a cofactor, a serum protein or glycoprotein (of approx 50 kDa) is essential for so-called antiphospholipid antibodies to bind to phospholipids. It may be that variations in this cofactor and its binding are some of the factors that determine whether high levels of antiphospholipid antibodies result in pathological consequences. Patients with antiphospholipid antibodies who have experienced previous fetal losses will continue to experience fetal wastage without some form of therapeutic intervention. The optimum therapy for these patients is yet to be determined, but recent isolated anecdotal reports suggest that IVIG may be of some benefit. IVIG appears to be less toxic to the mother than prednisone. The true benefit of IVIG, however, can be determined only by randomized, well controlled trials. Adequate numbers of patients could only be obtained by multicenter studies, and these should be designed to compare anticoagulation alone with anticoagulation and IVIG. Justifying a placebo group is difficult, as it is known that greater than 90% of pregnancies in women with aPL who have previously experienced fetal wastage fail to produce a live infant. It is only by doing such studies that the true role of IVIG in the management of pregnant patients with aPL can be determined.

Intravenous immunoglobulin treatment for recurrent abortions caused by antiphospholipid antibodies

There is an association between the presence of antibodies that bind to anionic phospholipids and the occurrence of repeated spontaneous abortion. Many uncontrolled studies have reported favorable pregnancy outcome in women treated with steroids, low-dose aspirin, heparin, or their combination. Similarly, treatment failures have been reported with most of these therapeutic regimens. Immunoglobulins play a central role in immune regulation. A wide spectrum of human diseases are associated with decreased or abnormal regulation of Ig levels. Recently, IV preparations of Ig have become available for clinical use, including treatment of patients with recurrent abortions and high levels of antiphospholipid antibodies. The effectiveness of this new mode of therapy can be related to several immunological mechanisms such as blockade of antibody binding to receptors on macrophages, increase in T suppressor cells, or decrease in antibody synthesis. The latter effect may be mediated by anti-idiotypic antibodies in the Ig preparation. Determination of dosage of IV Ig, duration of treatment, and treatment intervals are all empirical in patients with recurrent abortions and high levels of antiphospholipid antibodies because antiphospholipid antibody levels are not useful for monitoring therapy. Although the data available at present are promising, additional randomized trials are needed to determine the efficacy of IV Ig in patients with immunological recurrent abortions.

Primary antiphospholipid syndrome (PAPS). Two case reports and therapeutic implications

Antiphospholipid antibodies (aPL) interfere with the coagulation system and can cause thrombosis and other clotting disorders. The combination of recurrent venous thrombosis, arterial embolism and recurrent fetal loss is nowadays considered to be primary antiphospholipid syndrome (PAPS), provided an underlying systemic lupus erythematosus (SLE) has been excluded and aPL have been detected. We report on two patients with PAPs, and show the course of their IgG- and IgM-anticardiolipin antibody (aCL) titers during immunosuppressive therapy with prednisone and azathioprine or cyclophosphamide. Over a period of 18 months this therapy was effective in preventing relapses of thrombo-embolism and other complications. Therapy with cyclophosphamide resulted in normalization of the aCL titers in one of the two reported cases. Azathioprine treatment reduced the aCL titer in the other patient, without fully normalizing it. Based on our observation, we propose to treat PAPS-associated severe and recurrent thrombo-embolic complications by aggressive immunosuppression, including azathioprine and cyclophosphamide.

Mechanisms of action of intravenous immunoglobulin therapy and potential use in autoimmune connective tissue diseases

It has been almost 10 years since the observations on the efficacy of intravenous immunoglobulin (IVIG) in patients with autoimmune thrombocytopenic purpura. Over the next decade, IVIG was used in other types of autoimmune diseases. Much work has also been done on gaining a better understanding of the mechanism(s) by which IVIG exerts its effects in these autoimmune diseases. This review examines the proposed mechanisms of action of IVIG and establishes a rationale for the use of this type of therapy in systemic lupus erythematosus (SLE) and other autoimmune connective tissue disorders. Currently, only anecdotal reports are available on the treatment of SLE with IVIG. Nevertheless, studies thus far suggest that IVIG may be useful in selected SLE patients with cytopenias and cutaneous vasculitis and may have a steroid-sparing effect in patients with SLE and juvenile rheumatoid arthritis. In SLE patients with renal disease, it should be used cautiously because some patients have worsening of their renal function with IVIG infusions. These preliminary experiences suggest that multicenter controlled trials on the therapeutic use of IVIG in SLE and other connective tissue disorders would be important.

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)

Antiphospholipid antibody syndrome: immunologic and clinical aspects

Antiphospholipid antibody is associated with a clinical syndrome of vascular thrombosis, thrombocytopenia, recurrent fetal loss, and livedo reticularis, whether or not a clinical diagnosis of systemic lupus erythematosus (SLE) coexists. A positive antiphospholipid antibody test is defined by enzyme-linked immunosorbent assay (ELISA) (antiphospholipid antibody itself) or by coagulation assay (lupus anticoagulant). These are similar but not identical antibodies. The test for syphilis is less closely related to the preceding two and is less regularly associated with clinical complications. The mechanism of action of either antiphospholipid antibody or lupus anticoagulant is as yet unknown. SLE-induced but not infection-induced antiphospholipid antibody has immunoglobulin G2 (IgG2) and IgG4 predominance. It recognizes all negatively charged phospholipids, but various physical characteristics of the phospholipids alter the recognition patterns. Treatment for the antiphospholipid antibody syndrome has not been clearly defined. Anticoagulation with aspirin, heparin, or warfarin is currently favored. A role for corticosteroid remains to be demonstrated.

Pregnancy in the patient with rheumatic disease: the obstetrician's perspective

Patients with rheumatic diseases who become pregnant are justifiably categorized as having high-risk pregnancies. Utilizing a multidisciplinary approach, including perinatologists, rheumatologists and anaesthetists, successful pregnancies have become the rule rather than the exception. However, women with rheumatic disease are particularly prone to develop serious obstetric problems which often result in early hospitalization and delivery. Although vigilant obstetric care improves perinatal outcome, prematurity will continue to be a major problem complicating pregnancies in women with rheumatic disease.

Maternal autoantibodies and pregnancy--I: The antiphospholipid antibody syndrome

Despite the considerable interest in antiphospholipid antibodies during the last 10 years, the clinical disorders with which they are associated are still not well understood (Love and Santoro, 1990). The concept of the antiphospholipid syndrome (APS) and a means by which this can be defined (Harris, 1987) may aid us in better classifying these patients, evaluating their clinical features, and in conducting prospective studies. Standard methods for measurement of anticardiolipin antibodies (Harris et al, 1987b; Harris and the Kingston Anticardiolipin Standardization Group, 1990) and more attention to measurement of the lupus anticoagulant (Triplett and Brandt, 1988) will ultimately play an important role in improving the diagnosis of these patients. The initiation of the Kingston AntiPhospholipid Study (KAPS) group in January 1988 paves the way for future multicentre treatment trials of these patients (Harris, 1988; Triplett, 1989; Recker and Leff, 1989). For the practising physician managing a pregnant woman with the APS, there are few clear guidelines for treatment. An appropriate approach would be to assemble a multidisciplinary team for pregnancy management, exclude other causes of pregnancy loss and select the drug regimen which will cause the least harm and has some reported efficacy. Most importantly, the patient should be followed carefully throughout her pregnancy.

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.

Successful treatment in two women with antiphospholipid antibodies and refractory pregnancy losses with intravenous immunoglobulin infusions

In two women with antiphospholipid antibodies and recurrent fetal losses refractory to usual treatments, therapy consisting of aspirin, heparin, and intravenous gamma-globulin infusions was successful. Production of antiphospholipid antibodies was not suppressed. The transient decrease in anticoagulant activity noted in one case was not reproduced in vitro and was probably not physiologically important.

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.