Catastrophic antiphospholipid syndrome related to severe ovarian hyperstimulation

Antiphospholipid antibodies and idiopathic infertility

OBJECTIVE

The aim of our study was to evaluate obstetric outcome of women affected by idiopathic infertility showing persistently positive antiphospholipid antibodies (aPL).

METHODS

: From 2000 consecutive patients undergoing ART, we selected 151 (7.55%) clinical records of patients affected by idiopathic infertility undergoing ICSI and showing positive aPL.

RESULTS

Persistently positive aPL were found in 64/151 (42.38%) of the patients: in 34/64 (53.12%) at medium/high titers (group A) and in 30/64 (46.87%) at low titers (group B). Primary or secondary antiphospholipid syndrome (APS) was diagnosed in 25% of the patients, whereas 37.5% women showed clinical and/or laboratory features suggestive of APS, but not fulfilling clinical or laboratory classification criteria. Idiopathic infertility was the sole symptom in 31.25%. In 55% of these infertile patients, a history of recurrent failures of assisted reproductive techniques (ART) was also observed. Eighty-eight percent (88.88%) of women became pregnant and 77.77% gave birth. During pregnancy, an increase of aPL values was observed in 29.41% women of group B.

CONCLUSIONS

A careful selection of patients allowed us to confirm that women affected by idiopathic infertility show a high prevalence of aPL, suggesting that these autoantibodies can also affect conception. Considering pregnancy complications and thrombotic risk related to ovarian stimulation, measuring aPL can represent a valid tool to identify among infertile women undergoing ART those at higher risk of pregnancy complications potentially life-threatening for mother and the fetus. In such patients, an accurate diagnosis and an adequate therapy are related to a better ART outcome.

Incidence, risk factors, and prognosis of abnormal liver biochemical tests in COVID-19 patients: a systematic review and meta-analysis

BACKGROUND AND AIMS

Coronavirus disease 2019 (COVID-19) pandemic is ongoing. Except for lung injury, it is possible that COVID-19 patients develop liver injury. Thus, we conducted a systematic review and meta-analysis to explore the incidence, risk factors, and prognosis of abnormal liver biochemical tests in COVID-19 patients.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases were searched. The incidence of abnormal liver biochemical tests, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), total bilirubin (TBIL), and albumin (ALB), was pooled. Risk ratio (RR) was calculated to explore the association of abnormal liver biochemical tests with severity and prognosis of COVID-19 patients.

RESULTS

Forty-five studies were included. The pooled incidence of any abnormal liver biochemical indicator at admission and during hospitalization was 27.2% and 36%, respectively. Among the abnormal liver biochemical indicators observed at admission, abnormal ALB was the most common, followed by GGT, AST, ALT, TBIL, and ALP (39.8%, 35.8%, 21.8%, 20.4%, 8.8%, and 4.7%). Among the abnormal liver biochemical indicators observed during hospitalization, abnormal ALT was more common than AST and TBIL (38.4%, 28.1%, and 23.2%). Severe and/or critical patients had a significantly higher pooled incidence of abnormal liver biochemical indicators at admission than mild and/or moderate patients. Non-survivors had a significantly higher incidence of abnormal liver biochemical indicators than survivors (RR = 1.34, p = 0.04).

CONCLUSIONS

Abnormal liver biochemical tests are common in COVID-19 patients. Liver biochemical indicators are closely related to the severity and prognosis of COVID-19 patients.

Anti-phospholipid antibodies and reproductive failures

Anti-phospholipid syndrome (APS) recapitulates the link between autoimmunity and pregnancy failure: Acquired anti-phospholipid antibodies (aPL) play a pathogenic role in pregnancy complications. The diagnosis of obstetric APS can easily be pursued when women present with laboratory and clinical features fulfilling the international classification criteria. Standard therapeutic approach to obstetric APS consists in the association of anti-platelet agents and anticoagulants. Most patients achieve a live birth thanks to conventional treatment; however, approximately 20% fail to respond and are managed with additional therapeutic tools added on the top of conventional treatment. Surely, a refinement of risk stratification tools would allow early identification of high-risk pregnancies that warrant tailored treatment. In real life, obstetricians and rheumatologists face complex diagnostic scenarios including women with pregnancy morbidities other than those mentioned in classification criteria such as one or two early losses and premature birth after 34 weeks due to preeclampsia or placental insufficiency, women with low-titer aPL not fulfilling criteria laboratory requirements, women with positive non-criteria aPL, asymptomatic aPL carriers, and infertile women found to be aPL-positive. This review focuses on some of the several unanswered questions related to diagnostic, prognostic, and therapeutic aspects in obstetric APS.

Safety of fertility treatments in women with systemic autoimmune diseases (SADs)

Introduction: Systemic Autoimmune Diseases (SADs) include systemic lupus erythematosus, antiphospholipid antibody syndrome, rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome, mixed connective tissue disease, idiopathic inflammatory myopathies and vasculitis. SADs often occur in women of childbearing age and can affect fertility. Both infertility treatments and fertility preservation techniques are thus often indicated. Areas covered: The literature regarding the safety of fertility-related drugs for both fertility preservation and infertility treatment in patients affected by SADs was reviewed. Based on current knowledge, all the options for fertility preservation should be contemplated in patients with SADs who are at risk for fertility loss, including GnRH analogue administration, oocyte/embryo vitrification and ovarian tissue cryopreservation. Similarly, if pregnancy is not contraindicated in a patient with a SAD, neither should be any fertility treatment. Expert opinion: Women with SADs should postpone conception until a stable disease has been achieved for at least 6 months. When infertility treatments are needed, women with antiphospholipid antibodies should receive concomitant anticoagulation. If in vitro fertilization/intra-cytoplasmic sperm injection and embryo transfer is required, ovarian hyperstimulation and the inherent risk of thrombosis should be eliminated by GnRH-agonist trigger and cycle segmentation. Counselling about adherence to anti-rheumatic therapy to prevent disease exacerbations is also critical.

Ovarian Hyperstimulation Syndrome and Myocardial Infarction: A Systematic Review

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a rare but serious complication of ovarian stimulation occurring during assisted reproduction technologies (ART). It is characterized by increased vascular permeability and hypercoagulable states resulting in strokes and peripheral ischemia. Acute myocardial infarction and cardiac thrombosis, however, have been rarely reported complications of OHSS.

METHODS

A literature search was performed for reports on myocardial infarction and cardiac thrombosis associated with ovarian stimulation with a summary of their clinical characteristics.

RESULTS

A total of twelve published cases were reviewed with 5 out of 12 (41.67%) of the reported cases were 35 years of age or older. Myocardial infarction was reported in 10 out of the 12 cases (83.3%). Two of the cases were pregnant at presentation (16.67%). The mean duration between starting ovarian stimulation medications and clinical presentation was 23 days. Chest pain was the most common presenting symptom (66.67%), 2 cases presented with stroke (16.67%) and 2 cases presented with abdominal distention (16.67%). A total of 8 patients underwent coronary angiography with 2 of these cases were treated with percutaneous coronary intervention. No mortality reported in any of the twelve cases.

CONCLUSION

Women of a relatively younger age undergoing ovarian stimulation may be at risk for developing myocardial infarction and cardiac thrombosis. Once thrombosis is suspected, initiating appropriate therapy in a timely manner is crucial.

The Clinical Characteristics of Acute Cerebrovascular Accidents Resulting from Ovarian Hyperstimulation Syndrome

BACKGROUND AND PURPOSE

Ovarian hyperstimulation syndrome (OHSS) is a serious complication that occurs after the ovarian-induction treatment. Acute cerebrovascular accident is one of the most dangerous manifestations of the syndrome. However, the characteristics of stroke resulting from OHSS have so far not been well summarised in any study.

METHODS

We reported 2 cases of acute cerebrovascular accidents secondary to OHSS. And then we performed a literature search for reports on this type of stroke, and summarised their characteristics.

RESULTS

Thirty-six published cases of this type of stroke were reviewed. Thirty two out of 36 (88.9%) of the women were 35 years old or younger. Stroke in 28 out of 36 (77.8%) of these cases was caused by arterial thrombosis. In 17 out of 28 cases, the involved cerebral vascular branches were mainly middle cerebral artery (MCA) and internal carotid artery (ICA). The acute cerebrovascular accidents happened 7 and 9.25 days after embryo transplantation or 8 and 8.33 days after last human chorionic gonadotropin treatment respectively. The prognosis of patients was relatively good after anticoagulation and some supportive treatments.

CONCLUSION

The MCA and ICA are easily involved in stroke resulting from OHSS. The young age may be a risk factor for developing stroke secondary to OHSS. Once thromboembolism develops, administering appropriate therapy is crucial.

[In vitro fertilization and systemic lupus erythematosus or antiphospholipid syndrome: An update]

Fertility is not impaired in systemic lupus erythematosus or antiphospholipid syndrome, but, similarly to the general population, these patients may undergo in vitro fertilization. This type of treatment increases the risk of lupus flare, thrombosis, and ovarian hyperstimulation syndrome. This review will focus on in vitro fertilization in systemic lupus erythematosus or antiphospholipid syndrome. Literature data are relatively scant with only 3 reported studies. The first one included 17 patients and 63 cycles of induction ovulation/in vitro fertilization leading to 25 % of lupus flare, no thrombosis, and 3 % of ovarian hyperstimulation syndrome. The second study included 10 patients and 40 cycles of in vitro fertilization showing 31 % of lupus flare, no thrombosis and no ovarian hyperstimulation syndrome. The last one included 34 patients and 83 procedures of in vitro fertilization leading to 8 % of flares, 5 % of thrombosis and no ovarian hyperstimulation syndrome. Interestingly, in this last study, half of the complications were explained by poor adherence to treatment. These data are reassuring but it is important to remember that in vitro fertilization should be scheduled and carefully supervised in the same way as the high-risk pregnancies occurring in these patients.

[Cerebral infarction after ovarian hyperstimulation in the era of thrombolysis]

Ischemic stroke is a very rare complication but classic ovarian hyperstimulation. We report the cases of three young women aged 35, 37 and 27 years. All three were victims of ischemic formed by proximal occlusion of the middle cerebral artery secondary to ovarian hyperstimulation. The first and the third had a proximal occlusion of the right middle cerebral artery occlusion and the second of the left middle cerebral artery. The last two have benefited from a patient intravenous thrombolysis. The first patient did not receive thrombolysis because it was out of time. Against by their evolution was different. The first has almost recovered its deficit, the second sequelae quite heavy after craniectomy and the third died despite her craniectomy.

Massive cerebrovascular infarct due to the catastrophic antiphospholipid syndrome in a patient with idiopathic thrombocytopenic purpura

Catastrophic antiphospholipid syndrome (APS) is caused by thrombotic vascular occlusions that affect both small and large vessels, producing ischemia in the affected organs as well as a systemic inflammatory response syndrome (SIRS). We report a case of a patient with idiopathic thrombocytopenic purpura (ITP) who developed massive cerebral ischemia due to this entity. Prompt and aggressive treatment may prevent and actually resolve lethal complications caused by this devastating syndrome.

Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome

OBJECTIVE

To review the current evidence regarding the relationship between systemic lupus erythematosus (SLE) and antiphospholipid syndrome and female infertility, as well as the risks associated with ovarian stimulation for ovulation induction and IVF. To establish, based on this information, guidelines for safe and successful assisted reproductive technology (ART).

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULT(S)

Systemic lupus erythematosus and antiphospholipid syndrome are not related to infertility, except for cases of amenorrhea accompanying severe flares, renal insufficiency-related hypofertility, and ovarian failure secondary to cyclophosphamide (CTX) therapy. The most threatening conditions in affected women undergoing ovarian stimulation are lupus flares and thrombosis, with the latter being especially associated with the occurrence of an overt ovarian hyperstimulation syndrome (OHSS). Friendly ovarian stimulation, single embryo transfer, avoidance of OHSS, administration of coadjuvant therapy, and use of natural E(2) or P through a nonoral route may constitute the safest approach. Systemic lupus manifested in acute flares, badly controlled arterial hypertension, pulmonary hypertension, advanced renal disease, severe valvulopathy or heart disease, and major previous thrombotic events are situations on which to discourage ART, especially due to the high risk of complications for both mother and fetus during pregnancy and puerperium.

CONCLUSION(S)

Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well-selected women with SLE and antiphospholipid syndrome.

Arterial thrombosis in young women after ovarian stimulation: case report and review of the literature

Both venous and arterial thrombosis have been described in women after ovarian stimulation and/or hyperstimulation for infertility management. The ratio between venous and arterial thrombosis in this condition is about 2 or 3 to 1, contrary to what seen during pregnancy or oral contraception where it is 5 or 10 to 1. An accurate perusal of the literature and of personal files has yielded 34 cases of arterial thrombosis after assisted reproductive technologies (ART) which entailed ovarian stimulation. There were 15 cases of ischemic strokes; 7 cases of carotid and/or vertebral artery occlusion; 6 of aorta and peripheral vessel thrombosis, 2 of mesenteric artery occlusion, 3 with myocardial infarction and 2 with intracardiac thrombosis. Associated risk factors were as follow: smoking in 4 women; antiphospholipid antibodies in 2; decrease in protein S in 1. Furthermore, polycystic ovaries were present in two women. Ovarian hyperstimulation was obtained with several protocols which included human chorionic gonadotropin (HCG) in all but a few instances. Age of women varied between 22 and 41 with an average of 32. Nineteen women were pregnant at the time of thrombosis. Only seven of these 19 pregnancies were brought to term with fetal survival. Abortion was spontaneous in 5 cases and therapeutic in the additional 7. There were two maternal fatalities.