Antinuclear antibodies in sera of patients with recurrent pregnancy wastage

Antinuclear antibodies positivity in women in reproductive age: From infertility to adverse obstetrical outcomes - A meta-analysis

This systematic review and meta-analysis were designed to identify possible correlations between isolated serum antinuclear antibody (ANA) and (i) infertility in the context of in-vitro fertilization (IVF), (ii) idiopathic recurrent pregnancy losses (RPL), and (iii) second/ third trimester pregnancy complications. We performed a systematic review and meta-analysis of the literature in PubMed Library database from inception to March 2022 following PRISMA guidelines. Our pooled results showed a lower pregnancy rate among ANA-positive women undergoing IVF/ICSI compared to ANA-negative women undergoing the same procedures (279/908 versus 1136/2347, random effect, odds ratio -OR- 0.50, 95% confidence interval -CI- 0.38-0.67, p 0.00001, I² = 58%). We also reported a higher miscarriage rate among ANA-positive compared to ANA-negative women (48/223 versus 109/999, random effect, OR: 3.25 95% CI: 1.57-6.76, p = 0.002, I² = 61%) and a lower implantation rate (320/1489 versus 1437/4205, random effect, OR: 0.51, 95% CI: 0.36-0.72, p = 0.0001, I² = 78%). Regarding RPL, pooled results demonstrated a higher prevalence of ANA-positivity in RPL women compared to controls (698/2947 versus 240/3145, random effect, OR: 3.22, 95% CI: 2.12-4.88, p 0.00001, I² 77%), either using > 2 or > 3 pregnancy losses threshold for defining RPL. Heterogeneity of reporting outcome did not allow a quantitative analysis and led to no clear demonstration of an effect of serum ANA on the incidence of stillbirth, preeclampsia and hypertensive disorders. In conclusion, the unfavorable effect of serum ANA was observed in women following IVF. Similarly, ANA were associated with the risk of RPL, while data were unconclusive in terms of late pregnancy complications.

Intravenous immunoglobulins improve live birth rate among women with underlying immune conditions and recurrent pregnancy loss: a systematic review and meta-analysis

Intravenous immunoglobulin (IVIG) is increasingly used as a treatment for recurrent pregnancy loss (RPL) despite lack of clear evidence on efficacy. Recent data suggest IVIG might be more effective in a subgroup of women with an aberrant immunological profile. Therefore, a systematic review and meta-analysis of studies on the effectiveness of IVIG treatment on pregnancy outcome among women with RPL and underlying immunological conditions (e.g., elevated NK cell percentage, elevated Th1/Th2 ratio, diagnosis with autoimmune disorders) was conducted. Eight non-randomized controlled trials, including 478 women (intervention: 284; control: 194), met eligibility criteria. Meta-analysis showed that treatment with IVIG was associated with a two-fold increase in live birth rate (RR 1.98, 95% CI 1.44–2.73, P < 0.0001). The effect of IVIG was particularly marked in the subgroup of studies including patients based on presence of elevated (> 12%) NK-cell percentage (RR 2.32, 95% CI 1.77–3.02, P < 0.0001) and when starting intervention prior to or during cycle of conception (RR 4.47, 95% CI 1.53–13.05, P = 0.006). In conclusion, treatment with IVIG may improve live birth rate in women with RPL and underlying immune conditions. However, these results should be interpreted with caution as studies are limited by low number of participants and the non-randomized design, which represent seriously biases. Future randomized controlled trials in women with RPL and underlying immune conditions are needed before using IVIG in a clinical setting.

Interplay of immune components and their association with recurrent pregnancy loss

Maintenance and progression of pregnancy is an intricate process governed by a variety of developmental cues. Recurrent pregnancy loss (RPL) is a complication experienced by expecting mothers that is defined as three or more consecutive pregnancy losses. This review focuses on the dysfunctions of the immune system as one of the key contributors towards RPL. The current data suggests that the alloimmune and autoimmune factors contribute to the loss of fetus. Such causes despite being recognized as a definitive reason for recurrent pregnancy loss, are still under extensive investigation with new parameters being discovered and scrutinized for their association with RPLs. More in-depth and high throughput studies are required for devising better diagnostic tools and management strategies for the affected female so that they can carry their pregnancy to term.

Antinuclear antibodies positivity is a risk factor of recurrent pregnancy loss: A meta-analysis

OBJECTIVE

Immunologic mechanisms have been proposed as part of the pathogenesis mechanisms involved in recurrent pregnancy loss (RPL). Presence of positive antinuclear antibodies (ANA) is regarded as a typical feature of autoimmunity. Many studies had tried to clarify the association of ANA with RPL, but the conclusions were controversial. The aim of this meta-analysis was to assess whether ANA was positively associated with increased RPL risk.

METHODS

We searched PubMed and Embase databases for relevant literatures on the association between ANA positivity and RPL. The odds ratios (OR) with 95% confidence intervals (95%CI) were pooled using meta-analysis, and either fixed-effect or random-effect model was used based on heterogeneity across the included studies.

RESULTS

Twenty-one studies with 5038 participants (including 2683 RPL patients and 2355 controls) met the inclusion criteria were included. The total positive rate of ANA was 22.0% (591/2683) in RPL group, and 8.3% (196/2355) in the control group. RPL patients had a significantly higher ANA positive rate than controls (OR = 2.97, 95%CI 1.91-4.64, P<0.00001; I² = 75%), and a significant association between positive ANA and unexplained RPL was also observed (OR = 3.27, 95%CI 2.01-5.31, P<0.00001; I² = 70%). ANA positivity was also significantly associated with increased risk of RPL in women without defined autoimmune diseases (OR = 2.23, 95%CI 1.40-3.55, P=0.0007). Subgroup analysis demonstrated low titers of ANA (1:40≤ANA≤1: 80) were not associated with RPL (OR = 2.44, 95%CI 0.42-14.06, P=0.32), while higher ANA titer (≥1:160) had a significant association with RPL (OR = 45.89, 95%CI 8.44-249.45, P<0.00001). A higher rate of homogenous pattern in RPL patients was observed (OR = 4.89, 95%CI 2.20-10.87, P<0.001), and no significant difference in speckled pattern or nucleolar pattern was found.

CONCLUSIONS

This study demonstrated that ANA positivity was positively associated with increased RPL risk. ANA positivity is an important risk factor for RPL which needed to be screened among women with RPL.

Do different IgG repertoires play a role in B- and T-cell functional modulation during ontogeny? The "hooks without bait" theory

The mechanisms by which immunoglobulin (Ig)G can modulate immunity have been investigated over the past few decades. In the past three years, some studies have demonstrated that IgG can play a pivotal role in mediating complex interactions that result in functional lymphocyte modulation during maturation in self or offspring primary lymphoid organs. This effect appears to be dependent on the IgG repertoire in the absence of the influence of antigens and the functionality of diverse cell populations, including B, αβT (CD4 T and CD8 T), invariant natural killer T and γδT cells, in mice and humans. Based on the literature, especially on findings resulting from the therapeutic use of purified IgG (intravenous Ig) and recent pieces of evidence obtained by my group, the "hooks without bait" theory is described here to guide the future development of therapies for specific immune regulation.

Antinuclear antibodies and recurrent miscarriage: Systematic review and meta-analysis

Studies have investigated the relationship between antinuclear antibodies (ANA) and recurrent miscarriage (RM). The objective of this paper is to evaluate the presence of ANA as a risk factor for spontaneous abortion in patients with RM. By considering the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis, the authors performed systematic review and meta-analysis by searching the databases of PubMed/Medline and SCOPUS. Review Manager, Version 5.3 performed the statistical analysis. Binary variables were analyzed by odds ratio (ORs) and 95% confidence interval (CI). The subgroup analysis compared the effect of different ANA titers. The authors analyzed the ANA patterns of immunofluorescence staining. Seven case-control studies were selected. The frequency of positive ANA was statistically higher in the RM group (20.6%, 288/1400) as compared to the control group (6.7%, 72/1080). The meta-analysis of the positive ANA showed a statistical difference between the two groups (OR 3.30, 95% CI 1.41-7.73; I²  = 87%, P = .006). Studies have revealed different frequencies of ANA patterns of immunofluorescence. This meta-analysis suggested that positive ANA might increase the risk of RM. However, it was not possible to conclude which ANA pattern of immunofluorescence staining is more frequent in the RM group.

Autoimmune Regulator is required in female mice for optimal embryonic development and implantation†

Autoimmune Regulator (AIRE) regulates central immune tolerance by inducing expression of tissue-restricted antigens in thymic medullary epithelial cells, thereby ensuring elimination of autoreactive T cells. Aire mutations in humans and targeted Aire deletion in mice result in multiorgan autoimmune disease, known in humans as autoimmune polyglandular syndrome type 1 (APS-1). APS-1 is characterized by the presence of adrenal insufficiency, chronic mucosal candidiasis, and/or hypoparathyroidism. Additionally, females often present with gonadal insufficiency and infertility. Aire-deficiency (KO) in mice results in oophoritis and age-dependent depletion of follicular reserves. Here, we found that while the majority of young 6-week-old Aire-KO females had normal follicular reserves, mating behavior, and ovulation rates, 50% of females experienced embryonic loss between gestation day (GD) 5.5 and 7.5 that could not be attributed to insufficient progesterone production or decidualization. The quality of GD0.5 embryos recovered from Aire KO mice was reduced, and when cultured in vitro, embryos displayed limited developmental capacity in comparison to those recovered from wild-type (WT) mice. Further, embryos flushed from Aire KO dams at GD3.5 were developmentally delayed in comparison to WT controls and had reduced trophoblastic outgrowth in vitro. We conclude that AIRE does not play a direct role in uterine decidualization. Rather, reduced fertility of Aire-deficient females is likely due to multiple factors, including oophoritis, delayed preimplantation development, and compromised implantation. These effects may be explained by autoimmune targeting of the ovary, embryo, or both. Alternatively, altered embryonic development could be due to a direct role for AIRE in early embryogenesis.

Modulatory effect of intravenous immunoglobulin on Th17/Treg cell balance in women with unexplained recurrent spontaneous abortion

Recurrent spontaneous abortion (RSA) is a growing problem worldwide. In a majority of cases, the cause remains unknown but there is increasing evidence that immunologic factors play an important role. Intravenous immunoglobulin (IVIg) therapy has been proposed to have immune modulatory effects and therefore been applicable for the treatment of patients with RSA. Although its efficacy is still controversial, several recent studies suggest that IVIg treatment may improve pregnancy outcomes. CD4⁺ T cells and their related cytokines play an important role in maternal-fetal immune regulation, and an imbalance of Th17/Treg cell ratio has been proposed as a cause for RSA. We review the scientific evidence supporting a modulatory effect of IVIg on Th17/Treg cell balance and discuss the potential mechanisms how IVIg might enhance Treg cells function. We propose that correction of Th17/Treg cell dysregulation could be one of the mechanisms that can explain the positive therapeutic effects of IVIg therapy. Consequently, selecting patients with abnormal Th17/Treg cell ratios could increase the success of IVIg therapy.

Allergen-specific IgG as a mediator of allergy inhibition: Lessons from mother to child

Allergen-specific IgG produced by immune mothers is associated with less predisposition to allergy development in their children. This finding has been described by several groups over the last few decades, but the mechanisms by which maternal IgG can inhibit allergy development are still not fully understood. With the purpose of summarizing past investigations, we review the literature on murine models of maternal immunization with allergens and on immune regulation in humans after passive therapy with purified IgG. Based on our review, a new hypothesis about these mechanisms is presented, which may provide a foundation for the future development of therapies to inhibit allergy development.

The effect of intravenous immunoglobulin passive immunotherapy on unexplained recurrent spontaneous abortion: a meta-analysis

The aim of this study was to investigate the effect of passive immunotherapy using intravenous immunoglobulin (IVIG) on unexplained recurrent spontaneous abortion (RSA). Live birth rates were analysed and binary data were calculated using risk ratio and 95% confidence interval. Meta-analysis of 11 studies showed that the difference in the live birth rate between the IVIG treatment and placebo groups was on the margin of significance (RR = 1.25, 95% CI 1.00 to 1.56, P = 0.05). Both cumulative and trial sequential meta-analyses indicated potential beneficial effect of IVIG but the evidence was inconclusive. Subgroup analysis showed that the live birth rate in primary (RR = 0.88, 95% CI 0.71 to 1.07) and secondary (RR = 1.26, 95% CI 0.99 to 1.61) RSA patients was not significantly different between the IVIG and placebo groups. Live birth rate was significantly different when IVIG was administered before conception (RR = 1.67, 95% CI 1.30 to 2.14, P < 0.0001) but not after implantation (RR = 1.10, 95% CI 0.93 to 1.29). Evidence is insufficient to support the beneficial effects of IVIG on an unexplained RSA. Further high quality studies are needed to elucidate the effectiveness of IVIG.

Uterine blood flow indices, antinuclear autoantibodies and unexplained recurrent miscarriage

OBJECTIVE

To study the correlation between 2D and 3D uterine flow indexes and the presence or the absence of antinuclear antibodies (ANA) in women with unexplained recurrent miscarriage (uRM).

METHODS

Fifty-two subjects (26 uRM and 26 control women) underwent 2D Doppler measurement of pulsatility index and resistance index of the uterine arteries in both the follicular and midluteal phase of the cycle. Additionally, 3D ultrasonography determination of vascularisation index, flow index, and vascularisation flow index was carried out with the aid of the VOCAL technique. Serum assay for the presence of ANA was performed in all women.

RESULTS

Pulsatility index of ANA+ uRM women was higher than that of ANA- uRM women and control ANA+ and ANAwomen, both in the follicular and in the midluteal phase of the cycle. Vascularisation index in ANA- uRM women was significantly higher than that in ANA+ control women. Flow index in uRM ANA+ women was significantly lower than that of each of the other groups.

CONCLUSION

ANA might be involved in uRM by determining an impairment in uterine blood flow hemodynamic, particularly in uterine blood flow intensity and uterine artery impedance.

Does the presence of autoantibodies without autoimmune diseases and hereditary thrombophilia have an effect on recurrent pregnancy loss?

OBJECTIVE

To assess whether the presence of autoantibodies has any effect on recurrent pregnancy loss (RPL) and obstetric complications in women who do not have autoimmune diseases and hereditary thrombophilia.

METHODS

Retrospectively, 515 patients who underwent antibody investigation with anti-nuclear antibody, extractable nuclear antigen, anti-double stranded DNA, anti-parietal cell, anti-smooth muscle, anti-mitochondrial (AMA), anti-thyroid peroxidase, anti-thyroglobulin (anti-TG) and anti-phospholipid (aPL) at Hacettepe University were included. Of those patients, 212 had one or more autoantibodies whereas the remaining 303 were negative for all autoantibodies. RPL was the primary outcome and was defined as ≥2 pregnancy losses (n = 119).

RESULTS

The frequency of RPL was significantly higher in the autoantibody positive group than controls (28.3% versus 14.5%, p<0.001). Anti-TG (21.2% versus 7.8%, p < 0.001), aPL (18.3% versus 5.6%, p < 0.001) and AMA (4.8% versus 0.5%, p = 0.001) antibodies were more common in patients with RPL. For the view of obstetric complications, oligohydramniosis (3.8% versus 0.7%, p = 0.03) and stillbirth (17.0% versus 10.6%, p = 0.002) were significantly higher in the autoantibody-positive group.

CONCLUSIONS

Even in women without autoimmune disease or hereditary thrombophilia, autoantibodies per se might directly increase the risk of RPL and obstetric complications. The screening anti-TG and aPL autoantibodies in the first step might be considered in patients with RPL.

The effects of immunotherapy with intravenous immunoglobulins versus no intervention, placebo, or usual care in patients with recurrent miscarriages: a protocol for a systematic review with meta-analyses, trial sequential analyses, and individual patient data meta-analyses of randomised clinical trials

BACKGROUND

Recurrent miscarriage is generally defined as three or more miscarriages before gestational week 20. Recurrent miscarriage affects 1% of all women and the condition can only be explained by parental chromosome abnormalities, uterine malformations, or endocrine or thrombophilic disturbances to a limited extent. Immunological disturbances are hypothesised to play an important role in recurrent miscarriage and, therefore, various types of immunologically-based therapies have been tested in recurrent miscarriage patients including intravenous immunoglobulins. So far, at least eight randomised placebo-controlled trials, with opposing results, investigating intravenous immunoglobulins with a total of 324 recurrent miscarriage patients have been published.

METHODS/DESIGN

We will include randomised clinical trials irrespective of publication date, publication type, publication language, and publication status investigating infusions with immunoglobulins in relation to pregnancy compared to placebo, no intervention, or treatment as usual for assessments of benefits and harms. The relevant published literature will be searched using the following databases: Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, and Ovid Medline In-Process and Other Non-Indexed Citations databases. Two review authors will independently extract data and assess risk of bias. We will undertake meta-analyses according to the recommendations stated in the Cochrane Handbook for Systematic Reviews of Interventions. Further, we will conduct trial sequential analyses and individual patient data meta-analyses.

DISCUSSION

A miscarriage results in great sorrow, loss of life quality, and personal concern. In particular, recurrent miscarriage is extremely stressful and burdensome. It is, therefore, very important to conduct research in this area. There is currently no evidence-based treatment for women with recurrent miscarriage which significantly improves their ability to give live birth. Therefore, a comprehensive up-to-date systematic review is needed. By using individual patient data, it will be possible to provide new knowledge about the benefits and harms of intravenous immunoglobulins and try to identify the subgroup in which the treatment will have the highest impact.This systematic review protocol was registered within the International Prospective Register of Systematic Reviews (PROSPERO) as number CRD42014007112.

Autoantibody profile and other immunological parameters in recurrent spontaneous abortion patients

BACKGROUND

An autoimmune cause and related immunological alterations resulting in recurrent spontaneous abortion (RSA) have been suggested in patients with unknown etiology.

MATERIALS AND METHODS

This study evaluated the autoantibody profile and other immunological parameters among RSA patients and normal pregnant women from Mumbai western India. Fifty RSA patients with unknown cause and greater than three consecutive abortions along with 50 normal pregnant women were studied for various auto antibodies such as ANA, anti-dsDNA, ANCA, AECA, 2 micro globulin, anti-HLA antibodies and ACLA using immunofluorescence microlymphocytotoxicity and ELISA. Immunological parameters such as HLA class I monoclonal antibody expression, CD3 (T cell), CD19 (B cell), and CD56 (NK cell) were estimated by flow cytometry.

RESULTS

The results revealed 34% positivity of all auto antibodies tested among patients. ANA(12%), ANCA (20%), AECA (24%), ACLA (8%), anti-dsDNA(0%), β2 microglobulin (14%), and anti-HLA antibodies(10%) among RSA patients were identified. An increased expression of HLA class I specific monoclonal antibody (10%) with HLA A3 (16%) specificity were found to correlate with shared HLA alleles among the RSA couples. Among normal pregnant (control) group ANA (2%), ANCA (2%), AECA (3%), ACLA (4%) and increased expression of CD56 with reduced HLA class I monoclonal were observed.

CONCLUSION

Our findings suggest a possible role of various autoantibodies along with the related immunological parameters underlying RSA.

Antinuclear autoantibodies in women with recurrent pregnancy loss

PROBLEM

To investigate the possibility that antinuclear antibodies (ANA) are involved in recurrent pregnancy loss (RPL).

METHODS

Case-control study carried out on 294 women (194 cases and 100 controls) in two University hospitals. The presence, the serum titers and the indirect immunofluorescence (IIF) patterns of ANA were determined in women with RPL and in control women.

RESULTS

Antinuclear antibodies at titers ≥ 1:80 were detected in 97 (50%) women with RPL and in 16 (16%) control women. Elevated ANA titers (≥1:180) were detected only in RPL women, whereas all control women had ANA titers no greater than 1:80. No differences could be detected in the IIF patterns between RPL and control women. No differences in ANA positivity could be detected according to the type (primary or secondary) or number (>2 versus ≥3) of losses.

CONCLUSIONS

ANA could be of some value in identifying women with RPL with potential, although still not fully defined, immune abnormalities.

Evidence-based investigations and treatments of recurrent pregnancy loss

PURPOSE OF REVIEW

The majority of investigations and treatments offered to women with recurrent pregnancy loss are not evidence-based. In this review a critical analysis is given of the current management of recurrent pregnancy loss often recommended in meta-analyses and guidelines.

RECENT FINDINGS

Our knowledge of genetic, endocrine, thrombophilic and immunological causes of recurrent pregnancy loss has been improved significantly, primarily by the introduction of modern laboratory techniques. Most clinical trials in this area, however, are still subject to serious methodological flaws.

SUMMARY

At present, the clinician must base their clinical practice on the few high-quality observational studies and intervention trials available rather than on meta-analyses, as there is a scarcity of good clinical trials. More high-quality clinical studies are urgently needed in this area.

Update on Treatment of Immunologic Abortion with Low-dose Intravenous Immunoglobulin

PROBLEM

Recurrent spontaneous abortion associated with immunologic abnormalities has been termed immunologic abortion. Previously we showed that treatment with low-dose intravenous immunoglobulin (IVIG) appears to be beneficial for older women with immunologic abortion. We now report the results of IVIG treatment in a larger group of women with this disorder.

METHOD OF STUDY

A total of 99 women were prospectively evaluated for immunologic abortion, which was defined as three or more miscarriages and the presence of specific immunologic abnormalities. Prior to the next conception, patients were treated with IVIG at a dose of 0.2 g/kg. Once conception was achieved, IVIG treatment was continued on a monthly basis through 26-30 weeks of pregnancy.

RESULTS

The average age of the women was 37 years (range: 28-49), and the average number of miscarriages was 3.8 (range: 3-12). Of the 99 women, 72 received initial IVIG treatment, and 50 subsequently became pregnant. Of these women, 42 (84%) had a successful term pregnancy. Of the 27 women who refused IVIG therapy, 20 became pregnant and 18 (90%) miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P = 0.001). Four women had mild allergic reactions during IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed.

CONCLUSION

We conclude that low-dose IVIG therapy is safe and effective for older women with immunologic abortion.

Impact of the sex of first child on the prognosis in secondary recurrent miscarriage

BACKGROUND

The carriage of a male fetus often initiates maternal immunological reactions against male-specific minor histocompatibility (HY) antigens, which, in theory, could result in subsequent recurrent miscarriage (RM).

METHODS

Information about subsequent pregnancy outcome was procured among 182 women with RM after a birth (secondary RM) referred since 1986 using questionnaires, telephone interviews and registers.

RESULTS

Significantly more of the women had had a male first-born as compared with a female first-born (110 versus 72; P < 0.02). By January 2002, 58% of those who had a male first-born had given birth to a second live infant compared with 76% of those who previously had had a female first-born (P = 0.01). Women in the former group had a significantly lower chance of having a second child than those in the latter (adjusted hazard ratio 0.59; 95% confidence interval 0.41-0.86). The number of miscarriages after admission and the risk of secondary infertility were significantly greater in women with a male first-born than among those with a female first-born (P < 0.001 and P = 0.02; respectively).

CONCLUSIONS

A male first-born seems to be associated with a less favourable reproductive potential among women with secondary RM. Maternal immunization against HY antigens may be responsible for these findings.

Active or passive immunization in unexplained recurrent miscarriage

Controversy exists as to whether active immunotherapy with allogeneic lymphocyte transfusions (ALT) or passive immunotherapy with intravenous immunoglobulin (IvIg) improve the chance of live birth in women with unexplained recurrent miscarriages (RM). Meta-analyses of the placebo-controlled trials carried out as Cochrane reviews have concluded than none of the different forms of immunotherapy has proved effective in the total RM population. However, the included trials have generally been small and very heterogenous with respect to the clinical histories of patients and the immunization protocols. Thus, other meta-analyses which have looked at the efficacy in subgroups of RM patients have reported that ALT and IvIg may be effective in women with primary RM and secondary RM, respectively. In RM clinics in Denmark, ALT with donor lymphocytes or IvIg immunotherapy have been tested in several placebo-controlled trials since 1986 in which greater doses than used in other trials have been administered, and both treatments are now used for routine therapy. Our results have convinced us that using the correct immunization protocols on the right subsets of RM patients is effective, but we admit that new placebo-controlled trials focusing on subsets of RM patients are now urgently needed. Furthermore, treated patients should be extensively monitored for changes in a series of immune parameters that may predict pregnancy success and be of importance for our understanding of the mechanisms of action of immunotherapy in RM.

[Antiphospholipid antibodies evolving into connective tissue disease: follow-up study of women with recurrent misscarriage]

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the clinical and immunologic profile, the rate of progression to connective tissue disease and the possible predictors of evolution in patients with antiphospholipid antibodies and abortions.

PATIENTS AND METHOD

In a prospective follow-up study, we determined the prevalence of antiphospholipid antibodies as well as other autoimmune abnormalities and the evolution to connective tissue disease in 200 women with unexplained recurrent abortions. IgG and IgM anticardiolipin antibodies were determined by ELISA and the lupus anticoagulant was determined by means of coagulometric tests.

RESULTS

Of 200 women with pregnancy losses, 69 (34.5%) had antiphospholipid antibodies. Thirty-one of 200 women (15.5%) had high or moderate positive anticardiolipin antibodies. During a mean follow-up of 32 months, 9 (13%) antiphospholipid-antibody-positive patients developed features of lupus- like disease or systemic lupus erythematosus. A low total hemolytic complement, increased circulating immune complexes and positive antinuclear antibodies (ANA) were more common in those patients evolving to a connective tissue disorder (p < 0.001, p = 0.003 and p < 0.001, respectively). Positive ANA in women with antiphospholipid antibodies predicted independently the evolution to a connective tissue disorder [Cox proportional hazard model; relative hazard = 4.92, p = 0.04].

CONCLUSIONS

A subgroup of patients with antiphospholipid antibodies and abortions may progress to a connective tissue disorder. A positive antinuclear antibody test result could be useful to identify those patients with antiphospholipid antibodies and abortions who are prone to evolve into a systemic autoimmune disease.

Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin

OBJECTIVE

To evaluate the efficacy of low-dose intravenous immunoglobulin (IVIG) treatment in older women with immunologic abnormalities and recurrent spontaneous abortion (RSA), a condition referred to as immunologic abortion.

DESIGN

Prospective clinical trial.

SETTING

Outpatient referral practice.

PATIENT(S)

Forty-seven women were enrolled in the study. The mean age of the women was 37 years (range, 28-45 years), and the mean number of prior miscarriages was 3.7. Immunologic abnormalities included antiphospholipid antibodies (32%), antithyroid antibodies (53%), antinuclear antibodies (28%), antiovarian antibodies (2%), increased natural killer cells (40%), increased immunoglobulin (Ig)M level (28%), and increased CD4/CD8 T-cell ratio (15%). One patient had IgA deficiency, and three women had endometriosis. Thirty-one of the 47 patients (66%) had more than one immunologic abnormality.

INTERVENTION(S)

Treatment with IVIG at a dose of 0.2 g/kg within 2 weeks of attempted conception. Once conception was achieved, IVIG treatment was continued on a monthly basis at the same dose through 26-30 weeks of gestation.

MAIN OUTCOME MEASURE(S)

Successful pregnancy or recurrent abortion.

RESULT(S)

Of the 47 women, 36 received initial IVIG treatment, and 24 subsequently became pregnant. Of these women, 20 continued IVIG treatment through 26-30 weeks of gestation, and 19 (95%) had a successful term pregnancy. Four women discontinued IVIG therapy after 10-12 weeks of gestation, and 3 (75%) had a successful pregnancy outcome. Of the 11 women who refused IVIG therapy, 7 became pregnant, and all 7 miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P=.001). Three women had adverse reactions during the low-dose IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed.

CONCLUSION(S)

Low-dose IVIG therapy is beneficial for older women with immunologic abortion. The optimum duration of IVIG treatment in these women requires further study.

Antineutrophil cytoplasmic antibodies and other immunologic abnormalities in patients with habitual abortion

PROBLEM

The immunologic mechanisms of pregnancy loss in habitual aborters with antiphospholipid and antinuclear antibodies have not been fully clarified. The possible association of antineutrophil cytoplasmic antibodies (ANCAs) with recurrent miscarriage was examined.

METHOD OF STUDY

In a prospective, controlled trial of 59 women with recurrent abortion, the prevalence of pANCA (antimyeloperoxidase), cANCA (antiproteinase-3), and immunoserologic abnormalities of systemic lupus erythematosus (SLE) anti double-stranded DNA, anti-SSA, anti-SSB, anti-U1RNP, anti-Sm, anticardiolipin and antinuclear antibodies, LE-cell, lupus anticoagulant, and complement-3 were investigated.

RESULTS

pANCA occurred in 2, and cANCA in 6 of 59 case patients, but neither was observed in the controls (P = 0.09 for cANCA). cANCA levels were significantly higher in patients than in controls (P = 0.028). Six recurrent aborters were identified as having a group of immunoserologic abnormalities characteristic of SLE.

CONCLUSIONS

Immunologic mechanisms detectable in SLE may operate in a subgroup of habitual aborters with suspected immunologic cause. ANCAs occur more frequently in patients with recurrent miscarriage than in controls.

Prevalence of autoantibodies in patients with recurrent miscarriages

PROBLEM

It is well known that the prevalence of several autoantibodies is higher in patients with recurrent miscarriages than in normal women. However, links between individual autoantibodies are unclear. The present study focuses on the possible association between beta 2-glycoprotein I (beta 2-GPI)-dependent anticardiolipin antibody (aCL), lupus anticoagulant (LA), and antinuclear antibody (ANA) in patients with recurrent miscarriages.

METHOD OF STUDY

Three hundred and one patients, with a history of two or more unexplained miscarriages, were studied. The titers of beta 2-GPI-dependent aCL and LA were then compared between single-antibody-positive and three-antibody-positive groups.

RESULTS

The prevalences of beta 2-GPI-dependent aCL, LA, and ANA were 3.3, 10.0, and 25.2%, respectively. Four of the 301 patients had all three antibodies. The LA titers in patients with positive values for three antibodies was significantly higher than in cases with only LA.

CONCLUSION

beta 2-GPI-dependent aCL, LA, and ANA define three distinct, but partly related populations in patients with recurrent miscarriage. We should test at least two kinds of autoantibodies in recurrent aborters, because it has been found that, e.g., beta 2-GPI-dependent aCL and LA are predictors for miscarriages.

Intravenous immunoglobulin in the prevention of recurrent spontaneous abortion: the European experience

PROBLEM

Clinical trials of the use of intravenous immunoglobulin (IvIg) in the treatment of recurrent spontaneous abortion (RSA) in Europe were reported and discussed.

METHOD OF STUDY

A search of the published literature, combined with our own published and unpublished results, was performed.

RESULTS

Two placebo-controlled trials have been concluded in Europe. One trial found high but equal success rates in both the IvIg and the placebo group. Another trial found that IvIg treatment may increase the success rate by 24% compared with placebo but that the result was not statistically significant, which might be due to the small number of patients. Reasons for the diverse results of the two trials were discussed.

CONCLUSION

More and larger placebo-controlled trials of IvIg treatment in RSA are needed before drawing definitive conclusions.

Immunologically mediated abortion (IMA)

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

Antinuclear and antiphospholipid antibodies in healthy women with recurrent spontaneous abortion

PROBLEM

To determine the presence of absence of subclinical autoimmunity in healthy women with first trimester recurrent spontaneous abortion (RSA), the sera of 72 healthy women with a history of three or more consecutive abortions were analyzed for the presence of antibodies to phospholipid and nuclear antigens.

METHOD

Lupus anticoagulant was determined, as were antibodies to cardiolipin. An indirect immunofluorescent antinuclear test was performed and specific antinuclear antibodies to double-stranded DNA, ribonucleoprotein, Smith antigen, and Sjogren's syndrome A and B antigens were tested.

RESULTS

Nine women (13.2%) had low levels of antinuclear antibodies, none of which were specific. Four women (5.6%) had moderate to high levels of aCL antibodies.

CONCLUSION

We conclude that the prevalence of aCLs and antinuclear antibodies in healthy women with first trimester RSA is low. Subclinical autoimmunity is not a common cause of first trimester RSA.

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

CONDENSATION

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

OBJECTIVE

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

LOCATION

Medical School-affiliated private Infertility Center.

MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Predictors for live birth after unexplained spontaneous abortions: correlations between immunologic test results, obstetric histories, and outcome of next pregnancy without treatment

Our objective was to determine whether results from tests for maternal serum antinuclear antibodies, cytotoxic antibodies to paternal lymphocytes, parental histocompatibility types, and blocking factors for maternal-paternal mixed lymphocyte reactions were predictive of pregnancy outcome without immunologic treatment. Pregnancy outcome data from 95 women with a history of unexplained recurrent spontaneous abortions who underwent immunologic tests at Jefferson Medical College were evaluated with multiple logistic regression analyses. The number of prior spontaneous abortions, history of another relevant diagnosis, parental sharing of one histocompatibility antigen, and maternal age were related to the outcome of the next pregnancy in women given no immunologic treatment (p = 0.05). No significant correlation was found between results from the immunologic tests or other history characteristics evaluated and outcome of the next pregnancy. The immunologic tests evaluated were not clinically useful predictors of pregnancy outcome.

Subchorionic hematomas and the presence of autoantibodies

Five cases of subchorionic hematoma detected by ultrasonography in patients with threatened abortion are presented. Three of these subjects had antinuclear antibodies, and the remaining two subjects had anticardiolipin antibodies. We recommend that patients with subchorionic hematomas be tested for autoantibodies regardless of their obstetric history.