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Mayer-Pickel K, Nanda M, Gajic M, Cervar-Zivkovic M. Preeclampsia and the Antiphospholipid Syndrome. Biomedicines 2023; 11:2298. [PMID: 37626793 PMCID: PMC10452741 DOI: 10.3390/biomedicines11082298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by venous or arterial thrombosis and/or adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies (aPLs). Preeclampsia complicates about 10-17% of pregnancies with APS. However, only early onset preeclampsia (<34 weeks of gestation) belongs to the clinical criteria of APS. The similarities in the pathophysiology of early onset preeclampsia and APS emphasize an association of these two syndromes. Overall, both are the result of a defective trophoblast invasion and decidual transformation at early gestation. Women with APS are at increased risk for prematurity; the reasons are mostly iatrogenic due to placental dysfunction, such as preeclampsia or FGR. Interestingly, women with APS have also an increased risk for preterm delivery, even in the absence of FGR and preeclampsia, and therefore it is not indicated but spontaneous. The basic treatment of APS in pregnancy is low-dose aspirin and low-molecular-weight heparin. Nevertheless, up to 20-30% of women develop complications at early and late gestation, despite basic treatment. Several additional treatment options have been proposed, with hydroxychloroquine (HCQ) being one of the most efficient. Additionally, nutritional interventions, such as intake of vitamin D, have shown promising beneficial effects. Curcumin, due to its antioxidant and anti-inflammatory properties, might be considered as an additional intervention as well.
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Affiliation(s)
- Karoline Mayer-Pickel
- Department of Obstetrics, Medical University Graz, 8036 Graz, Austria; (M.N.); (M.G.); (M.C.-Z.)
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
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3
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Kaneko K, Ozawa N, Murashima A. Obstetric anti-phospholipid syndrome: from pathogenesis to treatment. Immunol Med 2021; 45:79-93. [PMID: 34470570 DOI: 10.1080/25785826.2021.1969116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by clinical manifestations such as thrombosis and obstetric complications with documented persistence of antiphospholipid antibodies (aPLs). Recent studies have revealed that the cause of aPL-related obstetric complications is dysfunction of placental trophoblasts and inflammation of the maternal-fetal interface induced by aPLs, not thrombosis. Although aPLs are associated with recurrence of serious complications during pregnancy, appropriate combination therapy with heparin and low-dose aspirin can improve the course of 70-80% of subsequent pregnancies. Preconception counseling and patient-tailored treatment are fundamental to improving maternal and fetal outcomes. Non-anticoagulant treatments such as hydroxychloroquine and statins are being developed for cases refractory to conventional treatment. Risk factors for thrombosis after pregnancy complications were identified based on the analysis of large databases of obstetric APS.
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Affiliation(s)
- Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuaki Ozawa
- Division of Reproductive Medicine and Maternal Care/Immunology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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de Jesús GR, Benson AE, Chighizola CB, Sciascia S, Branch DW. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Obstetric Antiphospholipid Syndrome. Lupus 2020; 29:1601-1615. [PMID: 32883160 DOI: 10.1177/0961203320954520] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Obstetric antiphospholipid syndrome (APS) remains a clinical challenge for practitioners, with several controversial points that have not been answered so far. This Obstetric APS Task Force met on the 16th International Congress on Antiphospholipid Antibodies in Manchester, England, to discuss about treatment, diagnostic and clinical aspects of the disease. This report will address evidence-based medicine related to obstetric APS, including limitations on our current management, the relationship between antibodies against domain 1 of β2GPI and obstetric morbidity, hydroxychloroquine use in patients with obstetric APS and factors associated with thrombosis after obstetric APS. Finally, future directions for better understanding this complex condition are also reported by the Task Force coordinators.
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Affiliation(s)
- Guilherme R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ashley E Benson
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Cecilia B Chighizola
- Experimental Laboratory of Immunorheumatological Researches, Allergology, Clinical Immunology & Rheumatology Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - David W Branch
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
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Beltagy A, Trespidi L, Gerosa M, Ossola MW, Meroni PL, Chighizola CB. Anti-phospholipid antibodies and reproductive failures. Am J Reprod Immunol 2020; 85:e13258. [PMID: 32347616 DOI: 10.1111/aji.13258] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Asmaa Beltagy
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, Research Center for Adult and Pediatric Rheumatic Diseases, ASST G. Pini & CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Manuela Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Cecilia B Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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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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Antiphospholipid syndrome: Diagnosis and management in the obstetric patient. Best Pract Res Clin Obstet Gynaecol 2020; 64:31-40. [DOI: 10.1016/j.bpobgyn.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaría Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Carmona Ortells L, Cervantes Pérez EC, Díaz-Cordovés Rego G, Garrote Corral S, Fuego Varela C, Martín López M, Nishishinya B, Novella Navarro M, Pereda Testa C, Sánchez Pérez H, Silva-Fernández L, Martínez Taboada VM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part I: Diagnosis, Evaluation and Treatment. REUMATOLOGIA CLINICA 2020; 16:71-86. [PMID: 30713012 DOI: 10.1016/j.reuma.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for primary antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of four rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for drafting the document, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network [SIGN] levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS 46 recommendations were drawn up, addressing five main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the first 21, referring to the areas of: diagnosis, evaluation and treatment of primary APS. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS An update of the SER recommendations on APS is presented. This document corresponds to partI, related to diagnosis, evaluation and treatment. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A partII has also been prepared, which addresses aspects related to obstetric SAF and special situations.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clínic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaría Ortiz
- Unidad de Hemostasias y Trombosis, Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología, Facultad de Medicina, Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología, Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte, Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria; Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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Branch DW. What's new in obstetric antiphospholipid syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:421-425. [PMID: 31808896 PMCID: PMC6913435 DOI: 10.1182/hematology.2019000043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Antiphospholipid syndrome (APS) is a rare systemic autoimmune disease, the obstetric features of which include recurrent early miscarriage, fetal death at or beyond 10 weeks of gestation, and early delivery for severe preeclampsia or placental insufficiency. Controversies regarding the specificity of these obstetric clinical features, as well as the laboratory diagnostic criteria, are the subject of current debate and reanalysis. Clinical and laboratory features can be used to stratify women with APS in terms of risk of adverse second and third trimester pregnancy outcomes. Numerous "treatments" have been used in high-risk and refractory patients, but rigorously designed clinical trials are needed. APS is a rare disease that requires innovative investigative approaches to provide credible results.
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Affiliation(s)
- D Ware Branch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT
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Xu J, Chen D, Duan X, Li L, Tang Y, Peng B. The association between antiphospholipid antibodies and late fetal loss: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2019; 98:1523-1533. [PMID: 31131876 DOI: 10.1111/aogs.13665] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Antiphospholipid syndrome is a chronic autoimmune disease with a high prevalence in females. Published data have identified that antiphospholipid antibodies (APLA) of antiphospholipid syndrome are risk factors for poor pregnancy outcomes, such as recurrent spontaneous abortion, intrauterine growth restriction and preeclampsia. However, the association between APLA and late fetal loss is not fully understood and remains controversial. The aim of this study is to identify and analyze the recent publications to better understand the association between APLA and late fetal loss. MATERIAL AND METHODS The literature was searched on 31 January 2019 using Ovid, Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) to evaluate the association between APLA and late fetal loss, with articles published before January 2019, according to the PRISMA statement. Without imposing regional restrictions, referenced articles were selected. Quality assessment was conducted independently by two reviewers, based on the Newcastle-Ottawa scale. For the meta-analysis, we used odds ratios (random effects model). The between-study heterogeneity was assessed by Q test. Publication bias was assessed by funnel plots. RESULTS Nineteen studies (with 10 265 cases) were included in the final analysis. The odds ratio (OR) for the late fetal loss with lupus anticoagulant was 5.02 (95% confidence interval [CI] 2.14-7.89). Seven included studies reported that lupus anticoagulant had a statistically significant association with late fetal loss. The results did not show a statistically significant association between anticardiolipin antibodies and late fetal loss. The pooled odds ratio for the association of anticardiolipin antibodies with late fetal loss was 3.47 (95% CI 0.68-6.26). However, we did find the relation between anticardiolipin antibodies and late fetal loss among cohort studies (OR 2.27, 95% CI 1.20-3.44). Anti-beta2 glycoprotein 1 antibodies (β2GP1) showed a significant association with late fetal loss (OR 3.13, 95% CI 0.75-5.50). CONCLUSIONS Lupus anticoagulant is strongly associated with late fetal loss in antiphospholipid syndrome patients. However, the association between anticardiolipin antibodies and late fetal loss is inconsistent. There are currently insufficient data to support a significant relation between β2GP1 and late fetal loss.
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Affiliation(s)
- Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Daijuan Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Xia Duan
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Li Li
- Department of Medical Record, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuxin Tang
- Department of Medical Record, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
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Belhocine M, Coutte L, Martin Silva N, Morel N, Guettrot-Imbert G, Paule R, Le Jeunne C, Fredi M, Dreyfus M, Piette JC, Souchaud-Debouverie O, Deneux-Tharaux C, Tsatsaris V, Pannier E, Le Guern V, Costedoat-Chalumeau N. Intrauterine fetal deaths related to antiphospholipid syndrome: a descriptive study of 65 women. Arthritis Res Ther 2018; 20:249. [PMID: 30400982 PMCID: PMC6235231 DOI: 10.1186/s13075-018-1745-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Although one of the three obstetric manifestations of antiphospholipid syndrome (APS) is intrauterine fetal death (IUFD), little is known about it in this context. We report the first large series of patients with APS and IUFD. Methods We retrospectively analyzed the history and clinical data of women at four French hospitals. All had (1) APS diagnosis (Sydney criteria) and (2) IUFD at or after 10 weeks of gestation (weeks) between 2000 and 2016. Results The study included 65 women. Their median age at the index IUFD was 29 years (IQR 26–33); 38 (58%) were primigravidas. The index IUFD was the first APS clinical manifestation in 48 women (74%). Overall, 35% had a triple-positive antibody profile. IUFD occurred at a median gestational age of 24 weeks (IQR 18–27) and was associated with maternal obstetric complications in 16 women (25%), namely, preeclampsia (n = 12), hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) (n = 6), and/or placental abruption (n = 5). Half of the 50 women with available data had a small-for-gestational-age fetus. Overall, including during the follow-up period of 4 years (IQR 2–9), 28 women (43%) had at least one thrombosis, and 29% were diagnosed with systemic lupus erythematosus (SLE). Ultimately, 54 women (83%) had at least one live birth. Only one woman had three consecutive early miscarriages. Conclusion IUFD was most often the inaugural sign of APS. Of the APS classification criteria, IUFD, preeclampsia, and thromboses were common in this cohort, while the “3 consecutive early miscarriages” criterion was met only once. With treatment, most of the women successfully had at least one live birth.
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Affiliation(s)
- Mériem Belhocine
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Laetitia Coutte
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | | | - Nathalie Morel
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Gaëlle Guettrot-Imbert
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Romain Paule
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Claire Le Jeunne
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Micaela Fredi
- Spedali Civili di Brescia, Rheumatology and Clinical Immunology Department, Brescia, Italy
| | - Michel Dreyfus
- Caen University Hospital, Gynecology and Obstetrics Department, Caen, France
| | - Jean-Charles Piette
- AP-HP, Pitié-Salpétrière University Hospital, Internal Medicine and Clinical Immunology Department, Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Université Paris 6, Paris, France
| | | | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Université Paris Descartes, Paris, France
| | - Vassilis Tsatsaris
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Emmanuelle Pannier
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France. .,INSERM U1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France.
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Yelnik CM, Laskin CA, Porter TF, Branch DW, Buyon JP, Guerra MM, Lockshin MD, Petri M, Merrill JT, Sammaritano LR, Kim MY, Salmon JE. Lupus anticoagulant is the main predictor of adverse pregnancy outcomes in aPL-positive patients: validation of PROMISSE study results. Lupus Sci Med 2016; 3:e000131. [PMID: 26835148 PMCID: PMC4716418 DOI: 10.1136/lupus-2015-000131] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 01/28/2023]
Abstract
Objective We previously reported that lupus anticoagulant (LAC) is the main predictor of poor pregnancy outcome in antiphospholipid antibody (aPL)-positive patients. We sought to confirm this finding in an independent group of patients who were subsequently recruited into the PROMISSE study. Methods The PROMISSE study is a multicentre, prospective, observational study of pregnancy outcomes in women with aPL and/or systemic lupus erythematosus (SLE) that enrolled patients from 2003 to 2015. All consecutive, aPL-positive patients from the PROMISSE study who completed their pregnancy between April 2011 and January 2015 (after the previous PROMISSE report) are included in the current report. Patients were followed monthly until delivery, and aPL was tested at first, second and third trimesters of pregnancy and at 12 weeks post partum. Adverse pregnancy outcomes (APOs) were defined as fetal death after 12 weeks of gestation, neonatal death, delivery prior to 36 weeks of gestation due to pre-eclampsia or placental insufficiency or small-for-gestational age (birth weight <5th percentile). Results Forty-four aPL-positive patients are included in this paper. Thirteen patients had APOs, which occurred in 80% of cases during the second trimester of pregnancy. LAC was present in 69% of patients with APOs compared with 27% of patients without APOs (p=0.01). No association was found between anticardiolipin antibodies (aCL) or anti-β2 glycoprotein I antibodies (aβ2GPI) IgG or IgM positivity and APOs. Definite antiphospholipid syndrome (history of thrombosis and/or pregnancy morbidity and aPL) was found in 92% of patients with any APOs compared with 45% of patients without APOs (p=0.004). Conversely, the frequency of SLE was not statistically different between those with and without APOs (30% vs 39%). Conclusions Our findings, in an independent group of aPL-positive patients from the PROMISSE study, confirm that LAC, but not aCL and aβ2GPI, is predictive of poor pregnancy outcomes after 12 weeks of pregnancy. Trial registration number NCT00198068.
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Affiliation(s)
- Cecile M Yelnik
- Department of Medicine, Hospital for Special Surgery, New York City, New York, USA; Internal Medicine Department, University of Lille, UFR Médecine, Lille, France
| | - Carl A Laskin
- University of Toronto and LifeQuest Centre for Reproductive Medicine , Toronto , Canada
| | - T Flint Porter
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare , Salt Lake City, Utah , USA
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare , Salt Lake City, Utah , USA
| | - Jill P Buyon
- Department of Medicine, New York University School of Medicine , New York City, New York , USA
| | - Marta M Guerra
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Michael D Lockshin
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
| | - Joan T Merrill
- Department of Medicine, Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA
| | - Lisa R Sammaritano
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Mimi Y Kim
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine , New York City, New York , USA
| | - Jane E Salmon
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
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Patil R, Ghosh K, Vora S, Shetty S. Inherited and acquired thrombophilia in Indian women experiencing unexplained recurrent pregnancy loss. Blood Cells Mol Dis 2015; 55:200-5. [DOI: 10.1016/j.bcmd.2015.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/22/2015] [Indexed: 12/21/2022]
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Liu LC, Wang YC, Yu MH, Su HY. Major risk factors for stillbirth in different trimesters of pregnancy--a systematic review. Taiwan J Obstet Gynecol 2015; 53:141-5. [PMID: 25017256 DOI: 10.1016/j.tjog.2014.04.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022] Open
Abstract
Stillbirth remains an event that has an important impact on global health issues. Different levels of health care between countries suggest that the stillbirth rate may be one of the indicators of the quality of a country's medical system. In this review, major risk factors for stillbirth will be discussed, especially in different trimesters of pregnancy. Early identification of risk factors for stillbirth and appropriate antenatal management may reduce preventable stillbirths and improve general outcomes of pregnancy.
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Affiliation(s)
- Li-Chun Liu
- Department of Obstetrics and Gynecology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Yu-Chi Wang
- Department of Obstetrics and Gynecology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Mu-Hsien Yu
- Department of Obstetrics and Gynecology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Her-Young Su
- Department of Obstetrics and Gynecology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.
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Mohamed MS, Zahran KM, Mohamed HSE, Galal H, Mustafa AM. Pattern of glucose intolerance among pregnant women with unexplained IUFD. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2015. [DOI: 10.1016/j.mefs.2014.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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de Jesus GR, Agmon-Levin N, Andrade CA, Andreoli L, Chighizola CB, Porter TF, Salmon J, Silver RM, Tincani A, Branch DW. 14th International Congress on Antiphospholipid Antibodies Task Force report on obstetric antiphospholipid syndrome. Autoimmun Rev 2014; 13:795-813. [PMID: 24650941 DOI: 10.1016/j.autrev.2014.02.003] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/17/2014] [Indexed: 01/12/2023]
Abstract
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).
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Affiliation(s)
- Guilherme R de Jesus
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carlos A Andrade
- Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Immunorheumatological Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - T Flint Porter
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA; Intermountain Healthcare, Salt Lake City, USA
| | - Jane Salmon
- Hospital For Special Surgery, Weill Cornell Medical College, NY, USA; Kirkland Center for Lupus Research, NY, USA; Lupus and APS Center of Excellence, NY, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA; Intermountain Healthcare, Salt Lake City, USA
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Helgadóttir LB, Turowski G, Skjeldestad FE, Jacobsen AF, Sandset PM, Roald B, Jacobsen EM. Classification of stillbirths and risk factors by cause of death--a case-control study. Acta Obstet Gynecol Scand 2013; 92:325-33. [PMID: 23157574 DOI: 10.1111/aogs.12044] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 11/01/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate risk factors for stillbirths by cause, using the Causes of Death and Associated Conditions (CODAC) classification system for perinatal deaths. DESIGN Case-control study. SETTING Two university hospitals in Oslo, Norway, January 1990 through December 2003. SAMPLE Women with stillbirth after 22 gestational weeks (n = 377) and controls with live births (n = 1 215), and a subsample of 105 cases and 262 controls. METHODS Socio-demographic, clinical and thrombophilic risk factors for stillbirths were assessed by cause of death in univariate and multivariable logistic regression analyses. Stillbirths were classified according to CODAC based on information from medical records and validated placenta histology. MAIN OUTCOME MEASURES Causes of stillbirths in percentages, prevalence, odds ratios and adjusted odds ratios for potential risk factors. RESULTS Approximately half of the women (n = 190) had placental and 19.4% (n = 73) unknown cause of stillbirth. Placental-associated conditions were registered in 18% (n = 68) of cases with a non-placental or an unknown cause. Smoking and small-for-gestational age were more prevalent in all causal groups, compared with controls, whereas twin pregnancy, hypertension and diabetes were more prevalent only among women with placental and unknown causes of stillbirth. The F2rs179963 polymorphism and combined thrombophilia were significant risk factors for stillbirth with placental causes and antiphospholipid antibodies for stillbirth with non-placental causes. CONCLUSIONS Two-thirds of all stillbirths (68%) were caused by or associated with placental pathology. Risk factors differed somewhat according to cause, apart from smoking and small-for-gestational age, which were significant risk factors across the causal groups.
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Hypernephroma Presenting with Cutaneous Leukocytoclastic Vasculitis and Lupus Anticoagulant: Resolution after Nephrectomy. Case Rep Urol 2012; 2012:108230. [PMID: 22919534 PMCID: PMC3420098 DOI: 10.1155/2012/108230] [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: 04/21/2012] [Accepted: 07/04/2012] [Indexed: 11/20/2022] Open
Abstract
Hypernephroma can present as a variety of paraneoplastic, nonmetastatic conditions, including vasculitis, and rarely a lupus-type anticoagulant. Nephrectomy leads to the resolution of the systemic complaints. Malignancy, in this case hypernephroma, can present as an immune-mediated paraneoplastic syndrome which resolves after removal of the underlying tumor.
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