Anti-beta2 glycoprotein-I antibody increases the risk of pregnancy-induced hypertension: a case-controlled study

Anti-phospholipid antibodies in women presenting with preterm delivery because of preeclampsia or placental insufficiency

Objective:

To assess the proportion of women presenting with preterm delivery because of preeclampsia or placental insufficiency (PREPI) with anti-phospholipid antibodies (APLA).

Material and Methods:

This was a prospective cohort study conducted at an obstetrics and gynecology department. Women, aged 20-40 years, with preeclampsia who delivered before 34 weeks were cases while those who delivered before 34 weeks but did not have preeclampsia acted as controls. Both groups had APLA measured at diagnosis and 12-weeks postnatally. Anti-phospholipid antibody syndrome (APS) was diagnosed according to Sapporo’s criteria.

Results:

The study included 98 cases and 106 controls. Both cases and controls were similar in terms of age, gestational age and parity. The frequency of APS positivity was 17.3% in cases but only 3.8% in controls (p=0.001). Cases were more likely to be of Baloch ethnicity (34.7% vs. 11.3%, p=0.001), have a history of miscarriage (25.5% vs. 13.2%, p=0.026), use aspirin (p<0.001) or low molecular weight heparin (p<0.001), and be obese (p<0.001) than controls. Cases were more likely to have lupus anticoagulant antibodies (82.4% vs. 75%).

Conclusion:

Our study confirms a high prevalence of APLA in women who have preterm delivery due to PREPI. An opportunity to screen these women should be made, so that proper counselling can be given and future pregnancies can be managed in an appropriate and timely manner.

Antiphospholipid antibodies in women with severe preeclampsia and placental insufficiency: a case-control study

Objective Preterm delivery for preeclampsia or placental insufficiency (PREPI) is a clinical criterion for antiphospholipid syndrome (APS), but no prior prospective studies have used the international classification criteria for APS. Our objective is to determine the proportion of women with PREPI who test positive for aPL using international criteria for antiphospholipid antibody (aPL) assays. Methods We conducted a prospective, case-control study of 148 women delivered < 36 weeks because of PREPI compared to 148 controls. PREPI cases delivered < 36 weeks were compared to matched controls. Cases and controls were tested for aPL. Demographic variables were compared with chi-squared and Wilcoxon-rank-sum statistics. Rates of + aPL were compared using adjusted odds ratios (aORs) for maternal body mass index (BMI) and Caucasian race. Positive aPL (+aPL) was defined as lupus anticoagulant (LA), anticardiolipin (aCL) immunoglobulin G (IgG) (GPL) or immunoglobulin M (IgM) (MPL) ≥ 40, or anti-β2-glycoprotein I (aβ2GPI) IgG (SGU) or IgM (SMU) ≥ 40. Results Controls were more likely to be Caucasian (87% vs 70%, p = 0.006) and had lower BMIs (BMI 26 vs 33, p < 0.001). Positive aPL were found more commonly in cases than controls (11.5% vs 1.4%, aOR 8.9 (95% CI 1.9-41.4)). In + aPL cases, 76% had + LA, 41% had + aCL, and 24% had + aβ2GPI. Conclusion Women requiring early delivery for PREPI are more likely to have aPL (and thus APS) than controls. This is the first prospective study using both obstetric definitions and laboratory criteria in accordance with APS international criteria.

Pre-eclampsia as a manifestation of antiphospholipid syndrome: assessing the current status

The presence of antiphospholipid antibodies is considered a risk factor for pre-eclampsia. Two meta-analyses and a number of case-control and cohort studies have found associations between pre-eclampsia and lupus anticoagulant, anticardiolipin, and/or anti-β2 glycoprotein I. However, existing literature is inconsistent, with varying severity of pre-eclampsia phenotype examined, differing aPL titer cutoffs used to define positive status, and an overwhelming lack of repeat confirmatory aPL testing. This calls into question the link between aPLs and pre-eclampsia, or at least makes it less well defined. There is evidence for a mechanistic pathway between aPLs and adverse pregnancy outcomes (APOs) including pre-eclampsia via the complement pathway. Complement appears to be overactive in pregnancies affected by APOs. A mouse model has show that the fetal wastage caused by treatment with human aPLs can be salvaged by either creating genetic knockouts along the complement, TNF-alpha, and tissue factor pathways or be treating mice with monoclonal antibodies blocking key complement factors. Thus, this is worth further investigation to clarify the likely association of aPLs and pre-eclampsia in humans, as well is to further evaluate the interaction with complement in human pregnancies.

Catastrophic APS in the context of other thrombotic microangiopathies

The catastrophic antiphospholipid syndrome (CAPS) is a rare disease that affects 1 % of cases with antiphospholipid syndrome (APS). CAPS can mimic or overlap with different thrombotic diseases; many patients present with a microthrombotic storm or thrombotic microangiopathic hemolytic anemia (TMHA). Thus, the differential diagnosis of CAPS includes thrombotic thrombocytopenic purpura (TTP), typical and atypical hemolytic uremic syndrome (HUS), systemic infections, malignancies, pregnancy-related disorders, malignant hypertension, heparin-induced thrombocytopenia, and drug-induced thrombotic microangiopathies. Antiphospholipid antibody (aPL) positivity has been proposed as the clue in this differential diagnosis; however, aPL can also occur in healthy people and in those with infections or malignancies. Thus, the differential diagnosis of an aPL-positive patient presenting with a microthrombotic storm is broad; the workup should include a special attention to signs of infection and disseminated malignant disease, assessing the funduscopic signs of malignant hypertension, testing ADAMTS13 activity and anti-heparin-platelet factor 4 (HPF4) antibodies, and searching previous exposure to certain drugs. This article aims to review the main diseases included in the differential diagnosis of CAPS in the context of other thrombotic microangiopathies.

The challenge of pregnancy for patients with SLE

Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.

14th International Congress on Antiphospholipid Antibodies Task Force report on obstetric antiphospholipid syndrome

Pregnancy morbidity is one of the clinical manifestations used for classification criteria of antiphospholipid syndrome (APS). During the 14th International Congress on Antiphospholipid Antibodies (aPL), a Task Force with internationally-known experts was created to carry out a critical appraisal of the literature available regarding the association of aPL with obstetric manifestations present in actual classification criteria (recurrent early miscarriage, fetal death, preeclampsia and placental insufficiency) and the quality of the evidence that treatment(s) provide benefit in terms of avoiding recurrent adverse obstetric outcomes. The association of infertility with aPL and the effectiveness of the treatment of patients with infertility and positive aPL was also investigated. This report presents current knowledge and limitations of published studies regarding pregnancy morbidity, infertility and aPL, identifying areas that need better investigative efforts and proposing how critical flaws could be avoided in future studies, as suggested by participants of the Task Force. Except for fetal death, there are limitations in the quality of the data supporting the association of aPL with obstetric complications included in the current APS classification criteria. Recommended treatments for all pregnancy morbidity associated to APS also lack well-designed studies to confirm its efficacy. APL does not seem to be associated with infertility and treatment does not improve the outcomes in infertile patients with aPL. In another section of the Task Force, Dr. Jane Salmon reviewed complement-mediated inflammation in reproductive failure in APS, considering new therapeutic targets to obstetric APS (Ob APS).

Report of the Obstetric APS Task Force: 13th International Congress on Antiphospholipid Antibodies, 13th April 2010

The Obstetric APS Task Force of the 13th International Congress identified and discussed five general topics within 'Obstetric' Antiphospholipid Syndrome (APS) that contained areas of controversy or uncertainty: recurrent early miscarriage (REM), fetal death, delivery <34 weeks for severe preeclampsia or placental insufficiency, postpartum care, and long-term implications and care. The Task Force concluded that the frequency with which women with REM have a high titer of antiphospholipid antibodies (aPL) or lupus anticoagulant (LA) is somewhat controversial, especially with regard to the diagnostic titers required by the current international criteria for APS. Also, treatment trials involving heparin differ from one another with regard to the patients included and the outcomes achieved. Similarly, the frequency with which women with fetal death or delivery <34 weeks for severe preeclampsia or placental insufficiency have a high titer of aPL or LA is poorly defined, and there is no level I evidence to guide treatment in either group. Suggestions for future studies with regard to both REM and fetal death or delivery <34 weeks for severe preeclampsia or placental insufficiency were discussed and are outlined below. Postpartum and long-term care in women with APS diagnosed solely for obstetric criteria has been largely guided by expert opinion, and systematic evaluations of these populations would be welcome.

Cleaved high-molecular-weight kininogen accelerates the onset of endothelial progenitor cell senescence by induction of reactive oxygen species

OBJECTIVE

Cleaved high-molecular-weight kininogen (HKa), an activation product of the plasma kallikrein-kinin system, inhibits endothelial cell functions. We questioned whether HKa affects the function of endothelial progenitor cells (EPCs) and accelerates their senescence.

METHODS AND RESULTS

Treatment with HKa for 2 weeks markedly inhibited the formation of large colonies and proliferation of EPCs on collagen surfaces, whereas HKa did not affect collagen-mediated EPC adhesion and survival. Concomitantly, treated EPCs displayed flattened and giant cell morphological changes and formation of intracellular vacuoles. As determined by acidic β-galactosidase staining, HKa increased senescent EPCs by 2- and >3-fold after culture for 1 and 2 weeks, respectively. In addition, HKa suppressed the telomerase activity of EPCs. HKa concentration-dependently increased the generation of intracellular reactive oxygen species (ROS) and markedly upregulated p38 kinase phosphorylation and prosenescence molecule p16(INK4a) expression. SB203580, a p38 inhibitor, attenuated the level of HKa-enhanced p16(INK4a) expression. Either quenching of ROS or inhibition of p38 kinase prevented HKa-induced EPC senescence.

CONCLUSIONS

HKa accelerates the onset of EPC senescence by activating the ROS-p38 kinase-p16(INK4a) signaling cascade. This novel activity of HKa points out the likelihood of HKa serving as an endogenous inducer of EPC senescence.