Specific antiphospholipid antibodies as a predictive variable in patients with recurrent pregnancy loss

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.

The incidence of various antiphospholipid antibodies, measured by commercial-based laboratory, with recurrent spontenous abortion and the impact of their profiles on reproductive outcome with active anticoagulant therapy

Objective. To investigate the incidence of various antiphospholipid antibodies (aPLs), measured by commercial-based laboratory, with recurrent spontaneous abortion (RSA) patients and the impact of the species, isotype, titer, and number of positive aPLs on reproductive outcome in Japanese. Method. In this retrospective cohort study, 263 patients with RSA without possible causes were investigated. Of 131 patients with one or more positive aPL, 82 pregnant women under anticoagulant therapy were evaluated. Results. The incidence of various aPLs was almost consistent with previous report. Overall, successful pregnancy rate with anticoagulant therapy was 91.4% regardless of aPL profiles. There was no significant difference in the pregnancy maintenance rate between IgG and IgM groups or single positive and multiple positive groups, but there was a tendency for the rate with aspirin to be lower than with aspirin plus heparin in IgG group. Conclusion. aPL profile did not affect the pregnancy maintenance rate when anticoagulant therapy was actively introduced, however in IgG group, we recommend combination therapy with aspirin and heparin.

Prevalence and significance of antiphospholipid antibodies in selected at-risk obstetrics cases: a comparative prospective study

In a prospective comparative study we screened 112 women with a past history either of pre-eclampsia, eclampsia, recurrent abortion, IUGR, IUFD or abruptio placentae, with no apparent aetiology and a demographically matched cohort of 106 women having a past history of uncomplicated pregnancy outcome for the presence of antiphospholipid antibodies (aPL) and their significance. In the former group, the prevalence of aPL ranged from 10-46.87% compared with 8.49% in the later group. In women with the presence of aPL, the incidence of pre-eclampsia, early onset pre-eclampsia and abruptio placentae were 25%, 14.58% and 18.75%, respectively. In the same group, the abortion rate was 25% and live-birth rate was 64.58% with IUFD rate of 10.42%. Fetal morbidity rates were also higher in the mothers with aPL positivity, the incidence of IUGR was 27.08% and oligohydramnios was 33.33% in them. All these complications were statistically significant when compared with those of aPL negative mothers.

Thrombophilias and recurrent pregnancy loss: a critical appraisal of the literature

Thrombophilias are suggested to play a role in recurrent miscarriage. The aim of this study was to evaluate the literature of the past 10 years regarding the association between thrombophilias and recurrent miscarriage. We concluded that there is a large variety in applied study methodology. Therefore, we defined criteria for an adequate study on the relationship of thrombophilias on recurrent pregnancy loss: (i) no exclusion criteria for patients or at least the same criteria for patients and controls; (ii) a clear definition of the gestational age at previous losses; (iii) a well-described control group; (iv) clear description of the test methods and moment of testing; and (v) a clear description of the (non) significant differences or odds ratio between cases and controls. Eleven out of 69 studies fulfilled these criteria. Their results show significant higher serum homocysteine levels among women with a history of recurrent miscarriage. No relation was found between recurrent miscarriage and the methylenetetrahydrofolate reductase C667T mutation. No relation was observed for the levels of antithrombin, protein C and protein S. Seven studies on the association of factor V Leiden (FVL) and/or pathologic activated protein C ratio (pAPCR) showed that FVL may play a role in second trimester losses, as do antiphospholipid antibodies. Studies on the prothrombin gene mutation yielded conflicting results. Consequently, large prospective studies according to the aforementioned criteria are needed to establish if there is a relationship between thrombophilias and recurrent miscarriage at all. At present, there is only justification for testing for homocysteine levels, antiphospholipid antibodies and FVL in women with a history of recurrent miscarriage.

Laboratory tests for the antiphospholipid syndrome: current concepts

There is increased scientific interest in the diagnosis of the antiphospholipid syndrome (APS), as therapeutic interventions can lead to substantial improvement in clinical outcome. As the clinical features of APS are far from specific, a sound laboratory method is needed to support or exclude the diagnosis. Two methods are currently used for the diagnosis of APS: (1). ELISA-based immunoassays for the detection of anticardiolipin (aCL) antibodies; and (2). clotting assays for determination of the lupus anticoagulant (LA). However, the first method is limited by a low specificity, and the second by low sensitivity. Furthermore, for both methods standardisation is unsatisfactory. Therefore, a number of new assays have been proposed as alternative or supplementary to aCL and LA tests. These include the anti-beta-2-glycoprotein I or antiprothrombin ELISAs, an ELISA utilising a phospholipid mixture, clotting assays with varying activators and assays utilising chromogenic substrates. This review presents a brief outline of APS, the autoantibodies associated with this syndrome, the basic principles of the standard assays used and a description of newer methods currently being validated.

Polycystic ovary syndrome, the G1691A factor V Leiden mutation, and plasminogen activator inhibitor activity: associations with recurrent pregnancy loss

Our specific aim was to assess associations of thrombophilia, hypofibrinolysis, and polycystic ovary syndrome (PCOS) with recurrent pregnancy loss (RPL) (>/=3 consecutive pregnancy losses < 20 weeks gestation). Prospective studies were performed in 33 Caucasian women referred for diagnosis and treatment of PCOS who were subsequently found to have RPL and in 16 Caucasian women referred for diagnosis and treatment of RPL, who did not have PCOS. Cases (PCOS-RPL, RPL without PCOS) were compared with controls (116 healthy Caucasian females) for the G1691A Factor V Leiden, G20210A prothrombin, C677T methylenetetrahydrofolate reductase (MTHFR), plasminogen activator inhibitor 4G/5G, and platelet glycoprotein PL A1A2 gene mutations. Cases were compared with controls (44 healthy adult Caucasian females) for serologic coagulation tests including homocysteine, proteins C, S, free S, antithrombin III, anticardiolipin antibodies IgG and IgM, dilute Russel's viper venom time, activated partial thromboplastin time, Factor VIII, Factor XI, lipoprotein (Lp)(a), and plasminogen activator inhibitor activity (PAI-Fx). The 33 Caucasian women with PCOS subsequently found to have RPL were 10% of a cohort of 322 Caucasian women who had >/= 1 previous pregnancy and had been referred for diagnosis and therapy of PCOS over a 4.3-year period. The Factor V Leiden G1691 mutation was present in 6 of 33 women (18%) with PCOS-RPL and in 3 of 16 women with RPL without PCOS (19%) versus 2 of 116 (1.7%) female controls, Fisher's P (p(f)) =.0016, p(f) =.013. The 33 PCOS-RPL cases also differed from the 44 female controls for high PAI-Fx (>21.1 U/mL), 38% versus 8%, p(f) =. 004. The thrombophilic G1691A Factor V Leiden mutation is associated with RPL in women with and without PCOS; hypofibrinolysis (high PAI-Fx) is also associated with RPL in women with PCOS.

Antiphospholipid antibodies: discovery, definitions, detection and disease

Antiphospholipid antibodies (aPL) are immunoglobulins of IgG, IgM and IgA isotypes that target phospholipid (PL) and/or PL-binding plasma proteins. Detection of aPL in the laboratory is done currently by both immunoassays and functional coagulation tests. Convention defines aPL specificity in immunoassays according to the particular PL substrate present, for example aPS represents antiphosphatidylserine antibodies. This may be technically incorrect inasmuch as a particular PL may be responsible for binding and highly concentrating a specific plasma protein, the latter then becomes the target for the aPL. The binding of beta(2)GP-I (apolipoprotein H) to the negatively charged PL, cardiolipin (CL) provides a good example of this circumstance. In contrast, aPL which specifically prolong coagulation times in in vitro are called lupus anticoagulants (LA). The precise PL target(s) of the aPL responsible for LA activities are unknown and often debated. The persistent finding of aPL in patients in association with abnormal blood clotting and a myriad of neurological, obstetrical and rheumatic disorders often compounded by autoimmune diseases has led to an established clinical diagnosis termed antiphospholipid syndrome (APS). The common denominator for these APS patients is the presence of circulating aPL on two or more occasions and the observation of events attributable to abnormal or accelerated blood clotting somewhere in vivo. The purpose of this review is to collect, collate, and consolidate information concerning aPL.

Immunopathogenesis of the antiphospholipid antibody syndrome: an update

The primary antiphospholipid antibody syndrome is characterized clinically by the presence of venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. The presence of antiphospholipid antibodies is a central serologic finding in primary antiphospholipid antibody syndrome, and plays a critical role in diagnosis. Contrary to initial reports, it is now widely accepted that these autoantibodies are directed predominantly against two antigens: phospholipid-binding plasma protein beta2-glycoprotein I and prothrombin. The mechanism by which antiphospholipid antibodies cause disease is under vigorous investigation. It is hypothesized that antiphospholipid antibodies induce a procoagulant state by binding to antigens on endothelial cells and trophoblast cell surfaces. Indeed, beta2-glycoprotein I appears to function as a cofactor that facilitates this interaction. The resulting endothelial cell activation is associated with cell-surface expression of adhesion molecules that lead to monocyte adhesion - the first steps in thrombosis. Although the precise mechanism that mediates endothelial cell-platelet interaction have not been fully elucidated, platelet binding to the endothelium appears to be the next phase in thrombosis. Thus, the antiphospholipid antibody may be a triggering or activating factor in placental spiral artery thrombosis and subsequent placental infarction. More recently, a role for annexin V has emerged. Studies suggest that thrombosis in the antiphospholipid syndrome may be due to disruption of the annexin shield by antiphospholipid (and cofactor) antibodies, which results in the increased exposure of trophoblasts and endothelial cells to thrombogenic phospholipids.

Anti-phosphatidylethanolamine (aPE) antibodies: a survey

Reports of anti-phosphatidylethanolamine antibodies (aPE) with similar or identical pathogenic associations as those described for anticardiolipin (aCL) and anti-phosphatidylserine (aPS) are found in the literature. In some instances, aPE is the sole antiphospholipid antibody (aPL) observed. Lupus anticoagulant antibodies (LA) appear to represent a subset of aPE as hexagonal phase PE can specifically inhibit the LA ability to prolong clotting times. As documented for aPL to the negatively charged phospholipids (PL), plasma proteins have been implicated for a positive aPE signal in the ELISA. Other aPE appear independent of known PE-binding plasma proteins. Among the described PE-binding proteins are high and low molecular weight kininogens (HMWK and LMWK) and the HMWK-binding proteins, factor XI and prekallikrein. Recently prothrombin has been added to this list. The reports of aPE published since 1986 are reviewed and discussed in this presentation.

Differences of IgG and IgM antibodies to phospholipids and APTT among non-pregnant and pregnant women

OBJECTIVE

The objective of our study was to assess the difference in IgG and IgM antibodies to cardiolipin(CL), phosphatidylserine(PS), and APTT among non-pregnant and pregnant women.

METHODS

IgG and IgM antibodies to CL and PS among 102 healthy non-pregnant women and 154 healthy pregnant women were measured by an ELISA. The activated partial thromboplastin time(APTT) was measured in 67 healthy non-pregnant women, in 67 healthy women at 10-14 weeks of gestation, and in 67 healthy women at 30-32 weeks of gestation. We compared the titer of +2SD in each group.

RESULTS

The titers +2SD of IgG antibodies to CL and PS in pregnant women were lower than in non-pregnant women (p < 0.05), whereas the values of the IgM antibody to CL and PS were the same in pregnant and non-pregnant women. The APTT in pregnant women was significantly shorter than in non-pregnant women (p = 0.0001).

CONCLUSION

Standard criteria for the positivity of the IgG antibody to CL and PS and the prolongation of APTT in pregnancy should employ the values of normal pregnant women rather than those of non-pregnant women.

Lack of association between antiphospholipid antibodies and first-trimester spontaneous abortion: prospective study of pregnancies detected within 21 days of conception

OBJECTIVE

To determine the role of antiphospholipid antibodies and anticardiolipin antibodies in first-trimester losses, addressing experimental pitfalls that preclude excluding the possibility that these antibodies reflect merely the selection bias of studying couples only after they have already experienced losses.

DESIGN

Given that retrospective studies cannot exclude the possibility that such antibodies arise as a result of the fetal death, blood samples were obtained either before pregnancy or very early in pregnancy. Sera were obtained within 21 days of conception.

SETTING

Multicenter university-based hospitals (National Institute of Child Health and Human Development collaborative study).

PATIENT(S)

Subjects for the current study were 93 women who later experienced pregnancy loss (48 diabetic; 45 nondiabetic), matched 2:1 with 190 controls (93 diabetic and 97 nondiabetic) who subsequently had normal live-born offspring.

INTERVENTION(S)

Sera from these 283 women were analyzed for antiphospholipid antibodies by enzyme immunoassay. In 260 of the 283 women (87 with pregnancy losses; 173 with live-born infants), sera were also available to perform assays for anticardiolipin antibodies by enzyme immunoassay.

MAIN OUTCOME MEASURE(S)

Pregnancy losses.

RESULT(S)

No association was observed between pregnancy loss and the presence of antiphospholipid antibodies or anticardiolipin antibodies. Levels of antiphospholipid antibodies were 6-19 PL/mL in 62.4% of the pregnancies that ended in losses and > or = 20 PL/mL in 5.4%; among pregnancies resulting in live-born infants, the percentages were 56.8% and 6.8%, respectively. Of the pregnancies that ended in a loss, 5.7% had anticardiolipin antibodies > or = 16 GPL/mL, compared with 5.2% of those ending in a live birth.

CONCLUSION(S)

This prospective study suggests that anticardiolipin antibodies and antiphospholipid antibodies are not associated with an increased risk for first-trimester pregnancy loss.

Antiphospholipid antibodies and reproductive outcome: the current state of affairs

Antiphospholipid antibodies were first linked to pregnancy loss more than 20 years ago, and the condition known as antiphospholipid syndrome is perhaps the most convincing 'immunologic' disturbance other than anti-erythrocyte and anti-platelet alloimmunization disorders. Specific criteria for the antiphospholipid syndrome have been delineated, the anticardiolipin assay has been standardized, and authorities agree on laboratory criteria defining lupus anticoagulant. Nonetheless, considerable confusion exists regarding antiphospholipid syndrome and related reproductive problems. The state of affairs primarily derives from two problems: the first is the premature introduction of non-standardized antiphospholipid assays into clinical use without rigorous standardization and prior to convincing proof of clinical utility. As a result, well-intending, but less well-versed clinicians sometimes make the diagnosis of antiphospholipid syndrome in women who are negative for lupus anticoagulant and anticardiolipin antibodies. This is especially confusing in the face of of growing evidence that the relevant in vivo antiphospholipid antigen is formed by a complex between beta 2-glycoprotein 1 and phospholipids. A second major problem is that of unwarranted discrepancies in the clinical and laboratory features of patients considered to have a diagnosis of antiphospholipid syndrome. This problem is most apparent in the case selection for pregnancy-loss treatment series and trials. Many series have included women with predominantly pre-embryonic and embryonic pregnancy losses, while others included a large majority of patients with one or more second or third trimester pregnancy losses. Some treatment trials purposefully excluded patients with a history of thrombosis or systemic lupus erythematosus, features found in nearly 50% of patients in other series. Though most authorities require the presence of either lupus anticoagulant or medium-to-high titer IgG anticardiolipin antibodies to make a diagnosis of antiphospholipid syndrome, in some series no more than half of the study patients had lupus anticoagulant and as many as 20% had only IgM anticardiolipin antibodies. It is very unlikely that patients with such disparate clinical and laboratory findings have the same autoimmune syndrome, and a stated or implicit diagnosis of antiphospholipid syndrome in such a wide variety of women is scientifically unsound and clinically dangerous. The relationship between antiphospholipid antibodies and poor reproductive outcomes must be approached through rigorous scientific study and appropriate treatments established by well-designed clinical trials.

IgG anticardiolipin antibody titer > 40 GPL and the risk of subsequent thrombo-occlusive events and death. A prospective cohort study

BACKGROUND

Anticardiolipin antibodies (aCL) have been associated with an increased risk of stroke and thrombo-occlusive events. Little is known about the influence of aCL on recurrent thrombo-occlusive events.

METHODS

Consecutively identified patients (n = 132) with focal cerebral ischemia [stroke = 112, transient ischemic attack (TIA) = 20] harboring aCL of at least 10 GPL units at the time of their index event were prospectively followed to estimate the effect of aCL titer on time to and risk of subsequent thrombo-occlusive events (stroke, TIA, deep venous thrombosis, pulmonary embolism, myocardial infarction) and death. On the basis of prior literature, we divided patients into those with aCL < or = 40 GPL (n = 111; mean age, 63 +/- 14 years; mean follow-up, 1.95 years) and those with aCL > 40 GPL (n = 21; mean age, 54 +/- 20 years; mean follow-up, 1.50 years).

RESULTS

There was no difference between groups for prevalence of hypertension, diabetes mellitus, cigarette smoking, atrial fibrillation, prior TIA, or sex. The GPL > 40 group was younger (54 +/- 20 versus 63 +/- 14 years; P = .055), had more prior strokes [9/21 (48%) versus 27/111 (20%); P = .030], more frequent subsequent thrombo-occlusive events and death [15/21 (71%) versus 51/111 (48%); P = .030], and a shorter median time (years) to event (0.15 versus 0.61, log rank P = .005). The risk ratio for recurrent event and death with GPL > 40 obtained from Cox proportional hazards models, adjusted for prior strokes, prior TIAs, hypertension, diabetes mellitus, atrial fibrillation, and cigarette smoking was 1.9 (95% confidence interval, 1.0 to 3.5; P = .051).

CONCLUSIONS

Our data suggest that subsequent thrombo-occlusive events and death after focal cerebral ischemia associated with IgG aCL may occur sooner and more frequently with GPL > 40.

Midfollicular anticardiolipin and antiphosphatidylserine antibody titers do not correlate with in vitro fertilization outcome

OBJECTIVE

To determine the prevalence of anticardiolipin and antiphophatidylserine antibodies in an IVF population and to correlate their presence and specific isotype with IVF cycle outcome.

DESIGN

Retrospective clinical study using stored midfollicular sera for determination of antibody status.

SETTING

University hospital infertility clinic.

PATIENT(S)

Women who underwent IVF treatment in 1991.

INTERVENTION(S)

Midfollicular sera were used to assess antibody status during the time of stimulation for IVF.

MAIN OUTCOME MEASURE(S)

Anticardiolipin and antiphosphatidylserine antibody titers and biochemical or sonographic documentation of IVF cycle outcome.

RESULT(S)

The overall prevalence of anticardiolipin and antiphosphatidylserine antibodies in IVF patients was 7.0% and 11.2%, respectively. There was no statistically significant difference in the prevalence of these antibodies in the groups of patients with a biochemical pregnancy (0 for anticardiolipin and 2.8% for antiphosphatidylserine), spontaneous miscarriage (11.4% for anticardiolipin and 20% for antiphosphatidylserine), ongoing pregnancy (7.3% for anticardiolipin and 11.6% for antiphosphatidylserine), and patients who failed to conceive (7.2% for anticardiolipin and 10.8% for antiphosphatidylserine). There was no correlation between outcome and the antibody isotype expressed.

CONCLUSION(S)

Anticardiolipin and antiphosphatidylserine antibodies are poorly predictive of the IVF cycle outcome. Routine testing of IVF patients for the presence of these antibodies is of limited clinical utility.

Thyroid antibodies and their relation to antithrombin antibodies, anticardiolipin antibodies and lupus anticoagulant in women with recurrent spontaneous abortions (antithyroid, anticardiolipin and antithrombin autoantibodies and lupus anticoagulant in habitual aborters)

OBJECTIVE

This study was undertaken to evaluate the incidence of thyroid autoantibodies in women with a history of recurrent spontaneous abortions (RSA) and to investigate their relationship to non-organ specific autoantibodies.

STUDY DESIGN

28 euthyroid non-pregnant habitual aborters were analysed for thyreoglobulin (TG), thyroid peroxidase antibodies (TPO), and autoantibodies to thromboplastin, cardiolipin and lupus anticoagulant. 28 multigravidae without previous abortions or endocrine dysfunctions served as controls.

RESULTS

11 of 28 women with recurrent spontaneous miscarriage (39%), but only 2 of 28 controls (7%) (Chi square test: p < 0.01) demonstrated positive titres of TG, TPO, or both antibodies, 12 patients were positive for antithrombin antibodies and 3 for anticardiolipin. Only one women was lupus anticoagulant positive. No significant correlation between thyroid antibody positivity and positivity for antiphospholipids (Fisher's exact test: p = 0.441), anticardiolipin (p = 0.664) or lupus coagulant (p = 0.607) was found.

CONCLUSIONS

The incidence of thyroid antibodies in euthyroid women with recurrent pregnancy loss appears to be significantly increased compared with controls of reproductive age without previous abortions. No correlation between the presence of thyroid autoantibodies and non-organ specific autoantibodies could be established.

Antiphospholipid syndrome in pregnancy. Obstetric concerns and treatment

To be sure, antiphospholipid antibody syndrome is a protean disease with many manifestations, some of which are exacerbated during pregnancy, and some of which even lead to its initial diagnosis during pregnancy. Although the best treatment during pregnancy is uncertain at this point, and some of the treatments are even experimental, there does seem to be a benefit in at least identifying and probably treating those with risk factors. If treatment is not instituted with heparin, aspirin, or other medical management, at least monitoring for the known superimposed disease states, such as intrauterine growth retardation, preeclampsia, and fetal loss, should be judicious, with close antenatal surveillance.

Anticardiolipin antibodies in patients with pregnancy loss induce factor Xa production in the presence of beta 2-glycoprotein I

PROBLEM

Anticardiolipin antibodies (aCL) are commonly associated with recurrent pregnancy loss, though the mechanism is uncertain. Some investigators have indicated that aCL may be directed at a complex made up of cardiolipin and a blood anticoagulant, beta 2-glycoprotein I (beta 2GPI). We therefore investigated the effects of beta 2GPI-dependent aCL IgG enriched fractions, isolated from sera of patients with pregnancy losses, on blood coagulation.

METHOD

beta 2GPI-dependent aCL were prepared from sera of three women with second trimester pregnancy losses, by cardiolipin affinity column chromography, following by anti-beta 2GPI affinity column chromatography. The effects of beta 2GPI and beta 2GPI-dependent aCL on the activation of factor X in vitro were examined.

RESULTS

beta 2GPI inhibited the activation of factor X and beta 2GPI-dependent aCL blocked this inhibitory effect in a dose dependent manner.

CONCLUSION

These results imply the possibility of beta 2GPI-dependent aCL induce hypercoagulation or thrombus by blocking the inhibitory effect of beta 2GPI on activation of factor X, which may result in pregnancy loss.

Specific antiphospholipid antibodies (aPL) eluted from placentae of pregnant women with aPL-positive sera

The mechanism by which antiphospholipid antibodies (aPL) cause recurrent pregnancy loss remains unclear. It has however been reported that aPL may affect cytotrophoblasts in vitro and thus direct placental damage might occur. Therefore, we investigated whether aPL are bound directly to placental tissues in patients with immunoglobulin G (IgG)-aPL positive sera. The material investigated comprised the placentae of six patients with a history of recurrent pregnancy loss and subclinical autoimmune disorder and one with systemic lupus erythematosus, who were treated with a combination of prednisolone and aspirin. Normal controls consisted of placentae derived from six women, negative for serum aPL, with no medical or obstetrical complication during their pregnancy. Five kinds of IgG- and IgM-antiphospholipid (anti-PS, PI, PA, PG and CL) antibodies were eluted from the placentae of both patients and controls, which were measured by enzyme-linked immunosorbent assay. IgG-aPL were detected in the placental eluates of four of seven (57%) patients, whereas IgM-aPL were not found in any. With respect to the pregnancy outcome of the four patients with IgG-aPL-positive placental eluates, one experienced intrauterine fetal death (IUFD) at 23 weeks of gestation and three demonstrated intrauterine growth retardation (IUGR). In contrast, the remaining three patients, evaluated negative for IgG-aPL in placental eluates, gave birth to one baby with IUGR and two appropriate-for-date babies. The placentae of the four mothers with IgG-aPL-positive placental eluates pathologically showed severe thrombotic findings. These results suggest that IgG-aPL can directly bind to placental tissue and might cause pathologic damage resulting in IUFD or IUGR.

Cerebrovascular disease with antiphospholipid antibodies: immune mechanisms, significance, and therapeutic options

There has been a recent, dramatic surge in interest in antiphospholipid antibodies and associated clinical disorders, especially focal ischemic cerebrovascular disease. Antiphospholipid antibodies are a heterogeneous group of antibodies with varying specificities. Coagulation assays will detect lupus anticoagulants while enzyme-linked immunosorbent assays detect anticardiolipin antibodies. There are numerous potential links between antiphospholipid antibodies and coagulation disorders, including interaction of antiphospholipid antibodies and a cofactor, beta 2-glycoprotein I, which itself is involved in coagulation mechanisms. While the specific mechanism of antiphospholipid antibody-related coagulopathy is unknown, it is clear that antiphospholipid antibodies are associated with an immune-mediated prothrombotic state. Patients with the highest titers of IgG antiphospholipid antibodies have a relatively high risk of recurrent thrombotic events, especially stroke, deep venous thrombosis, and spontaneous abortion. Because of limited controlled, prospective data, current therapy remains empiric and directed at coagulation mechanisms, immune mechanisms, or both.

Clinical significance of anti-GM3 antibodies in recurrent pregnancy loss with elevated level of antiphospholipid antibodies

PROBLEM

The ganglioside-GM3 neutralizes the reactivity of antiphospholipid antibodies (APLs) to phospholipids in vitro. The question of whether anti-GM3 antibodies might exert influence in APLs-positive recurrent pregnancy loss patients who are undergoing prednisolone and aspirin (PSL/ASA) treatment was investigated.

METHOD

The anti-GM3 antibody assay of sera was accomplished by ELISA. Sera of 56 patients with recurrent pregnancy loss, including 30 APLs-positive cases given PSL/ASA treatment, were examined.

RESULTS

Patients positive for IgG or IgM type anti-GM3 antibodies constituted 13/30 (43%) of the APLs-positive group as compared with only 2/26 (8%) of those who were negative (P < 0.01). In pregnant women with APLs-positive treated with PSL/ASA, live births occurred in only 6/13 (46%) patients with detectable anti-GM3 antibodies, while in 16/17 (94%) who tested negative for anti-GM3 antibodies (P < 0.01).

CONCLUSIONS

This observation suggests the possibility that presence of anti-GM3 antibodies may be an indicator for determining the prognosis in recurrent pregnancy loss with elevated level of APLs.

Clinical significance of beta 2-glycoprotein I-dependent anticardiolipin antibodies in the reproductive autoimmune failure syndrome: correlation with conventional antiphospholipid antibody detection systems

OBJECTIVE

Our purpose was to determine whether beta 2-glycoprotein I-dependent anticardiolipin antibodies may represent a superior marker of reproductive risk than do conventional antiphospholipid antibodies.

STUDY DESIGN

The incidence of beta 2-glycoprotein I-dependent and beta 2-glycoprotein I-independent anticardiolipin antibodies and of six conventional antiphospholipid antibodies was statistically compared between study groups with and without autoantibody-associated features of reproductive failure. Sera from 356 women were randomly selected from the frozen sera bank at the Center for Human Reproduction, Chicago. They included sera from 259 patients with autoantibody-associated features of reproductive failure such as unexplained infertility, endometriosis, and repeated pregnancy loss and 97 infertile controls. Autoantibody levels by a modified enzyme-linked immunosorbent assay for beta 2-glycoprotein I-dependent and beta 2-glycoprotein I-independent anticardiolipin antibodies and a standard enzyme-linked immunosorbent assay for anticardiolipin antibody and five other antiphospholipid antibodies were then compared.

RESULTS

Patients demonstrated a significantly higher incidence of beta 2-glycoprotein I-dependent anticardiolipin antibodies (5.4%) than did controls (0%) in a modified enzyme-linked immunosorbent assay (p = 0.01). No such difference was, however, noted for beta 2-glycoprotein I-independent anticardiolipin antibodies or any one of six antiphospholipid antibodies. Two or more among six antiphospholipid antibodies, especially if involving anticardiolipin antibodies, antiphosphatidylserine and antiphosphatidylinositol, as assayed by standard enzyme-linked immunosorbent assay, were significantly more often (p = 0.02) positive in the patients (5.0%) than in the controls (0%). Moreover, positivity in two of those three antiphospholipid antibodies correlated in 59% of cases to positivity in the beta 2-glycoprotein I-dependent anticardiolipin antibody.

CONCLUSIONS

As a single test beta 2-glycoprotein I-dependent anticardiolipin antibody appears to be superior to cofactor-independent anticardiolipin antibody or any other single conventional antiphospholipid antibody for the detection of autoantibody-associated conditions of reproductive failure. A broadly based panel of conventional antiphospholipid antibodies, especially if inclusive of anticardiolipid antibody, antiphosphatidylserine, and antiphosphatidylinositol, may, however, achieve similar results.

A prospective study on pregnancy risk of antiphospholipid antibodies in association with systemic lupus erythematosus

This prospective study is an attempt to address the issues of whether or not antiphospholipid antibodies (aPL) constitute a significant risk factor for pregnancy in individuals with systemic lupus erythematosus (SLE) and whether or not combination therapy of high-dose prednisolone (PSL) and low-dose acetylsalicylic acid (ASA) offers efficient control. Antibodies against six phospholipids were measured in sera of patients with stable SLE who had no severe complications before pregnancy, and were followed up during subsequent pregnancies. Four of 12 patients with SLE demonstrated aPL-positivity. Six of 8 patients without aPL had appropriate-for-date (AFD) live babies, the remaining two suffering intrauterine fetal death (IUFD) in the first trimester, one having a chromosome abnormality. Two aPL-positive patients treated only with 5-15 mg/day PSL during pregnancy ended in IUFD in the second trimester. In contrast, the other two patients treated with high-dose PSL and low-dose ASA each had AFD live babies at 38 weeks gestation. The results suggest that APL is a crucial risk factor in pregnancy with stable SLE. Combination therapy of high-dose PSL and low-dose ASA may enable aPL-positive patients with SLE to have AFD live babies.

Presence of multiple anti-phospholipid antibody specificities in a pediatric population

Thrombotic related events are thought to be associated with the presence of anti-phospholipid antibodies (APA). However, the association of anti-cardiolipin antibody is much weaker than the association with antibodies to other phospholipids. Much of the literature equates antiphospholipid antibodies and anticardiolipin antibodies because of the relationship of APA and false positive tests for syphilis. However, recently the presence of antibodies to naturally occurring phospholipids other than cardiolipin have been reported. In fact, some investigators report that antibodies to phosphatidylserine appear to correlate more closely to disease processes than anti-cardiolipin antibodies. We describe here the presence of non-anti-cardiolipin antiphospholipid antibodies in a pediatric population that lack anti-cardiolipin antibodies and demonstrate the association of these antibodies with thrombotic disease. Antibodies to phosphatidic acid were the most prevalent and correlated (p < .001) with thrombotic disease and idiopathic thrombocytopenia purpura. The rank order of prevalence of antibodies to phospholipids was phosphatidic acid, phosphatidylglycerol, phosphatidylinosital, phosphatidylserine, cardiolipin and phosphatidylethanolamine. Antiphospholipid antibodies of the three major sera isotypes were present in the positive sera examined. These descriptive findings suggest that the significance of APA other than anti-cardiolipin antibodies in pediatric patients should be further investigated.