Recurrent fetal loss and antiphospholipid antibodies: clinical and therapeutic aspects

[Biological monitoring of autoimmune diseases during pregnancy]

This review focuses on auto-immune diseases which frequently affect women and can have interactions with pregnancy: lupus erythematosus (LES), antiphospholipide syndrome (SAPL), Sjögren's syndrome (GS), rheumatoid arthritis (PR) and auto-immune thyroiditis. LES may flare at the end of a pregnancy and during post-partum. Its biological monitoring during pregnancy is well established. SAPL is at risk of sterility, prematurity, Hellp syndrome, eclampsia and retroplacental hematoma. The main risk, actually risk is foetal loss by placental ischemia, which has to be well known as 2 randomised studies have proven the efficacy of treatments with aspirin +/- subcutaneous heparin. LES, GS and PR can both be associated with anti SS-A +/- anti SS-B antibodies linked to a risk of congenital auriculo-ventricular block, which is fortunately low (less than 5% of the cases). Auto-immune thyroiditis are often revealed during pregnancy and may be enhanced during the six first months of post-partum.

[Value of intravenous immunoglobulins during antiphospholipid syndrome]

BACKGROUND

The antiphospholipid syndrome was individualized 12 years ago. Treatment was initially based on steroids, immunosuppressive drugs and intravenous immunoglobulin therapy. More recently, several retrospective studies have established that in most clinical conditions therapeutic doses of oral vitamin K antagonists (INR > or = 3) are sufficient to control the disease.

THE ROLE OF IMMUNOGLOBULIN THERAPY

However, high dose immunoglobulin therapy is still indicated in a few cases, especially in life-threatening immune peripheral thrombocytopenia, and in recurrent foetal loss: in the latter indication, immunoglobulin therapy alone is efficient in 80% of cases.

FUTURE PROSPECTS

Prospective studies are needed to assess the efficacy of intravenous immunoglobulin therapy in neurological complications occurring in spite of anticoagulant therapy, and in the context of repeated foetal losses when antithrombotic therapy with aspirin and subcutaneous heparin has failed.