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Yang X, Mu F, Zhang J, Yuan L, Zhang W, Yang Y, Wang F. Reproductive factors and subsequent pregnancy outcomes in patients with prior pregnancy loss. BMC Pregnancy Childbirth 2024; 24:219. [PMID: 38528474 PMCID: PMC10964557 DOI: 10.1186/s12884-024-06422-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/14/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND At present, individualized interventions can be given to patients with a clear etiology of pregnancy loss to improve the subsequent pregnancy outcomes, but the current reproductive status of the patient cannot be changed. The aim of this study was to investigate the association between female reproductive status and subsequence pregnancy outcome in patients with prior pregnancy loss (PL). METHODS A prospective, dynamic population cohort study was carried out at the Second Hospital of Lanzhou University. From September 2019 to February 2022, a total of 1955 women with at least one previous PL were enrolled. Maternal reproductive status and subsequent reproductive outcomes were recorded through an electronic medical record system and follow-up. Logistic regression was used to evaluate the association between reproductive status and the risk of subsequent reproductive outcomes. RESULTS Among all patients, the rates of subsequent infertility, early PL, late PL, and live birth were 20.82%, 24.33%, 1.69% and 50.77% respectively. In logistic regression, we found that age (OR 1.08, 95% CI 1.04-1.13) and previous cesarean delivery history (OR 2.46, 95% CI 1.27-4.76) were risk factors for subsequent infertility in patients with PL. Age (OR 1.06, 95% CI 1.03-1.10), age at first pregnancy (OR 1.06, 95% CI 1.03-1.10), BMI (OR 1.06, 95% CI 1.02-1.11), previous PL numbers (OR 1.18, 95% CI 1.04-1.57) and without pre-pregnancy intervention (OR 1.77, 95% CI 1.35-2.24) were risk factors for non-live birth. Age (OR 1.06, 95% CI 1.03-1.09), age at first pregnancy (OR 1.06, 95% CI 1.02-1.09), BMI (OR 1.07, 95% CI 1.02-1.11), previous PL numbers (OR 1.15, 95% CI 1.02-1.31) and without pre-pregnancy intervention (OR 2.16, 95% CI 1.65-2.84) were risk factors for PL. CONCLUSIONS The reproductive status of people with PL is strongly correlated with the outcome of subsequent pregnancies. Active pre-pregnancy intervention can improve the subsequent pregnancy outcome. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry with the registration number of ChiCTR2000039414 (27/10/2020).
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Affiliation(s)
- Xin Yang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Fangxiang Mu
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Jian Zhang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Liwei Yuan
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Wei Zhang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Yanting Yang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Fang Wang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China.
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Mu F, Wang M, Zeng X, Wang F. Predicting risk of subsequent pregnancy loss among women with recurrent pregnancy loss: An immunological factor-based multivariable model. Am J Reprod Immunol 2024; 91:e13837. [PMID: 38514448 DOI: 10.1111/aji.13837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
PROBLEM Studies on subsequent pregnancy loss prediction models specific for recurrent pregnancy loss (RPL) patients are very limited. This study aims to develop a risk predictive model based on the immunological parameters for the subsequent pregnancy loss risk in northwest Chinese RPL patients. METHOD OF STUDY Totally of 357 RPL patients recruited from Lanzhou University Second Hospital were included in this retrospective study. Univariate analysis was performed on RPL patients with outcomes of live birth or pregnancy loss. Subsequently, the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were utilized to select variables among baseline and clinical characteristics and to develop a pregnancy loss risk prediction model with all 357 RPL patients. The area under the curve (AUC), calibration curve and decision curve analyses were used to evaluate the performance of the prediction model; moreover, 10-fold cross-validation was used for internal validation. RESULTS Ten factors of maternal age, age of menarche, previous pregnancy loss, IL-10, complement 4, IgA, antiprothrombin antibody IgG/IgM, rheumatoid factor IgA, and lupus anticoagulant (LA) 1/LA2 ratio were finally selected as variables for the prediction model of pregnancy loss risk. The AUC value and Hosmer-Lemeshow test p-value of the model were .707 and .599, respectively, indicating a satisfactory discrimination and calibration performance. Moreover, the clinical decision curve suggested this prediction model have a good positive net benefit. CONCLUSIONS This is the first prediction model for the risk of subsequent pregnancy loss in northwest Chinese women with RPL, providing a user-friendly tool to clinicians for the early prediction and timely management of RPL patients.
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Affiliation(s)
- Fangxiang Mu
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou, China
| | - Mei Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou, China
| | - Xianghui Zeng
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou, China
| | - Fang Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou, China
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Tao JJ, Adurty S, D'Angelo D, DeSancho MT. Management and outcomes of women with antiphospholipid syndrome during pregnancy. J Thromb Thrombolysis 2023; 55:751-759. [PMID: 36967425 DOI: 10.1007/s11239-023-02789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 04/30/2023]
Abstract
Women with antiphospholipid syndrome (APS) have an increased risk of adverse pregnancy outcomes. To define clinical, serologic, and treatment factors that can predict outcomes in pregnant women with APS. Retrospective cohort study of pregnant women with APS evaluated at a university medical center between January 2006 and August 2021. Demographics, personal and family history of thrombosis, autoimmune disease, antithrombotic use, pregnancy outcomes, maternal and fetal complications were collected. We compared pregnancy outcomes in the presence or absence of lupus anticoagulant (LA), systemic lupus erythematosus (SLE), prior thrombosis or pregnancy losses, and antithrombotic use. There were 169 pregnancies in 50 women; 79 (46.7%) occurred after maternal diagnosis of APS. The most common antithrombotic regimen was aspirin and low molecular weight heparin (LMWH) in 26.6% of pregnancies; 55.0% of all pregnancies and 68.4% of pregnancies post-APS diagnosis resulted in a live birth. In age-adjusted analyses, aspirin plus LMWH regardless of dosage was associated with significantly higher odds of live birth compared with no antithrombotic use (OR = 7.5, p < 0.001) and compared with aspirin alone (OR = 13.2, p = 0.026). SLE increased the risk for preterm birth and preeclampsia. A positive LA did not impact the outcomes evaluated and anticardiolipin IgM decreased the risk of pre-eclampsia. The presence of SLE is a significant risk factor for adverse outcomes in pregnant women with APS. Treatment with LMWH and aspirin was superior to aspirin alone. The creation of a global registry may be useful in improving the management of these patients.
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Affiliation(s)
- Jacqueline J Tao
- Department of Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | | | - Debra D'Angelo
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine, New York, NY, USA
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA.
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, USA.
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Savona-Ventura C, Mahmood T. The role of traditional complementary physical interventions in obstetrics – A scientific review commissioned by the European board and college of obstetrics and gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol 2022; 279:84-87. [DOI: 10.1016/j.ejogrb.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Toth B, Bohlmann M, Hancke K, Kuon R, Nawroth F, von Otte S, Rogenhofer N, Rudnik-Schöneborn S, Schleußner E, Tempfer C, Vomstein K, Wischmann T, von Wolff M, Würfel W, Zschocke J. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/050, May 2022). Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1895-9940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Abstract
Purpose The aim of this guideline is to standardize the diagnosis and therapy of recurrent miscarriage (RM) using evidence from the recent literature. This is done by using
consistent definitions, objective evaluations and standardized treatment protocols.
Methods When this guideline was compiled, special consideration was given to previous recommendations in prior versions of this guideline and the recommendations of the European
Society of Human Reproduction and Embryology, the Royal College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists and the American Society for
Reproductive Medicine, and a detailed individual search of the literature about the different topics was carried out.
Recommendations Recommendations about the diagnostic and therapeutic procedures offered to couples with RM were developed based on the international literature. Special attention was
paid to known risk factors such as chromosomal, anatomical, endocrinological, physiological coagulation, psychological, infectious and immune disorders. Recommendations were also developed
for those cases where investigations are unable to find any abnormality (idiopathic RM).
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Affiliation(s)
- Bettina Toth
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Michael Bohlmann
- Zentrum für Gynäkologie und Geburtshilfe, St. Elisabeth Krankenhaus Lörrach, Lörrach, Germany
| | - Katharina Hancke
- Klinik für Frauenheilkunde, Universitätsklinikum Ulm, Ulm, Germany
| | - Ruben Kuon
- Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | | | - Sören von Otte
- Kinderwunschzentrum, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Nina Rogenhofer
- Klinikum der Universität München – Frauenklinik Maistraße, München, Germany
| | | | | | - Clemens Tempfer
- Universitätsfrauenklinik, Ruhr-Universität Bochum, Bochum, Germany
| | - Kilian Vomstein
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Tewes Wischmann
- Institut für Medizinische Psychologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael von Wolff
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Bern, Switzerland
| | | | - Johannes Zschocke
- Zentrum für Medizinische Genetik, Universität Innsbruck, Innsbruck, Austria
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Efficacy of Hydroxychloroquine for Improving Pregnancy Outcomes in a Female with Systemic Lupus Erythematosus and Antiphospholipid Syndrome. Case Rep Obstet Gynecol 2022; 2022:5612091. [PMID: 36046125 PMCID: PMC9420616 DOI: 10.1155/2022/5612091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022] Open
Abstract
The use of heparin and low-dose aspirin is the current conventional treatment for pregnant females with antiphospholipid syndrome (APS). However, there is no additional treatment recommended for cases where the standard treatment cannot prevent obstetric complications such as fetal loss and placental insufficiency. Recently, the addition of a novel antimalarial, hydroxychloroquine (HCQ), to the conventional treatment has shown the potential to prevent obstetric complications. Herein, we report a case in which the addition of HCQ improved adverse pregnancy outcomes in a pregnant female with systemic lupus erythematosus and aspirin-heparin-resistant APS.
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Moar L, Simela C, Nanda S, Marnerides A, Al-Adnani M, Nelson-Piercy C, Nicolaides KH, Shangaris P. Chronic histiocytic intervillositis (CHI): current treatments and perinatal outcomes, a systematic review and a meta-analysis. Front Endocrinol (Lausanne) 2022; 13:945543. [PMID: 35937841 PMCID: PMC9355722 DOI: 10.3389/fendo.2022.945543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Chronic histiocytic intervillositis (CHI) is a rare placental lesion with a high recurrence rate and poor perinatal outcomes. There are currently limited guidelines regarding the diagnosis of this condition in the index pregnancy and treatment where recurrence is suspected. OBJECTIVE The primary objective of this systematic review and meta-analysis was to determine the perinatal outcomes of pregnancies affected by chronic histiocytic intervillositis and to what extent they can be improved with treatment. The secondary objective was to assess the relationship between CHI lesion severity and pregnancy loss. METHODS A systematic search of Ovid Embase, Web of Science, Science Direct, PubMed, Ovid Medline, Google Scholar and CINAHL was carried out. Case reports, cohort, case-control and randomised controlled trials (RCT) detailing the perinatal outcomes of CHI pregnancies, both treated and untreated, were included. RESULTS No RCTs were identified. However, in a review population of 659 pregnancies, with additional 7 in case reports, CHI treatments included aspirin, prednisone, prednisolone, low molecular weight heparin (LMWH), hydroxychloroquine and adalimumab. A descriptive synthesis of data found mixed results for treatments in relation to live birth, miscarriage and fetal growth restriction outcomes. Furthermore, quantitative synthesis of 38 pregnancies revealed a non-significant improvement in live birth rate with CHI targeted treatment (OR 1.79 [95% CI 0.33-9.61] (p=0.50), while meta-analysis of CHI severity in line with pregnancy loss, in a sample of 231 pregnancies, revealed lower odds of pregnancy loss with less severe lesions (OR: 0.17 [0.03-0.80], p=0.03). CONCLUSIONS This systematic review and meta-analysis reinforce notions surrounding the insufficient evidence for CHI treatment. It also strengthens previous hypotheses detailing the positive association between CHI lesion severity and odds of pregnancy loss. Aspirin, LMWH, prednisolone, hydroxychloroquine and adalimumab are candidates with varying levels of weak to moderate evidence supporting their use. Further prospective research is required to obtain robust evidence pertaining to treatment safety and efficacy and optimal drug regimes. SYSTEMATIC REVIEW REGISTRATION [website], identifier CRD42021237604.
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Affiliation(s)
- Laurel Moar
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Chloe Simela
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Surabhi Nanda
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Andreas Marnerides
- Department of Histopathology, St. Thomas Hospital, Westminster Bridge Road, London, United Kingdom
| | - Mudher Al-Adnani
- Department of Histopathology, St. Thomas Hospital, Westminster Bridge Road, London, United Kingdom
| | - Catherine Nelson-Piercy
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Kypros H. Nicolaides
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College London, London, United Kingdom
| | - Panicos Shangaris
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- *Correspondence: Panicos Shangaris,
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8
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Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodríguez G, Londono J. Obstetric Antiphospholipid Syndrome From the Perspective of a Rheumatologist. Cureus 2022; 14:e21090. [PMID: 35165550 PMCID: PMC8830433 DOI: 10.7759/cureus.21090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/31/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease that can lead to thrombotic or obstetric complications. Recent histopathological studies have shown the absence of placental thrombosis, leading to the consideration of other pathophysiological pathways such as inflammation and complement activation. Due to this, various clinical studies are being carried out with different drug agents in order to avoid their complications. The combination of prophylactic heparin treatment and low doses of aspirin today result in successful pregnancies in most cases. Despite this, a minority of patients require alternative therapies to avoid recurrent miscarriage and decrease obstetric morbidity. Thanks to the better understanding of its pathophysiology, other treatments such as low doses of glucocorticoids, hydroxychloroquine (HCQ), immunoglobulin, pravastatin, and plasmapheresis have been considered in refractory cases, achieving favorable results. Despite the great advances regarding its treatment, unfortunately, there are no treatments with a good level of evidence to reduce late obstetric complications. The evaluation of preconception risk factors, as well as the antiphospholipid antibody profile, is necessary to establish individual risk and thus anticipate possible complications.
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Affiliation(s)
| | | | - Igor Rueda
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
| | - Sandra Pulido
- Rheumatology Department, Universidad Militar Nueva Granada, Bogotá, COL
| | - Gustavo Rodríguez
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
| | - John Londono
- Spondyloarthropathies Research Group, Universidad de La Sabana, Chía, COL
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Arora S, Nair S, Prabhu R, Avanthika C, Jhaveri S, Samayam S, Katta MR, Agarwal P. Role of Direct Oral Anticoagulation Agents as Thromboprophylaxis in Antiphospholipid Syndrome. Cureus 2021; 13:e19009. [PMID: 34824926 PMCID: PMC8610415 DOI: 10.7759/cureus.19009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 01/13/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that causes venous, arterial and small-vessel thrombosis, pregnancy loss, and premature birth. Cardiac valvular disease, renal thrombotic microangiopathy, thrombocytopenia, hemolytic anemia, and cognitive impairment are some of its other clinical symptoms. Antiphospholipid antibodies cause endothelial cells, monocytes, and platelets to become activated, as well as an increase in tissue factor and thromboxane A2. Complement activation might play a key function in pathogenesis. Long-term oral anticoagulation is used to treat thrombosis, and individuals having arterial episodes should be treated quickly. Patients with systemic lupus erythematosus (SLE), as well as those with solely obstetric antiphospholipid syndrome, should get primary thromboprophylaxis. Obstetric care is based on a combination of medical and obstetric high-risk management, as well as aspirin and heparin therapy. Possible supplementary therapy for this condition is hydroxychloroquine. Statins, rituximab, and novel anticoagulant medicines are all potential future treatments for non-pregnant individuals with antiphospholipid syndrome. We aim to review the role of direct-acting oral anticoagulants (DOACs) as thromboprophylactic drugs in the treatment of APS in this article. The treatment of venous thromboembolism has been transformed by a new class of DOACs. These drugs, such as rivaroxaban, function by inhibiting factor Xa directly. Not only do they have known anticoagulant actions, but they also obviate the need for dosage monitoring and modification, in contrast to warfarin. We conducted an exhaustive literature search of PubMed/MEDLINE and Google Scholar Indexes using the keywords "Antiphospholipid syndrome," "thromboprophylaxis," and "oral anticoagulants" up to September 2021. We found that DOACs have been shown to be non-inferior to warfarin in a variety of anticoagulation situations in a number of high-powered clinical studies. In many hypercoagulable conditions such as APS, DOACs are quickly establishing themselves as first-line therapy. This article is focused on comprehensively reviewing the mechanism of action of DOACs, their role as thromboprophylactic drugs, risks and complications of DOACs, and comparing their efficacy with the standard treatment protocol and warfarin.
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Affiliation(s)
- Shreya Arora
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Shaalina Nair
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Rishab Prabhu
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Chaithanya Avanthika
- Medicine and Surgery, Karnataka Institute of Medical Sciences, Hubli, IND.,Pediatrics, Karnataka Institute of Medical Sciences, Hubli, IND
| | - Sharan Jhaveri
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Shilpa Samayam
- Internal Medicine, Government Medical College Siddipet, Siddipet, IND
| | - Maanya R Katta
- Internal Medicine, Gandhi Medical College, Hyderabad, IND
| | - Pahel Agarwal
- Internal Medicine, Bhaskar Medical College, Hyderabad, IND
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Pablo RD, Cacho PM, López-Hoyos M, Calvo-Río V, Riancho-Zarrabeitia L, Martínez-Taboada VM. Risk Factors for the Development of the Disease in Antiphospholipid Antibodies Carriers: A Long-term Follow-up Study. Clin Rev Allergy Immunol 2021; 62:354-362. [PMID: 34216367 PMCID: PMC8994711 DOI: 10.1007/s12016-021-08862-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 01/22/2023]
Abstract
The natural history of antiphospholipid antibodies (aPL) carriers is not well-established. The objectives of the present study were (a) to study the probability of developing clinical criteria of antiphospholipid syndrome (APS), (b) to identify potential risk factors for developing thrombosis and/or obstetric complications, (c) to study the association between the antibody profile and development of APS, and (d) to determine the efficacy of primary prophylaxis. We retrospectively analyzed 138 subjects with positive aPL who did not fulfill clinical criteria for APS. The mean follow-up time was 138 ± 63.0 months. Thirteen patients (9.4%) developed thrombosis after an average period of 73.0 ± 48.0 months. Independent risk factors for thrombosis were smoking, hypertension, thrombocytopenia, and triple aPL positivity. Low-dose acetyl salicylic acid did not prevent thrombotic events. A total of 28 obstetric complications were detected in 92 pregnancies. During the follow-up, only two women developed obstetric APS. Prophylactic treatment in pregnant women was associated with a better outcome in the prevention of early abortions. The thrombosis rate in patients with positive aPL who do not meet diagnostic criteria for APS is 0.82/100 patients-year. Smoking, hypertension, thrombocytopenia, and the aPL profile are independent risk factors for the development of thrombosis in aPL carriers. Although the incidence of obstetric complications in this population is high (31.6%), only a few of them meet APS criteria. In these women, prophylactic treatment might be effective in preventing early abortions.
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Affiliation(s)
- Rosalía Demetrio Pablo
- Servicio de Oftalmología, Hospital Universitario Marqués de Valdecilla, Cantabria, Spain
| | - Pedro Muñoz Cacho
- Gerencia de Atención Primaria IDIVAL, Servicio Cántabro de Salud, Cantabria, Spain.
| | - Marcos López-Hoyos
- Servicio de Inmunología, Hospital Universitario Marqués de Valdecilla, Cantabria, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Vanesa Calvo-Río
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla IDIVAL, Cantabria, Spain
| | | | - Víctor M Martínez-Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla IDIVAL, Cantabria, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
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Shi T, Gu ZD, Diao QZ. Meta-analysis on aspirin combined with low-molecular-weight heparin for improving the live birth rate in patients with antiphospholipid syndrome and its correlation with d-dimer levels. Medicine (Baltimore) 2021; 100:e26264. [PMID: 34160390 PMCID: PMC8238312 DOI: 10.1097/md.0000000000026264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/22/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Antiphospholipid antibody syndrome (APS) is a systemic, autoimmune, prothrombotic disease characterized by persistent antiphospholipid antibodies, thrombosis, recurrent abortion, complications during pregnancy, and occasionally thrombocytopenia. At present, there is no consensus on the treatment of this disease. Long-term anticoagulation is recommended in most cases in patients with thrombotic APS. This study aimed to evaluate whether aspirin combined with low-molecular-weight heparin (LMWH) can improve the live birth rate in antiphospholipid syndrome and its correlation with D-dimer. METHODS The data were retrieved from the WanFang Data, CBM, VIP, CNKI, the Cochrane Library, PubMed, EMBASE, OVID, and Web of Science databases. We collected data on randomized controlled trials of aspirin combined with LMWH in the treatment of pregnant women with APS. The "Risk of Bias Assessment" tool and the "Jadad Scale" provided by the Cochrane Collaboration were used to evaluate the risk of bias and quality of the collected literature. The risk ratio (RR) and its 95% confidence interval (CI) were determined using Statase-64 software. RESULTS In this study, a total of 11 studies were included, comprising a total of 2101 patients. The live birth rate in pregnant women with APS was higher on administration of aspirin combined with LMWH than with aspirin alone (RR = 1.29, 95% CI = 1.22-1.35, P < .001). d-dimer concentration in plasma predicted the live birth rate, which was higher below the baseline than above it (RR = 1.16, 95% CI = 1.09-1.23, P < .001). The subgroup analysis of the live birth rate was carried out based on the course of treatment, and the results were consistent with the overall results. Begg funnel plot test revealed no publication bias. Sensitivity analysis showed that deleting any study did not affect the results. CONCLUSION Aspirin combined with LMWH for APS may improve live birth rate, and detection of d-dimer levels in APS pregnant women may predict pregnancy complications and guide the use of anticoagulants.
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MESH Headings
- Abortion, Habitual/blood
- Abortion, Habitual/immunology
- Abortion, Habitual/prevention & control
- Antibodies, Antiphospholipid/blood
- Antibodies, Antiphospholipid/immunology
- Anticoagulants/administration & dosage
- Antiphospholipid Syndrome/blood
- Antiphospholipid Syndrome/complications
- Antiphospholipid Syndrome/drug therapy
- Antiphospholipid Syndrome/immunology
- Aspirin/administration & dosage
- Biomarkers/blood
- Birth Rate
- Drug Therapy, Combination/methods
- Female
- Fibrin Fibrinogen Degradation Products/analysis
- Heparin, Low-Molecular-Weight/administration & dosage
- Humans
- Live Birth
- Pregnancy
- Pregnancy Complications, Hematologic/blood
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/drug therapy
- Pregnancy Complications, Hematologic/immunology
- Prognosis
- Randomized Controlled Trials as Topic
- Thrombosis/blood
- Thrombosis/complications
- Thrombosis/drug therapy
- Thrombosis/immunology
- Treatment Outcome
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Affiliation(s)
- Ting Shi
- The Department of Blood Transfusion
| | | | - Qi-Zhi Diao
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital, Chongqing Medical University, Yongchuan, Chongqing, China
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12
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Toktas O, Toprak N. Treatment Results of Intralesional Steroid Injection and Topical Steroid Administration in Pregnant Women with Idiopathic Granulomatous Mastitis. Eur J Breast Health 2021; 17:283-287. [PMID: 34263157 DOI: 10.4274/ejbh.galenos.2021.2021-2-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/20/2021] [Indexed: 12/01/2022]
Abstract
Objective Idiopathic granulomatous mastitis (IGM) is an inflammatory and chronic benign breast disease that has proven difficult to diagnose and treat. Since most treatment modalities cannot be used in pregnant patients, the choice of treatment is more difficult and the need for surgery is more pressing. In this first and innovative study, we assess the results of local corticosteroid therapy of IGM in pregnant women. Materials and Methods Pregnant women with IGM were evaluated between June 2017 and May 2019. The six pregnant women were treated using intralesional steroid injections and topical steroid administration. The treatment response was evaluated, both clinically and radiologically, at the end of 2 weeks and once more at the end of 1 month. Results The median patient age was 26 years. The mean duration of complaints was 4.3 months. The median number of children was 2, and the mean breastfeeding time was 41 months. The predominant complaints at onset were a breast mass or local pain and inflammation in four (66.7%) patients and a breast mass with pain and without signs of local skin inflammation in two (33.3%) patients. Diagnosis was made using a tru-cut biopsy in two patients, and with an incisional biopsy in four patients who had abscess drainage and fistulation to the skin. Five (83.3%) patients achieved a complete response, and one (16.7%) patient responded only partially after the first course of treatment. A second course of treatment was given to the patient with partial response. All patients achieved complete response at the end of the second course of treatment. The mean follow-up time was 19.5 months. During the follow-up period, one patient experienced a recurrence at 4 months after giving birth, and she then received a third course of treatment. Topical and systemic side effects of the corticosteroids were not observed in any patient. Conclusion While the state of pregnancy generally precludes the use of most drugs, the use of local corticosteroid in the treatment of IGM is effective in terms of treatment response, treatment duration, need for surgery, and reduced recurrence and side effects.
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Affiliation(s)
- Osman Toktas
- Department of Surgery, Van Yüzüncü Yıl University Faculty of Medicine, Van, Turkey
| | - Nurşen Toprak
- Department of Radiology, Van Yüzüncü Yıl University Faculty of Medicine, Van, Turkey
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13
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Grbac E, So T, Varshney S, Williamson N, Dimitriadis E, Menkhorst E. Prednisolone Alters Endometrial Decidual Cells and Affects Decidual-Trophoblast Interactions. Front Cell Dev Biol 2021; 9:647496. [PMID: 33898438 PMCID: PMC8063028 DOI: 10.3389/fcell.2021.647496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/18/2021] [Indexed: 12/14/2022] Open
Abstract
Poor pregnancy outcomes such as recurrent pregnancy loss (RPL) and preeclampsia are associated with impaired decidualization and abnormal trophoblast invasion. Emerging evidence suggests that use of corticosteroids, including prednisolone affects fertility by altering uterine function and may be associated with preeclampsia incidence. In this study, using primary and gestational-age appropriate tissue, we aimed to define the effect of prednisolone on human endometrial stromal fibroblast (hESF) decidualization and determine whether hESF decidualization in the presence of prednisolone would alter hESF regulation of trophoblast function. We found that prednisolone treatment reduced hESF cytokine expression (IL6, IL11, IL18, LIF, and LIFR) but had no effect on hESF expression or secretion of the classic markers of decidualization [prolactin (PRL) and IGFBP1]. Using proteomics we determined that prednisolone altered decidualized hESF protein production, enriching hESF proteins associated with acetylation and mitrochondria. Conditioned media from hESF decidualized in the presence of prednisolone significantly enhanced trophoblast outgrowth and trophoblast mRNA expression of cell motility gene PLCG1 and reduced trophoblast production of PGF. Prednisolone treatment during the menstrual cycle and 1st trimester of pregnancy might alter decidual interactions with other cells, including invasive trophoblast.
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Affiliation(s)
- Eliza Grbac
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Gynaecology Research Centre, Royal Women's Hospital, Parkville, VIC, Australia
| | - Teresa So
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Gynaecology Research Centre, Royal Women's Hospital, Parkville, VIC, Australia
| | - Swati Varshney
- Melbourne Mass Spectrometry and Proteomics Facility, Bio21 Molecular Science and Biotechnology, Parkville, VIC, Australia
| | - Nicholas Williamson
- Melbourne Mass Spectrometry and Proteomics Facility, Bio21 Molecular Science and Biotechnology, Parkville, VIC, Australia
| | - Evdokia Dimitriadis
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Gynaecology Research Centre, Royal Women's Hospital, Parkville, VIC, Australia.,Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC, Australia
| | - Ellen Menkhorst
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Gynaecology Research Centre, Royal Women's Hospital, Parkville, VIC, Australia
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14
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Vomstein K, Feil K, Strobel L, Aulitzky A, Hofer-Tollinger S, Kuon RJ, Toth B. Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art. J Clin Med 2021; 10:869. [PMID: 33672505 PMCID: PMC7923780 DOI: 10.3390/jcm10040869] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 02/06/2023] Open
Abstract
Around 1-5% of all couples experience recurrent pregnancy loss (RPL). Established risk factors include anatomical, genetic, endocrine, and hemostatic alterations. With around 50% of idiopathic cases, immunological risk factors are getting into the scientific focus, however international guidelines hardly take them into account. Within this review, the current state of immunological risk factors in RPL in international guidelines of the European Society of Reproduction and Embryology (ESHRE), American Society of Reproductive Medicine (ASRM), German/Austrian/Swiss Society of Obstetrics and Gynecology (DGGG/OEGGG/SGGG) and the Royal College of Obstetricians and Gynecologists (RCOG) are evaluated. Special attention was drawn to recommendations in the guidelines regarding diagnostic factors such as autoantibodies, natural killer cells, regulatory T cells, dendritic cells, plasma cells, and human leukocyte antigen system (HLA)-sharing as well as treatment options such as corticosteroids, intralipids, intravenous immunoglobulins, aspirin and heparin in RPL. Finally, the current state of the art focusing on both diagnostic and therapeutic options was summarized.
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Affiliation(s)
- Kilian Vomstein
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Katharina Feil
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Laura Strobel
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Anna Aulitzky
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Susanne Hofer-Tollinger
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Ruben-Jeremias Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, Ruprecht-Karls University Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany;
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
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15
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The Variations of Metabolic Detoxification Enzymes Lead to Recurrent Miscarriage and Their Diagnosis Strategy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1300:259-280. [PMID: 33523438 DOI: 10.1007/978-981-33-4187-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Spontaneous abortion has been a common obstetrical and gynecological disease, which occurs in 10-15% of all pregnancies. Recurrent miscarriage (RM) refers to the occurrence of three or more times abortions with the same partner. It is generally believed that environmental pollution associated with economic development may cause infertility and RM. When xenobiotics from the environment enter the body, they must be cleared from the body by various metabolic enzymes in the body. The absence or variation of these enzymes may be the genetic basis of RM caused by environmental pollution. The variation of metabolic detoxification enzyme can directly affect the removal of harmful substances from internal and external sources. Therefore, the determination of metabolic enzyme activity may become an important factor in the diagnosis of RM etiology and seeking methods to improve the detoxification ability has a great significance for the treatment of RM.
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16
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Duan H, Li X, Liu C, Ge Y, Deng X. Risk factors for pregnancy failure in patients with antiphospholipid antibody positivity and prior pregnancy losses: A retrospective study. J Reprod Immunol 2020; 141:103171. [PMID: 32603990 DOI: 10.1016/j.jri.2020.103171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/20/2020] [Accepted: 06/17/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To analyze the risk factors associated with pregnancy failure in patients with positive antiphospholipid antibodies (aPL) and prior pregnancy losses, with or without a diagnosis of antiphospholipid syndrome. METHODS We retrospectively reviewed the medical records of all the pregnant patients with positive aPL that visited the Peking University Third Hospital on an inpatient or outpatient basis from 2010 to 2019. According to the pregnancy outcome during this study, patients were divided into successful and unsuccessful groups. The clinical characteristics, laboratory tests and treatments were collected. RESULTS In total, 105 patients were included. 74/105 (70.48 %) patients were in the successful group and 31/105 (29.52 %) patients were in the unsuccessful group. In univariate analysis, the patients with successful pregnancies had a significant prevalence of low-dose aspirin (LDA) prior to pregnancy (P = 0.049) and heparin plus LDA plus hydroxychloroquine (HCQ) and/or steroids (P = 0.037). Triple aPL positivity (P = 0.026), prior pregnancy losses ≥3 (P = 0.036), maternal age at pregnancy ≥35 years (P = 0.001) and no treatment during pregnancy (P < 0.001) were significantly prevalent in patients with unsuccessful pregnancies. In multivariate analysis, prior pregnancy losses ≥3 (P = 0.039; odds ratio (OR) 4.5; 95 %CI 1.3, 14.3), maternal age at pregnancy ≥35 years (P = 0.019; OR 4.3; 95 %CI 1.1, 18.5) and no treatment (P < 0.001; OR 0.03; 95 %CI 0.004, 0.2) were independent risk factors for subsequent pregnancy losses. CONCLUSION The risk factors affecting pregnancy outcomes for patients with aPL positivity and prior pregnancy losses included prior pregnancy losses ≥3, maternal age at pregnancy ≥35 years and no treatment during pregnancy.
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Affiliation(s)
- Hongji Duan
- Department of Rheumatology and Immunology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Xinyi Li
- Department of Rheumatology and Immunology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Chang Liu
- Department of Rheumatology and Immunology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yingying Ge
- Department of Rheumatology and Immunology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Xiaoli Deng
- Department of Rheumatology and Immunology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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17
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Hamulyák EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev 2020; 5:CD012852. [PMID: 32358837 PMCID: PMC7195627 DOI: 10.1002/14651858.cd012852.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aspirin and heparin are widely used as preventive strategy to reduce the high risk of recurrent pregnancy loss in women with antiphospholipid antibodies (aPL). This review supersedes a previous, out-of-date review that evaluated all potential therapies for preventing recurrent pregnancy loss in women with aPL. The current review focusses on a narrower scope because current clinical practice is restricted to using aspirin or heparins, or both for women with aPL in an attempt to reduce pregnancy complications. OBJECTIVES To assess the effects of aspirin or heparin, or both for improving pregnancy outcomes in women with persistent (on two separate occasions) aPL, either lupus anticoagulant (LAC), anticardiolipin (aCL) or aβ2-glycoprotein-I antibodies (aβ2GPI) or a combination, and recurrent pregnancy loss (two or more, which do not have to be consecutive). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 June 2019), and reference lists of retrieved studies. Where necessary, we attempted to contact trial authors. SELECTION CRITERIA Randomised, cluster-randomised and quasi-randomised controlled trials that assess the effects of aspirin, heparin (either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH]), or a combination of aspirin and heparin compared with no treatment, placebo or another, on pregnancy outcomes in women with persistent aPL and recurrent pregnancy loss were eligible. All treatment regimens were considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion criteria and risk of bias. Two review authors independently extracted data and checked them for accuracy and the certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Eleven studies (1672 women) met the inclusion criteria; nine randomised controlled trials and two quasi-RCTs. The studies were conducted in the USA, Canada, UK, China, New Zealand, Iraq and Egypt. One included trial involved 1015 women, all other included trials had considerably lower numbers of participants (i.e. 141 women or fewer). Some studies had high risk of selection and attrition bias, and many did not include sufficient information to judge the risk of reporting bias. Overall, the certainty of evidence is low to very low due to the small numbers of women in the studies and to the risk of bias. The dose and type of heparin and aspirin varied among studies. One study compared aspirin alone with placebo; no studies compared heparin alone with placebo and there were no trials that had a no treatment comparator arm during pregnancy; five studies explored the efficacy of heparin (either UFH or LMWH) combined with aspirin compared with aspirin alone; one trial compared LMWH with aspirin; two trials compared the combination of LMWH plus aspirin with the combination of UFH plus aspirin; two studies evaluated the combination of different doses of heparin combined with aspirin. All trials used aspirin at a low dose. Aspirin versus placebo We are very uncertain if aspirin has any effect on live birth compared to placebo (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71 to 1.25, 1 trial, 40 women, very low-certainty evidence). We are very uncertain if aspirin has any effect on the risk of pre-eclampsia, pregnancy loss, preterm delivery of a live infant, intrauterine growth restriction or adverse events in the child, compared to placebo. We are very uncertain if aspirin has any effect on adverse events (bleeding) in the mother compared with placebo (RR 1.29, 95% CI 0.60 to 2.77, 1 study, 40 women). The certainty of evidence for these outcomes is very low because of imprecision, due to the low numbers of women involved and the wide 95% CIs, and also because of risk of bias. Venous thromboembolism and arterial thromboembolism were not reported in the included studies. Heparin plus aspirin versus aspirin alone Heparin plus aspirin may increase the number of live births (RR 1.27, 95% CI 1.09 to 1.49, 5 studies, 1295 women, low-certainty evidence). We are uncertain if heparin plus aspirin has any effect on the risk of pre-eclampsia, preterm delivery of a live infant, or intrauterine growth restriction, compared with aspirin alone because of risk of bias and imprecision due to the low numbers of women involved and the wide 95% CIs. We are very uncertain if heparin plus aspirin has any effect on adverse events (bleeding) in the mother compared with aspirin alone (RR 1.65, 95% CI 0.19 to 14.03, 1 study, 31 women). No women in either the heparin plus aspirin group or the aspirin alone group had heparin-induced thrombocytopenia, allergic reactions, or venous or arterial thromboembolism. Similarly, no infants had congenital malformations. Heparin plus aspirin may reduce the risk of pregnancy loss (RR 0.48, 95% CI 0.32 to 0.71, 5 studies, 1295 women, low-certainty evidence). When comparing LMWH plus aspirin versus aspirin alone the pooled RR for live birth was 1.20 (95% CI 1.04 to 1.38, 3 trials, 1155 women). In the comparison of UFH plus aspirin versus aspirin alone, the RR for live birth was 1.74 (95% CI 1.28 to 2.35, 2 trials, 140 women). AUTHORS' CONCLUSIONS The combination of heparin (UFH or LMWH) plus aspirin during the course of pregnancy may increase live birth rate in women with persistent aPL when compared with aspirin treatment alone. The observed beneficial effect of heparin was driven by one large study in which LMWH plus aspirin was compared with aspirin alone. Adverse events were frequently not, or not uniformly, reported in the included studies. More research is needed in this area in order to further evaluate potential risks and benefits of this treatment strategy, especially among women with aPL and recurrent pregnancy loss, to gain consensus on the ideal prevention for recurrent pregnancy loss, based on a risk profile.
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Affiliation(s)
- Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luuk Jj Scheres
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mauritia C Marijnen
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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18
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High risk of adverse pregnancy outcomes in women with a persistent lupus anticoagulant. Blood Adv 2020; 3:769-776. [PMID: 30837214 DOI: 10.1182/bloodadvances.2018026948] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/04/2019] [Indexed: 11/20/2022] Open
Abstract
Lupus anticoagulant (LA) has been associated with pregnancy complications and pregnancy loss. Identification of predictive factors could aid in deciding on therapeutic management. To identify risk factors for adverse pregnancy outcomes in high-risk women with persistently positive LA, we prospectively followed 82 women of childbearing age, of whom 23 had 40 pregnancies within the Vienna Lupus Anticoagulant and Thrombosis Study. Pregnancy complications occurred in 28/40 (70%) pregnancies, including 22 (55%) spontaneous abortions (<10th week of gestation [WOG]: n = 12, 10th to 24th WOG: n = 10) and 6 deliveries <34th WOG (15%, 3 due to severe preeclampsia/HELLP [hemolysis, elevated liver enzymes, and a low platelet count] syndrome, 3 due to placental insufficiency). One abortion was followed by catastrophic antiphospholipid syndrome. Neither a history of pregnancy complications nor of thrombosis, or prepregnancy antiphospholipid antibody levels were associated with adverse pregnancy outcomes. In logistic regression analysis, higher age was associated with a lower risk of adverse pregnancy outcome (per 5 years' increase: odds ratio [OR] = 0.41, 95% confidence interval [CI]: 0.19-0.87), a high Rosner index (index of circulating anticoagulant) predicted an increased risk (OR = 4.51, 95% CI: 1.08-18.93). Live birth rate was 15/28 (54%) in women on the combination of low-molecular-weight heparin and low-dose aspirin and 3/12 (25%) in those with no treatment or a single agent. We conclude that the risk of severe, even life-threatening pregnancy complications and adverse pregnancy outcomes is very high in women with persistent LA. A high Rosner index indicates an increased risk. Improved treatment options for women with persistently positive LA are urgently needed.
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19
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Daimon A, Morihara H, Tomoda K, Morita N, Koishi Y, Kanki K, Ohmichi M, Asahi M. Intravenously Injected Pluripotent Stem Cell-derived Cells Form Fetomaternal Vasculature and Prevent Miscarriage in Mouse. Cell Transplant 2020; 29:963689720970456. [PMID: 33349053 PMCID: PMC7873769 DOI: 10.1177/0963689720970456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/26/2020] [Accepted: 10/13/2020] [Indexed: 01/22/2023] Open
Abstract
Miscarriage is the most common complication of pregnancy, and about 1% of pregnant women suffer a recurrence. Using a widely used mouse miscarriage model, we previously showed that intravenous injection of bone marrow (BM)-derived endothelial progenitor cells (EPCs) may prevent miscarriage. However, preparing enough BM-derived EPCs to treat a patient might be problematic. Here, we demonstrated the generation of mouse pluripotent stem cells (PSCs), propagation of sufficient PSC-derived cells with endothelial potential (PSC-EPs), and intravenous injection of the PSC-EPs into the mouse miscarriage model. We found that the injection prevented miscarriage. Three-dimensional reconstruction images of the decidua after tissue cleaning revealed robust fetomaternal neovascularization induced by the PSC-EP injection. Additionally, the injected PSC-EPs directly formed spiral arteries. These findings suggest that intravenous injection of PSC-EPs could become a promising remedy for recurrent miscarriage.
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Affiliation(s)
- Atsushi Daimon
- Department of Obstetrics and Gynecology, Osaka Medical College,
Takatsuki, Japan
- Department of Pharmacology, Osaka Medical College, Takatsuki,
Japan
- These authors contributed equally to
this article
| | - Hirofumi Morihara
- Department of Pharmacology, Osaka Medical College, Takatsuki,
Japan
- These authors contributed equally to
this article
| | - Kiichiro Tomoda
- Department of Pharmacology, Osaka Medical College, Takatsuki,
Japan
- Department of Life Science Frontiers, Center for iPS Cell Research
and Application, Kyoto University, Japan
- Gladstone Institute of Cardiovascular Disease, San Francisco, CA,
USA
- These authors contributed equally to
this article
| | - Natsuko Morita
- Department of Obstetrics and Gynecology, Osaka Medical College,
Takatsuki, Japan
- Department of Pharmacology, Osaka Medical College, Takatsuki,
Japan
| | - Yoshinori Koishi
- Division of Research Animal Laboratory and Translational Medicine,
Research and Development Center, Takatsuki, Osaka, Japan
| | - Kazuyoshi Kanki
- Department of Obstetrics and Gynecology, Osaka Medical College,
Takatsuki, Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology, Osaka Medical College,
Takatsuki, Japan
| | - Michio Asahi
- Department of Pharmacology, Osaka Medical College, Takatsuki,
Japan
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20
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Lazzaroni MG, Fredi M, Andreoli L, Chighizola CB, Del Ross T, Gerosa M, Kuzenko A, Raimondo MG, Lojacono A, Ramazzotto F, Zatti S, Trespidi L, Meroni PL, Pengo V, Ruffatti A, Tincani A. Triple Antiphospholipid (aPL) Antibodies Positivity Is Associated With Pregnancy Complications in aPL Carriers: A Multicenter Study on 62 Pregnancies. Front Immunol 2019; 10:1948. [PMID: 31475009 PMCID: PMC6702797 DOI: 10.3389/fimmu.2019.01948] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/01/2019] [Indexed: 01/20/2023] Open
Abstract
Objective: Antiphospholipid antibodies (aPL) are risk factors for thrombosis and adverse pregnancy outcomes (APO). The management of the so called “aPL carriers” (subjects with aPL positivity without the clinical criteria manifestations of APS) is still undefined. This study aims at retrospectively evaluating the outcomes and the factors associated with APO and maternal complications in 62 pregnant aPL carriers. Methods: Medical records of pregnant women regularly attending the Pregnancy Clinic of 3 Rheumatology centers from January 1994 to December 2015 were retrospectively evaluated. Patients with concomitant autoimmune diseases or other causes of pregnancy complications were excluded. Results: An aPL-related event was recorded in 8 out of 62 patients (12.9%) during pregnancy: 2 thrombosis and 6 APO. At univariate analysis, factors associated with pregnancy complications were acquired risk factors (p:0.008), non-criteria aPL manifestations (p:0.024), lupus-like manifestations (p:0.013), and triple positive aPL profile (p:0.001). At multivariate analysis, only the association with a triple aPL profile was confirmed (p:0.01, OR 21.3, CI 95% 1.84–247). Patients with triple aPL positivity had a higher rate of pregnancy complications, despite they were more frequently receiving combined treatment of low dose aspirin (LDA) and low molecular weight heparin (LMWH) at prophylactic dose. Conclusion: This study highlights the importance of risk stratification in pregnant aPL carriers, in terms of both immunologic and non-immunologic features. Combination treatment with LDA and LMWH did not prevent APO in some cases, especially in carriers of triple aPL positivity. Triple positive aPL carriers may deserve additional therapeutic strategies during pregnancy.
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Affiliation(s)
- Maria-Grazia Lazzaroni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Micaela Fredi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Cecilia Beatrice Chighizola
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy.,Rheumatology Unit, Istituto Auxologico Italiano, Milan, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Pini-CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Kuzenko
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Maria-Gabriella Raimondo
- Division of Clinical Rheumatology, ASST Pini-CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Andrea Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Obstetrics and Gynaecology Unit, ASST Spedali Civili, Brescia, Italy
| | | | - Sonia Zatti
- Obstetrics and Gynaecology Unit, ASST Spedali Civili, Brescia, Italy
| | - Laura Trespidi
- Obstetrics and Gynaecology Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier-Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac Thoracic and Vascular Sciences, Thrombosis Centre, University of Padova, Padova, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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21
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Tektonidou MG, Andreoli L, Limper M, Tincani A, Ward MM. Management of thrombotic and obstetric antiphospholipid syndrome: a systematic literature review informing the EULAR recommendations for the management of antiphospholipid syndrome in adults. RMD Open 2019; 5:e000924. [PMID: 31168416 PMCID: PMC6525610 DOI: 10.1136/rmdopen-2019-000924] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/31/2023] Open
Abstract
Objective To perform a systematic literature review (SLR) informing the European Lmmendations for the management of antiphospholipid syndrome (APS) in adults. Methods A SLR through January 2018 was performed. Research questions were constructed using the Patient, Intervention, Comparator, Outcome (PICO) format. We included data from articles that reported on each relevant intervention. Summary effect estimates were calculated for direct comparison studies that matched the PICO question exactly, and for studies with the relevant intervention and comparator. When meta-analyses were available, we used these estimates. Results From 7534 retrieved articles (+15 from hand searches), 188 articles were included in the review. In individuals with high-risk antiphospholipid antibody (aPL) profile without prior thrombotic or obstetric APS, two meta-analyses showed a protective effect of low-dose aspirin (LDA) against thrombosis. Two randomised controlled trials (RCTs) and three cohort studies showed no additional benefit of treatment with vitamin K antagonists at target international normalised ratio (INR) 3–4 versus INR 2–3 in patients with venous thrombosis. In patients with arterial thrombosis, two RCTs and two cohort studies showed no difference in risk of recurrent thrombosis between the two target INR groups. One open-label trial showed higher rates of thrombosis recurrences in triple aPL-positive patients treated with rivaroxaban than those treated with warfarin. RCTs and cohort studies showed that combination treatment with LDA and heparin was more effective than LDA alone in several types of obstetric APS. SLR results were limited by the indirect evidence and the heterogeneity of patient groups for some treatments, and only a few high-quality RCTs. Conclusion Well-designed studies of homogeneous APS patient populations are needed.
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Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, NIAMS/NIH, Bethesda, Maryland, USA
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22
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D'Angelo C, Franch O, Fernández-Paredes L, Oreja-Guevara C, Núñez-Beltrán M, Comins-Boo A, Reale M, Sánchez-Ramón S. Antiphospholipid Antibodies Overlapping in Isolated Neurological Syndrome and Multiple Sclerosis: Neurobiological Insights and Diagnostic Challenges. Front Cell Neurosci 2019; 13:107. [PMID: 30941020 PMCID: PMC6433987 DOI: 10.3389/fncel.2019.00107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/04/2019] [Indexed: 01/19/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis, pregnancy morbidity and fetal loss caused by pathogenic autoantibodies directed against phospholipids (PL) and PL-cofactors. Isolated neurological APS may represent a significant diagnostic challenge, as epidemiological, clinical and neuroimaging features may overlap with those of multiple sclerosis (MS). In an open view, MS could be considered as an organ-specific anti-lipid (phospholipid and glycosphingolipid associated proteins) disease, in which autoreactive B cells and CD8+ T cells play a dominant role in its pathophysiology. In MS, diverse autoantibodies against the lipid-protein cofactors of the myelin sheath have been described, whose pathophysiologic role has not been fully elucidated. We carried out a review to select clinical studies addressing the prevalence of antiphospholipid (aPL) autoantibodies in the so-called MS-like syndrome. The reported prevalence ranged between 2% and 88%, particularly aCL and aβ2GPI, with predominant IgM isotype and suggesting worse MS prognosis. Secondarily, an updated summary of current knowledge on the pathophysiological mechanisms and events responsible for these conditions is presented. We draw attention to the clinical relevance of diagnosing isolated neurological APS. Prompt and accurate diagnosis and antiaggregant and anticoagulant treatment of APS could be vital to prevent or at least reduce APS-related morbidity and mortality.
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Affiliation(s)
- Chiara D'Angelo
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain.,Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Oriol Franch
- Department of Neurology, Hospital Ruber Internacional, Madrid, Spain
| | - Lidia Fernández-Paredes
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
| | | | - María Núñez-Beltrán
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Alejandra Comins-Boo
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
| | - Marcella Reale
- Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Silvia Sánchez-Ramón
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
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23
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Eid MI, Abdelhafez MS, El-Refaie W, El-Zayadi AA, Samir K, Abdelrazik MM, Thabet M, Wageh A, Fyala EA, Abdeldayem Y, Badawy A. Timing of initiation of low-molecular-weight heparin administration in pregnant women with antiphospholipid syndrome: a randomized clinical trial of efficacy and safety. Int J Womens Health 2019; 11:41-47. [PMID: 30666167 PMCID: PMC6336021 DOI: 10.2147/ijwh.s193293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We aimed to evaluate the effect of different timing of initiation of low-molecular-weight heparin (LMWH) administration on the pregnancy outcomes in women with antiphospholipid syndrome (APS). Materials and methods A randomized controlled study was conducted on women with obstetrical APS. All participants were randomly divided at documentation of positive pregnancy test into two groups; early initiation group in which LMWH therapy was started once positive pregnancy test was established (in the fifth week of gestation), and later initiation group in which LMWH therapy was started after sonographic confirmation of fetal cardiac pulsation (in the seventh week of gestation). In both groups, LMWH (enoxaparin) was given at a dose of 40 mg/day subcutaneously and the therapy continued until end of pregnancy. The primary outcome measure was ongoing pregnancy rate and the secondary outcome measures were fetal loss, live birth rate, preterm labor before 34 weeks of gestation, intrauterine growth restriction (IUGR), and congenital fetal malformations. Results Ninety-four women (48 in the early initiation group and 46 in the later initiation group) were subjected to final analysis. The ongoing pregnancy rate was significantly higher in the early initiation group than in the later initiation group (81.2% vs 60.9%; P=0.040). However, both groups were similar in the incidences of fetal loss, preterm labor before 34 weeks of gestation, and IUGR, and live birth rate. No recorded congenital fetal malformations in both groups. Conclusion Early administration of LMWH for pregnant women with obstetrical APS reduces early pregnancy loss, but does not affect the incidence of late obstetrical complications.
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Affiliation(s)
- Mohamed Ibrahem Eid
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | | | - Waleed El-Refaie
- Department of Obstetrics and Gynecology, Port Said University, Port Said, Egypt
| | - Ahmed A El-Zayadi
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Khaled Samir
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | | | - Mahmoud Thabet
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Alaa Wageh
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Emad Ahmed Fyala
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Yasser Abdeldayem
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Ahmed Badawy
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
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24
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Infektiologische und immunologische Aspekte bei Kinderwunsch. GYNAKOLOGISCHE ENDOKRINOLOGIE 2018. [DOI: 10.1007/s10304-018-0196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Gerardi MC, Fernandes MA, Tincani A, Andreoli L. Obstetric Anti-phospholipid Syndrome: State of the Art. Curr Rheumatol Rep 2018; 20:59. [PMID: 30105597 DOI: 10.1007/s11926-018-0772-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW This review focuses on new pathogenesis and clinical-therapeutic aspects of obstetric anti-phospholipid syndrome (ob-APS) in the last 5 years. RECENT FINDINGS The pathogenesis of ob-APS is multifactorial, including placental infarctions, infiltration of inflammatory cells that cause acute and chronic inflammation, leading to uncontrolled inflammation and poor pregnancy outcomes. A preconception counseling and a patient-tailored treatment are fundamental to improve maternal and fetal outcomes. Thanks to conventional treatment, based on low-dose aspirin and heparin, 70% of women with ob-APS can have successful pregnancies. Women with positive anti-phospholipid antibodies (aPL) without clinical manifestations ("aPL carriers") or with obstetric manifestation not fulfilling ob-APS criteria need to be further investigated in order to assess their best management. Great interest has been given to drugs that could interact in the pathophysiological mechanisms, such as hydroxychloroquine, statins, and eculizumab. These drugs could be considered for patients refractory to conventional therapy.
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Affiliation(s)
- Maria Chiara Gerardi
- Rheumatology and Clinical Immunology Unit and Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy
| | - Melissa Alexandre Fernandes
- Autoimmune Disease Unit-Department of Internal Medicine, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit and Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit and Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy.
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26
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Bala MM, Paszek E, Lesniak W, Wloch‐Kopec D, Jasinska K, Undas A. Antiplatelet and anticoagulant agents for primary prevention of thrombosis in individuals with antiphospholipid antibodies. Cochrane Database Syst Rev 2018; 7:CD012534. [PMID: 30004572 PMCID: PMC6513409 DOI: 10.1002/14651858.cd012534.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid (aPL) antibodies that have prothrombotic activity. Antiphospholipid antibodies are associated with an increased risk of pregnancy complications (recurrent miscarriage, premature birth, intrauterine growth retardation) and thrombotic events (both arterial and venous). The most common thrombotic events include brain ischaemia (stroke or transient ischaemic attack) and deep vein thrombosis. To diagnose APS, the presence of aPL antibodies in two measurements and at least one thrombotic event or pregnancy complication are required. It is unclear if people with positive aPL antibodies but without any previous thrombotic events should receive primary antithrombotic prophylaxis. OBJECTIVES To assess the effects of antiplatelet or anticoagulant agents versus placebo or no intervention or other intervention on the development of thrombosis in people with aPL antibodies who have not had a thrombotic event. We did not address obstetric outcomes in this review as these have been thoroughly addressed by other Cochrane Reviews. SEARCH METHODS We searched the Cochrane Vascular Specialised Register (4 December 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (last search 29 November 2017), MEDLINE Ovid, Embase Ovid, CINAHL, and AMED (searched 4 December 2017), and trials registries (searched 29 November 2017). We also checked reference lists of included studies, systematic reviews, and practice guidelines, and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any antiplatelet or anticoagulant agents, or their combinations, at any dose and mode of delivery with placebo, no intervention, or other intervention. We also included RCTs that compared antiplatelet or anticoagulant agents with each other or that compared two different doses of the same drug. We included studies performed in people of any age and with no history of thrombosis (as defined by APS Sapporo classification criteria or updated Sydney classification criteria), but with aPL antibodies confirmed on at last two separate measurements. The studies included both pregnant women who tested positive for aPL antibodies and had a history of recurrent obstetric complications, as well as non-pregnancy related cases with positive screening for antibodies, in accordance with the criteria mentioned above. DATA COLLECTION AND ANALYSIS Pairs of authors independently selected studies for inclusion, extracted data, and assessed the risk of bias for the included studies and quality of evidence using GRADE. Any discrepancies were resolved through discussion or by consulting a third review author when necessary. In addition, one review author checked all the extracted numerical data. MAIN RESULTS We included nine studies involving 1044 randomised participants. The studies took place in several countries and had different funding sources. No study was at low risk of bias in all domains. We classified all included studies as at unclear or high risk of bias in two or more domains. Seven included studies focused mainly on obstetric outcomes. One study included non-pregnancy-related cases, and one study included both pregnancy-related cases and other patients with positive results for aPL antibodies. The remaining studies concerned women with aPL antibodies and a history of pregnancy failure. Four studies compared anticoagulant with or without acetylsalicylic acid (ASA) versus ASA only and observed no clear difference in thrombosis risk (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.25 to 3.77; 4 studies; 493 participants; low-quality evidence). No major bleeding was reported, but minor bleeding risk (nasal bleeding, menorrhagia) was higher in the anticoagulant with ASA group as compared with ASA alone in one study (RR 22.45, 95% CI 1.34 to 374.81; 1 study; 164 participants; low-quality evidence). In one study ASA was compared with placebo, and there were no clear differences in thrombosis (RR 5.21, 95% CI 0.63 to 42.97; 1 study; 98 participants; low-quality evidence) or minor bleeding risk between the groups (RR 3.13, 95% CI 0.34 to 29.01; 1 study; 98 participants; low-quality evidence), and no major bleeding was observed. Two studies compared ASA with low molecular weight heparin (LMWH) versus placebo or intravenous immunoglobulin (IVIG), and no thrombotic events were observed in any of the groups. Moreover, there were no clear differences in the risk of bleeding requiring transfusion (RR 9.0, 95% CI 0.49 to 164.76; 1 study; 180 participants; moderate-quality evidence) or postpartum bleeding (RR 1.30, 95% CI 0.60 to 2.81; 1 study; 180 participants; moderate-quality evidence) between the groups. Two studies compared ASA with high-dose LMWH versus ASA with low-dose LMWF or unfractionated heparin (UFH); no thrombotic events or major bleeding was reported. Mortality and quality of life data were not reported for any of the comparisons. AUTHORS' CONCLUSIONS There is insufficient evidence to demonstrate benefit or harm of using anticoagulants with or without ASA versus ASA alone in people with aPL antibodies and a history of recurrent pregnancy loss and with no such history; ASA versus placebo in people with aPL antibodies; and ASA with LMWH versus placebo or IVIG, and ASA with high-dose LMWH versus ASA with low-dose LMWH or UFH, in women with aPL antibodies and a history of recurrent pregnancy loss, for the primary prevention of thrombotic events. In a mixed population of people with a history of previous pregnancy loss and without such a history treated with anticoagulant combined with ASA, the incidence of minor bleeding (nasal bleeding, menorrhagia) was increased when compared with ASA alone. Studies that are adequately powered and that focus mainly on thrombotic events are needed to draw any firm conclusions on the primary prevention of thrombotic events in people with antiphospholipid antibodies.
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Affiliation(s)
- Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine; Department of Hygiene and Dietetics; Systematic Reviews Unit ‐ Polish Cochrane BranchKopernika 7KrakowPoland31‐034
| | - Elżbieta Paszek
- Jagiellonian University Medical CollegeDepartment of Interventional CardiologyPradnicka 80KrakowPoland
| | - Wiktoria Lesniak
- Jagiellonian University Medical College2nd Department of Internal Medicineul. Skawinska 8KrakowPoland31‐066
| | - Dorota Wloch‐Kopec
- Jagiellonian University Medical CollegeNeurology DepartmentBotaniczna 3KrakowPoland31‐503
| | - Katarzyna Jasinska
- Jagiellonian University Medical CollegeStudents' Research Group, Systematic Reviews Unit‐Polish Cochrane BranchKrakowPoland
| | - Anetta Undas
- Jagiellonian University Medical CollegeInstitute of CardiologyPradnicka 80KrakowPoland31‐202
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27
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Fredi M, Andreoli L, Aggogeri E, Bettiga E, Lazzaroni MG, Le Guern V, Lojacono A, Morel N, Piette JC, Zatti S, Costedoat-Chalumeau N, Tincani A. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol 2018; 9:864. [PMID: 29867924 PMCID: PMC5949611 DOI: 10.3389/fimmu.2018.00864] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/09/2018] [Indexed: 01/24/2023] Open
Abstract
Objective Antiphospholipid antibodies positivity (aPL) is considered as a risk factor for adverse pregnancy outcome (APO). The aim of this study was to determine the risk factors for APO in patients with confirmed aPL positivity, isolated (aPL carriers) or associated with a definite primary antiphospholipid syndrome (PAPS). Methods The clinical and laboratory features of 283 pregnancies occurring between 2000 and 2014 in 200 women were collected in three institutions. Results The rate of live birth was 87.9% and APO was observed in 50 cases (17.7%). Multivariate analysis showed that the independent variables related to APO were the concomitant diagnosis of an organ-specific autoimmune disease (p = 0.012, odds ratio (OR) 3.29, confidence interval (CI) 95% 1.29–8.38) and the presence of low complement levels during the first trimester (p = 0.02, OR 2.3, CI 95% 1.17–9.15). No statistical differences were found in APO occurrence among patients treated with low-dose aspirin (LDA) versus those treated with LDA plus heparin (LMWH), but LDA + LMWH was more frequently administered in patients with triple aPL positivity (p = 0.001, OR 3.21, CI 95% 1.48–7.11) and with PAPS (p < 0.001, OR 8.08, CI 95% 4.3–15.4). Based on clinical history, the patients were divided into four groups: obstetric, thrombotic, non-criteria antiphospholipid syndrome (clinical non-criteria), and aPL carriers. APOs were more frequent in the thrombotic group (24%). Seven patients had a thrombotic event during pregnancy or puerperium (2.4%). Conclusion Maternal and fetal complications were observed in some aPL-positive patients despite their efficient management according to the current recommendations. A higher risk of APO was observed in patients with a previous thrombosis and/or more complex autoimmune phenotype.
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Affiliation(s)
- Micaela Fredi
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elena Aggogeri
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisa Bettiga
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Véronique Le Guern
- Internal Medicine Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Andrea Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Obstetrics and Gynecology Department, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Nathalie Morel
- Internal Medicine Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Jean Charles Piette
- Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Internal Medicine Department, Pitié-Salpêtrière Hospital, Assistance Publique Hopitaux De Paris (AP-HP), Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Sonia Zatti
- Obstetrics and Gynecology Department, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Nathalie Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Internal Medicine Department, Cochin Hospital, Assistance Publique Hopitaux De Paris (AP-HP), Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France.,INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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28
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Toth B, Würfel W, Bohlmann M, Zschocke J, Rudnik-Schöneborn S, Nawroth F, Schleußner E, Rogenhofer N, Wischmann T, von Wolff M, Hancke K, von Otte S, Kuon R, Feil K, Tempfer C. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/050). Geburtshilfe Frauenheilkd 2018; 78:364-381. [PMID: 29720743 PMCID: PMC5925690 DOI: 10.1055/a-0586-4568] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Official guideline of the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (ÖGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). The aim of this guideline was to standardize the diagnosis and treatment of couples with recurrent miscarriage (RM). Recommendations were based on the current literature and the views of the involved committee members. Methods Based on the current literature, the committee members developed the statements and recommendations of this guideline in a formalized process which included DELPHI rounds and a formal consensus meeting. Recommendations Recommendations for the diagnosis and treatment of patients with RM were compiled based on the international literature. Specific established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders were taken into consideration.
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Affiliation(s)
- Bettina Toth
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | | | | | - Johannes Zschocke
- Zentrum für Medizinische Genetik, Universität Innsbruck, Innsbruck, Austria
| | | | | | | | - Nina Rogenhofer
- Klinikum der Universität München - Frauenklinik Maistraße, München, Germany
| | - Tewes Wischmann
- Institut für Medizinische Psychologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael von Wolff
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Bern, Switzerland
| | - Katharina Hancke
- Klinik für Frauenheilkunde, Universitätsklinikum Ulm, Ulm, Germany
| | - Sören von Otte
- Kinderwunschzentrum, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Ruben Kuon
- Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Katharina Feil
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Clemens Tempfer
- Universitätsfrauenklinik, Ruhr-Universität Bochum, Bochum, Germany
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29
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Bender Atik R, Christiansen OB, Elson J, Kolte AM, Lewis S, Middeldorp S, Nelen W, Peramo B, Quenby S, Vermeulen N, Goddijn M. ESHRE guideline: recurrent pregnancy loss. Hum Reprod Open 2018; 2018:hoy004. [PMID: 31486805 PMCID: PMC6276652 DOI: 10.1093/hropen/hoy004] [Citation(s) in RCA: 413] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/05/2018] [Indexed: 12/19/2022] Open
Abstract
STUDY QUESTION What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized. WHAT IS KNOWN ALREADY A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL. LIMITATIONS, REASONS FOR CAUTION Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest. ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | - Ruth Bender Atik
- Miscarriage Association, 17 Wentworth Terrace, Wakefield WF1 3QW, UK
| | - Ole Bjarne Christiansen
- Aalborg University Hospital, Department of Obstetrics and Gynaecology Aalborg, Reberbansgade 15, Aalborg 9000, Denmark.,University Hospital Copenhagen, Rigshospitalet, Recurrent Pregnancy Loss Unit Kobenhavn, Fertility Clinic 4071Blegdamsvej 9, DK 2100 Kobenhavn, Denmark
| | - Janine Elson
- CARE Fertility Group, John Webster House, 6 Lawrence Drive, Nottingham NG8 6PZ, UK
| | - Astrid Marie Kolte
- University Hospital Copenhagen, Rigshospitalet, Recurrent Pregnancy Loss Unit Kobenhavn, Fertility Clinic 4071Blegdamsvej 9, DK 2100 Kobenhavn, Denmark
| | - Sheena Lewis
- School of Medicine, Obstetrics and Gynaecology, The Queens University of Belfast, Weavers Court Business Park, Linfield Road, Belfast, Northern Ireland BT12 5GH, UK
| | - Saskia Middeldorp
- Academic Medical Center, Department of Vascular Medicine Amsterdam, Meilbergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Willianne Nelen
- Radboudumc, Department of Obstetrics and Gynaecology Nijmegen, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - Braulio Peramo
- Al Ain Fertility Clinic, Al Ain, 29 Street, Al Jimi PO Box 13844, Al Ain 13844, United Arab Emirates
| | - Siobhan Quenby
- University of Warwick, Division of Reproductive Health Clinical Science Laboratories, University Hospitals Coventry and Warwickshire, Coventry CV2 2DX, UK
| | | | - Mariëtte Goddijn
- Academic Medical Center, Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam, Meilbergdreef 9, Amsterdam 1105 AZ, The Netherlands
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Ruffatti A, Hoxha A, Favaro M, Tonello M, Colpo A, Cucchini U, Banzato A, Pengo V. Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:28-39. [PMID: 27342460 DOI: 10.1007/s12016-016-8571-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
- Reumatologia, Policlinico Universitario, Via Giustiniani, 2-35128, Padova, Italy.
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Anna Colpo
- Blood Transfusion Unit, University-Hospital of Padua, Padua, Italy
| | - Umberto Cucchini
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandra Banzato
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Vittorio Pengo
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Stefanski AL, Specker C, Fischer-Betz R, Henrich W, Schleussner E, Dörner T. Maternal Thrombophilia and Recurrent Miscarriage - Is There Evidence That Heparin is Indicated as Prophylaxis against Recurrence? Geburtshilfe Frauenheilkd 2018; 78:274-282. [PMID: 29576632 PMCID: PMC5862552 DOI: 10.1055/s-0044-100919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 12/19/2022] Open
Abstract
Background
Recurrent miscarriage, also referred to as recurrent spontaneous abortion (RSA), affects 1 – 5% of couples and has a multifactorial genesis. Acquired and congenital thrombophilia have been discussed as hemostatic risk factors in the pathogenesis of RSA.
Method
This review article was based on a selective search of the literature in PubMed. There was a special focus on the current body of evidence studying the association between RSA and antiphospholipid syndrome and hereditary thrombophilia disorders.
Results
Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia and recurrent miscarriage is one of its clinical classification criteria. The presence of lupus anticoagulant has been shown to be the most important serologic risk factor for developing complications of pregnancy. A combination of low-dose acetylsalicylic acid and heparin has shown significant benefits with regard to pregnancy outcomes and APS-related miscarriage. Some congenital thrombophilic disorders also have an increased associated risk of developing RSA, although the risk is lower than for APS. The current analysis does not sufficiently support the analogous administration of heparin as prophylaxis against miscarriage in women with congenital thrombophilia in the same way as it is used in antiphospholipid syndrome. The data on rare, combined or homozygous thrombophilias and their impact on RSA are still insufficient.
Conclusion
In contrast to antiphospholipid syndrome, the current data from studies on recurrent spontaneous abortion do not support the prophylactic administration of heparin to treat women with maternal hereditary thrombophilia in subsequent pregnancies. Nevertheless, the maternal risk of thromboembolic events must determine the indication for thrombosis prophylaxis in pregnancy.
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Affiliation(s)
- Ana-Luisa Stefanski
- Zentrum Innere Medizin, Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité Berlin, Berlin, Germany.,Rheumatologie, klinische Immunologie und Allergologie, Inselspital Universitätsspital Bern, Bern, Switzerland
| | - Christoph Specker
- Krankenhaus St. Josef, Klinik für Rheumatologie und klinische Immunologie, Universitätsklinikum Essen, Essen, Germany
| | - Rebecca Fischer-Betz
- Poliklinik für Rheumatologie, Schwangerschaftsambulanz, Heinrich-Heine-Universität Düsseldorf Medizinische Fakultät, Düsseldorf, Germany
| | | | | | - Thomas Dörner
- Zentrum Innere Medizin, Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité Berlin, Berlin, Germany
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Dobson SJA, Jayaprakasan KM. Aetiology of recurrent miscarriage and the role of adjuvant treatment in its management: a retrospective cohort review. J OBSTET GYNAECOL 2018; 38:967-974. [DOI: 10.1080/01443615.2018.1424811] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Kanna Mannadiar Jayaprakasan
- Derby Fertility Unit, Royal Derby Hospital, Derby, UK
- Division of Obstetrics and Gynaecology, The University of Nottingham, Nottingham, UK
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Khan A, Thomas M, P. K. SD. Pregnancy complicated by systemic lupus erythematosus and its outcome over 10 years. J OBSTET GYNAECOL 2018; 38:476-481. [DOI: 10.1080/01443615.2017.1381673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Asima Khan
- Department of Obstetrics and Gynecology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Mathew Thomas
- Department of Immunology and Haematology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Syamala Devi P. K.
- Department of Obstetrics and Gynecology, Kerala Institute of Medical Sciences, Trivandrum, India
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34
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Lu C, Liu Y, Jiang HL. Aspirin or heparin or both in the treatment of recurrent spontaneous abortion in women with antiphospholipid antibody syndrome: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2018; 32:1299-1311. [PMID: 29179589 DOI: 10.1080/14767058.2017.1404979] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Chang Lu
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yong Liu
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Hai-Li Jiang
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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35
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Dugalić S, Petronijević M. Complication of pregnancy as sequence of hypoxemia of uteroplacental unit. MEDICINSKI PODMLADAK 2018. [DOI: 10.5937/mp69-16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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36
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Scheres LJJ, Marijnen MC, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Luuk JJ Scheres
- Academic Medical Center; Department of Vascular Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Mauritia C Marijnen
- Academic Medical Center; Department of Vascular Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Saskia Middeldorp
- Academic Medical Center; Department of Vascular Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Navaratnam K, Alfirevic Z, Pirmohamed M, Alfirevic A. How important is aspirin adherence when evaluating effectiveness of low-dose aspirin? Eur J Obstet Gynecol Reprod Biol 2017; 219:1-9. [PMID: 29024912 DOI: 10.1016/j.ejogrb.2017.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 01/09/2023]
Abstract
Low-dose aspirin (LDA) is advocated for women at high-risk of pre-eclampsia, providing a modest, 10%, reduction in risk. Cardiology meta-analyses demonstrate 18% reduction in serious vascular events with LDA. Non-responsiveness to aspirin (sometimes termed aspirin resistance) and variable clinical effectiveness are often attributed to suboptimal adherence. The aim of this review was to identify the scope of adherence assessments in RCTs evaluating aspirin effectiveness in cardiology and obstetrics and discuss the quality of information provided by current methods. We searched MEDLINE, EMBASE and the Cochrane Library, limited to humans and English language, for RCTs evaluating aspirin in cardiology; 14/03/13-13/03/16 and pregnancy 1957-13/03/16. Search terms; 'aspirin', 'acetylsalicylic acid' appearing adjacent to 'myocardial infarction' or 'pregnancy', 'pregnant', 'obstetric' were used. 38% (25/68) of obstetric and 32% (20/62) of cardiology RCTs assessed aspirin adherence and 24% (6/25) and 29% (6/21) of obstetric and cardiology RCTs, respectively, defined acceptable adherence. Semi-quantitative methods (pill counts, medication weighing) prevailed in obstetric RCTs (93%), qualitative methods (interviews, questionnaires) were more frequent in obstetrics (67%). Two obstetric RCTs quantified serum thromboxane B2 and salicylic acid, but no quantitative methods were used in cardiology Aspirin has proven efficacy, but suboptimal adherence is widespread and difficult to accurately quantify. Little is currently known about aspirin adherence in pregnancy. RCTs evaluating aspirin effectiveness show over-reliance on qualitative adherence assessments vulnerable to inherent inaccuracies. Reliable adherence data is important to assess and optimise the clinical effectiveness of LDA. We propose that adherence should be formally assessed in future trials and that development of quantitative assessments may prove valuable for trial protocols.
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Affiliation(s)
- Kate Navaratnam
- Centre for Women's Health Research, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK.
| | - Zarko Alfirevic
- Centre for Women's Health Research, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK
| | - Munir Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Brownlow Street, Liverpool, L69 3GL, UK
| | - Ana Alfirevic
- The Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Brownlow Street, Liverpool, L69 3GL, UK
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Bala MM, Celinska‐Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2017; 10:CD012169. [PMID: 28968483 PMCID: PMC6485894 DOI: 10.1002/14651858.cd012169.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial or venous thrombosis (or both) and/or pregnancy morbidity in association with the presence of antiphospholipid antibodies. The prevalence is estimated at 40 to 50 cases per 100,000 people. The most common sites of thrombosis are cerebral arteries and deep veins of the lower limbs. People with a definite APS diagnosis have an increased lifetime risk of recurrent thrombotic events. OBJECTIVES To assess the effects of antiplatelet or anticoagulant agents, or both, for the secondary prevention of recurrent thrombosis, particularly ischemic stroke, in people with antiphospholipid syndrome. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2017), CENTRAL (last search February 2017), MEDLINE (from 1948 to February 2017), Embase (from 1980 to February 2017), and several ongoing trials registers. We also checked the reference lists of included studies, systematic reviews, and practice guidelines, and we contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated any anticoagulant or antiplatelet agent, or both, in the secondary prevention of thrombosis in people diagnosed with APS according to the criteria valid when the study took place. We did not include studies specifically addressing women with obstetrical APS. DATA COLLECTION AND ANALYSIS Pairs of review authors independently selected studies for inclusion, extracted data, and assessed the risk of bias for the included studies. We resolved any discrepancies through discussion or by consulting a third review author and, in addition, one review author checked all the extracted data. MAIN RESULTS We included five studies involving 419 randomized participants with APS. Only one study was at low risk of bias in all domains. One study was at low risk of bias in all domains for objective outcomes but not for quality of life (measured using the EQ-5D-5L questionnaire). We judged the other three studies to be at unclear or high risk of bias in three or more domains.The duration of intervention ranged from 180 days to a mean of 3.9 years. One study compared rivaroxaban (a novel oral anticoagulant: NOAC) with standard warfarin treatment and reported no thrombotic or major bleeding events, but it was not powered to detect such differences (low-quality evidence). Investigators reported similar rates of clinically relevant non-major bleeding (risk ratio (RR) 1.45, 95% confidence interval (CI) 0.25 to 8.33; moderate-quality evidence) and minor bleeding (RR 1.21, 95% CI 0.51 to 2.83) for participants receiving rivaroxaban and the standard vitamin K antagonists (VKA). This study also reported some small benefit with rivaroxaban over the standard VKA treatment in terms of quality of life health state measured at 180 days with the EQ-5D-5L 100 mm visual analogue scale (mean difference (MD) 7 mm, 95% CI 2.01 to 11.99; low-quality evidence) but not measured as health utility (MD 0.04, 95% CI -0.02 to 0.10 [on a scale from 0 to 1]).Two studies compared high dose VKA (warfarin) with moderate/standard intensity VKA and found no differences in the rates of any thrombotic events (RR 2.22, 95% CI 0.79 to 6.23) or major bleeding (RR 0.74, 95% CI 0.24 to 2.25) between the groups (low-quality evidence). Minor bleeding analyzed using the RR and any bleeding using the hazard ratio (HR) were more frequent in participants receiving high-intensity warfarin treatment compared to the standard-intensity therapy (RR 2.55, 95% CI 1.07 to 6.07; and HR 2.03, 95% CI 1.12 to 3.68; low-quality evidence).In one study, it was not possible to estimate the RR for stroke with a combination of VKA plus antiplatelet agent compared to a single antiplatelet agent, while for major bleeding, a single event occurred in the single antiplatelet agent group. In one study, comparing combined VKA plus antiplatelet agent with dual antiplatelet therapy, the RR of the risk of stroke over three years of observation was 5.00 (95% CI 0.26 to 98.0). In a single small study, the RR for stroke during one year of observation with a dual antiplatelet therapy compared to single antiplatelet drug was 0.14 (95% CI 0.01 to 2.60). AUTHORS' CONCLUSIONS There is not enough evidence for or against NOACs or for high-intensity VKA compared to the standard VKA therapy in the secondary prevention of thrombosis in people with APS. There is some evidence of harm for high-intensity VKA regarding minor and any bleeding. The evidence was also not sufficient to show benefit or harm for VKA plus antiplatelet agent or dual antiplatelet therapy compared to a single antiplatelet drug. Future studies should be adequately powered, with proper adherence to treatment, in order to evaluate the effects of anticoagulants, antiplatelets, or both, for secondary thrombosis prevention in APS. We have identified five ongoing trials mainly using NOACs in APS, so increasing experimental efforts are likely to yield additional evidence of clinical relevance in the near future.
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Affiliation(s)
- Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine; Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Magdalena Celinska‐Lowenhoff
- Jagiellonian University Medical College2nd Department of Internal Medicine, Department of Allergy and ImmunologySkawinska 8KrakowPoland31‐066
| | - Wojciech Szot
- Jagiellonian University Medical CollegeDepartment of Hygiene and DieteticsKrakowPoland
| | - Agnieszka Padjas
- Jagiellonian University Medical College2nd Department of Internal Medicine, Department of Allergy and ImmunologySkawinska 8KrakowPoland31‐066
| | - Mateusz Kaczmarczyk
- Jagiellonian University Medical CollegeSystematic Reviews Unit ‐ Polish Cochrane BranchKrakowPoland
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics, Systematic Reviews UnitKrakowPoland
| | - Anetta Undas
- Jagiellonian University Medical CollegeInstitute of CardiologyPradnicka 80KrakowPoland31‐202
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Chaturvedi S, McCrae KR. Diagnosis and management of the antiphospholipid syndrome. Blood Rev 2017; 31:406-417. [PMID: 28784423 DOI: 10.1016/j.blre.2017.07.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 06/22/2017] [Accepted: 07/28/2017] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (APLA). Laboratory diagnosis of APLA depends upon the detection of a lupus anticoagulant, which prolongs phospholipid-dependent anticoagulation tests, and/or anticardiolipin (aCL) and anti-β2-glycoprotein-1 (β2GPI) antibodies. APLA are primarily directed toward phospholipid binding proteins. Pathophysiologic mechanisms underlying thrombosis and pregnancy loss in APS include APLA induced cellular activation, inhibition of natural anticoagulant and fibrinolytic systems, and complement activation, among others. There is a high rate of recurrent thrombosis in APS, especially in triple positive patients (patients with lupus anticoagulant, aCL and anti-β2GPI antibodies), and indefinite anticoagulation with a vitamin K antagonist is the standard of care for thrombotic APS. There is currently insufficient evidence to recommend the routine use of direct oral anticoagulants (DOAC) in thrombotic APS. Aspirin with low molecular weight or unfractionated heparin may reduce the incidence of pregnancy loss in obstetric APS. Recent insights into the pathogenesis of APS have led to the identification of new potential therapeutic interventions, including anti-inflammatory and immunomodulatory therapies. Additional research is needed to better understand the effects of APLA on activation of signaling pathways in vascular cells, to identify more predictive biomarkers that define patients at greatest risk for a first or recurrent APLA-related clinical event, and to determine the safety and efficacy of DOACs and novel anti-inflammatory and immune-modulatory therapies for refractory APS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Keith R McCrae
- Department of Hematology and Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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El Hachem H, Crepaux V, May-Panloup P, Descamps P, Legendre G, Bouet PE. Recurrent pregnancy loss: current perspectives. Int J Womens Health 2017; 9:331-345. [PMID: 28553146 PMCID: PMC5440030 DOI: 10.2147/ijwh.s100817] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.
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Affiliation(s)
- Hady El Hachem
- Department of Reproductive Medicine, Ovo Clinic, Montréal, QC, Canada.,Department of Obstetrics and Gynecology, University of Montreal, Montréal, QC, Canada
| | - Vincent Crepaux
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Biology, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
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Abstract
There is biological plausibility that coagulation activation underlies a proportion of in vitro fertilisation IVF failures and recurrent early clinical pregnancy loss (RPL). However, low-molecular-weight heparin (LMWH) use, based upon previous clinical outcome alone, is not effective in preventing RPL. RPL is heterogeneous in mechanism. Identifying those with an underlying thrombotic mechanism would allow stratification for LMWH treatment. Annexin A5 is an anticoagulant protein expressed on the trophoblast surface. The annexin A5 M2 haplotype (ANXA5 M2) is associated with several placenta mediated pregnancy complications (PMPC) and poor IVF outcome. It is transmitted equally by males and females. A pragmatic observational study of IVF couples screened for M2 carriage and treated with LMWH achieved a 37.9% live birth rate, similar to an unscreened and untreated group with fewer adverse risk factors for conception and a better prognosis from assisted conception. This suggests that LMWH may counteract the adverse effects of M2 carriage. Using this biomarker to stratify IVF and PMPC patients for LMWH treatment merits further evaluation.
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Affiliation(s)
- Simon Fishel
- CARE Fertility Group, John Webster House, 6 Lawrence Drive, Nottingham, United Kingdom
| | - Deborah J Baker
- IHG Pharmaco Ltd, 20-22 Wenlock Road, London, United Kingdom.
| | - Ian A Greer
- Faculty of Biology Medicine and Health, Core Technology, Facility, University of Manchester, Manchester, United Kingdom
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Abstract
Preeclampsia (PE) is disorder of new onset hypertension and proteinuria during the second half of pregnancy. There is increasing evidence to implicate placental over-expression of tissue factor and PAR-1 in the pathophysiology of PE. Excessive activation of platelets, neutrophils and the complement system may also contribute to the placental pathology and maternal endothelial responsible for the symptoms of PE. Increased knowledge in this field may identify new therapeutic strategies for the treatment of PE.
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Affiliation(s)
- Chris Gardiner
- Haemostasis Research Unit, Department of Haematology, University College London, United Kingdom.
| | - Manu Vatish
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, United Kingdom
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43
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Cadavid AP. Aspirin: The Mechanism of Action Revisited in the Context of Pregnancy Complications. Front Immunol 2017; 8:261. [PMID: 28360907 PMCID: PMC5350130 DOI: 10.3389/fimmu.2017.00261] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/23/2017] [Indexed: 01/04/2023] Open
Abstract
Aspirin is one of the most frequently used and cheapest drugs in medicine. It belongs to the non-steroidal anti-inflammatory drugs with a wide range of pharmacological activities, including analgesic, antipyretic, and antiplatelet properties. Currently, it is accepted to prescribe a low dose of aspirin to pregnant women who are at high risk of preeclampsia (PE) because it reduces the onset of this complication. Another pregnancy alteration in which a low dose of aspirin is recommended is the obstetric antiphospholipid syndrome (APS). The most recognized mechanism of action of aspirin is to inhibit the synthesis of prostaglandins but this by itself does not explain the repertoire of anti-inflammatory effects of aspirin. Later, another mechanism was described: the induction of the production of aspirin-triggered lipoxins (ATLs) from arachidonic acid by acetylation of the enzyme cyclooxygenase-2. The availability of a stable analog of ATL has stimulated investigations on the use of this analog and it has been found that, similar to endogenously produced lipoxins, ATL resolves inflammation and acts as antioxidant and immunomodulator. If we consider that in PE and in the obstetric APS, there is an underlying inflammatory process, aspirin might be used based on the induction of ATL. The objective of this review is to revisit the old and new mechanisms of action of aspirin. In particular, it intends to show other potential uses of this drug to prevent certain pregnancy complications in the light of its ability to induce anti-inflammatory and pro-resolving lipid-derived mediators.
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Affiliation(s)
- Angela P. Cadavid
- Reproduction Group, Department of Microbiology and Parasitology, School of Medicine, University of Antioquia, Medellín, Colombia
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44
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong female predilection. Pregnancy remains a commonly encountered but high-risk situation in this setting. Both maternal and fetal mortality and morbidity are still significantly increased despite improvements in outcomes. Maternal morbidity includes higher risk of disease flares, preeclampsia and other pregnancy-related complications. Fetal issues include higher rates of preterm birth, intrauterine growth restriction, and neonatal lupus syndromes. Treatment options during pregnancy are also limited and maternal benefit has to be weighed against fetal risk. A coordinated approach, with close monitoring by a multidisciplinary team, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Hospital, National University Health System, 1E, Kent Ridge Road, Singapore 119074
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins Lupus Center, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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45
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Ormesher L, Simcox LE, Tower C, Greer IA. 'To test or not to test', the arguments for and against thrombophilia testing in obstetrics. Obstet Med 2017; 10:61-66. [PMID: 28680464 DOI: 10.1177/1753495x17695696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 01/26/2017] [Indexed: 11/16/2022] Open
Abstract
Clinicians increasingly investigate women for thrombophilias due to their associations with venous thromboembolism and placenta-mediated pregnancy complication. These associations, however, are modest and based largely on retrospective data from studies with heterogeneous classifications and populations, leading to discordance between evidence and guidelines. Current evidence suggests a contributory rather than causative role for thrombophilia in placenta-mediated pregnancy complication and venous thromboembolism. With little evidence of benefit from antithrombotic therapy in placenta-mediated pregnancy complication, thrombophilia screening remains controversial. Given the low absolute risk of placenta-mediated pregnancy complication and gestational venous thromboembolism with heritable thrombophilia, universal screening is inappropriate. Selective screening for antiphospholipid syndrome is supported by robust evidence of benefit. Conversely, selective screening for heritable thrombophilia has not been shown to effectively manage placenta-mediated pregnancy complication. Therefore, at present heritable thrombophilia screening is not warranted for placenta-mediated pregnancy complication. Until we have better evidence from better stratified patient groups, caution should remain if we wish to practice evidence-based medicine.
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Affiliation(s)
- Laura Ormesher
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK.,Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, UK
| | - Louise E Simcox
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK.,Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, UK
| | - Clare Tower
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK.,Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, UK
| | - Ian A Greer
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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46
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Bala MM, Paszek EM, Wloch-Kopec D, Lesniak W, Undas A. Antiplatelet and anticoagulant agents for primary prevention of thrombosis in individuals with antiphospholipid antibodies. Hippokratia 2017. [DOI: 10.1002/14651858.cd012534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Malgorzata M Bala
- Jagiellonian University Medical College; Department of Hygiene and Dietetics; Systematic Reviews Unit - Polish Cochrane Branch; Kopernika 7 Krakow Poland 31-034
| | - Elzbieta M Paszek
- Jagiellonian University Medical College; Department of Interventional Cardiology; Pradnicka 80 Krakow Poland
| | - Dorota Wloch-Kopec
- Jagiellonian University Medical College; Neurology Department; Botaniczna 3 Krakow Poland 31-503
| | - Wiktoria Lesniak
- Jagiellonian University Medical College; 2nd Department of Internal Medicine; ul. Skawinska 8 Krakow Poland 31-066
| | - Anetta Undas
- Jagiellonian University Medical College; Institute of Cardiology; Pradnicka 80 Krakow Poland 31-202
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47
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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48
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Shen MC, Wu WJ, Cheng PJ, Ma GC, Li WC, Liou JD, Chang CS, Lin WH, Chen M. Low-molecular-weight-heparin can benefit women with recurrent pregnancy loss and sole protein S deficiency: a historical control cohort study from Taiwan. Thromb J 2016; 14:44. [PMID: 27799851 PMCID: PMC5084381 DOI: 10.1186/s12959-016-0118-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 10/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heritable thrombophilias are assumed important etiologies for recurrent pregnancy loss. Unlike in the Caucasian populations, protein S and protein C deficiencies, instead of Factor V Lieden and Prothrombin mutations, are relatively common in the Han Chinese population. In this study we aimed to investigate the therapeutic effect of low molecular weight heparin upon women with recurrent pregnancy loss and documented protein S deficiency. METHODS During 2011-2016, 68 women with recurrent pregnancy loss (RPL) and protein S deficiency (both the free antigen and function of protein S were reduced) were initially enrolled. All the women must have experienced at least three recurrent miscarriages. After excluding those carrying balanced translocation, medical condition such as diabetes mellitus, chronic hypertension, and autoimmune disorders (including systemic lupus erythematosus and anti-phospholipid syndrome), coexisting thrombophilias other than persistent protein S deficiency (including transient low protein S level, protein C deficiency, and antithrombin III), only 51 women with RPL and sole protein S deficiency were enrolled. Initially they were prescribed low dose Aspirin (ASA: 100 mg/day) and unfortunately there were still 39 women ended up again with early pregnancy loss (12 livebirths were achieved though). Low-molecular-weight-heparin (LMWH) was given for the 39 women in a dose of 1 mg/Kg every 12 h from the day when the next clinical pregnancy was confirmed to the timing at least 24 h before delivery. The perinatal outcomes were assessed. RESULTS Of 50 treatment subjects performed for the 39 women (i.e. 11 women enrolled twice for two pregnancies), 46 singletons and one twin achieved livebirths. The successful live-birth rate in the whole series was 94 % (47/50). Nineteen livebirths delivered vaginally whereas 28 delivered by cesarean section. The cesarean delivery rate is thus 59.57 %. Emergent deliveries occurred in 3 but no postpartum hemorrhage had been noted. CONCLUSIONS Our pilot study in Taiwan, an East Asian population, indicated anti-coagulation therapy is of benefit to women with recurrent pregnancy loss who had documented sole protein S deficiency. TRIAL REGISTRATION ISRCTN64574169. Retrospectively registered 29 Jun 2016.
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Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wan-Ju Wu
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang-Gung Memorial Hospital Linkou Medical Center and Chang-Gung University, Taoyuan, Taiwan
| | - Gwo-Chin Ma
- Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Wen-Chu Li
- Department of Obstetrics and Gynecology, Puli Christian Hospital, Nantou, Taiwan
| | - Jui-Der Liou
- Department of Obstetrics and Gynecology, Taipei Chang-Gung Memorial Hospital, Taipei, Taiwan
| | - Cheng-Shyong Chang
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Hsiang Lin
- Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Ming Chen
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan.,Department of Obstetrics and Gynecology, and Department of Medical Genetics, College of Medicine, and Hospital, National Taiwan University, Taipei, Taiwan.,Department of Life Science, Tunghai University, Taichung, Taiwan
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49
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Pons-Estel GJ, Andreoli L, Scanzi F, Cervera R, Tincani A. The antiphospholipid syndrome in patients with systemic lupus erythematosus. J Autoimmun 2016; 76:10-20. [PMID: 27776934 DOI: 10.1016/j.jaut.2016.10.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 11/18/2022]
Abstract
The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the occurrence of venous and/or arterial thrombosis and pregnancy morbidity in the presence of pathogenic autoantibodies known as antiphospholipid antibodies (aPL). APS may be associated with other diseases, mainly systemic lupus erythematosus (SLE). The presence or absence of SLE might modify the clinical or serological expression of APS. Apart from the classical manifestations, APS patients with associated SLE more frequently display a clinical profile with arthralgias, arthritis, autoimmune hemolytic anemia, livedo reticularis, epilepsy, glomerular thrombosis, and myocardial infarction. The management of patients with SLE and APS/aPL should include an accurate stratification of vascular risk factors. Low dose aspirin and hydroxychloroquine should be considered as primary prophylaxis. In high risk situations, such as surgery, prolonged immobilization, and puerperium, the prophylaxis should be potentiated with low molecular weight heparin. The challenge of treating patients with a previous vascular event (secondary prophylaxis) is the choice of treatment (anti-platelet agents, anticoagulation with vitamin K antagonists or combined therapy) and its duration, based on individual risk stratification and the site of vascular presentation. The role of novel anticoagulants in APS patients is still to be clearly defined. Novel approaches are needed since the prognosis of SLE patients with APS/aPL is still worse than that of SLE patients with negative aPL. The goal for the future is to improve the outcome of these patients by means of early recognition and optimal preventative treatment.
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Affiliation(s)
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - Francesco Scanzi
- Department of Clinical and Experimental Sciences, University of Brescia, Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy.
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50
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Betts D, Smith CA, Dahlen HG. Does acupuncture have a role in the treatment of threatened miscarriage? Findings from a feasibility randomised trial and semi-structured participant interviews. BMC Pregnancy Childbirth 2016; 16:298. [PMID: 27717319 PMCID: PMC5055689 DOI: 10.1186/s12884-016-1092-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/04/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Threatened miscarriage is a common complication of early pregnancy increasing the risk of miscarriage or premature labour. Currently there is limited evidence to recommend any biomedical pharmacological or self-care management, resulting in a 'watchful waiting' approach. The objective of this study was to examine the feasibility of offering acupuncture as a therapeutic treatment for women presenting with threatened miscarriage. METHODS A mixed methods study involving a randomised controlled trial and semi structured interviews. A pragmatic acupuncture protocol including medical self-care advice was compared to an active control receiving touch intervention and medical self-care advice. Descriptive statistics were used to examine the demographic and baseline characteristics. Endpoints were analysed between groups using a mean t-test and chi-square tests with P < 0.05 considered statistically significant. Dichotomous data was expressed as Risk Ratio with 95 % confidence intervals. Eleven participants were purposively interviewed about their experiences on exiting the trial with interviews analysed using thematic analysis. RESULTS Forty women were successfully randomised. For women receiving acupuncture there was a statically significant reduction with threatened miscarriage symptoms including bleeding, cramping and back pain compared with the control (p = 0.04). Thematic analysis revealed women were dissatisfied with the medical support and advice received. An overarching theme emerged from the data of 'finding something you can do.' This encompassed the themes: 'they said there was nothing they could do,' 'feeling the benefits' and 'managing while marking time.' CONCLUSION Acupuncture was a feasible intervention and reduced threatened miscarriage symptoms when compared to a touch intervention. Further research is required to further explore acupuncture use for this common complication and whether it can reduce the incidence of miscarriage. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12610000850077 . Date of registration 12/10/2010. Retrospectively registered, with first participant enrolled 11/10/2012.
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Affiliation(s)
- Debra Betts
- National Institute of Complementary Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
- New Zealand School Acupuncture and Traditional Chinese Medicine, P.O. Box 11076, Wellington, 6142 New Zealand
| | - Caroline A. Smith
- National Institute of Complementary Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Hannah G. Dahlen
- School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
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