Elevated antiphospholipid antibody titers and adverse pregnancy outcomes: analysis of a population-based hospital dataset

Preeclampsia and the Antiphospholipid Syndrome

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.

Presence of antiphospholipid antibodies is associated with increased implantation failure following in vitro fertilization technique and embryo transfer: A systematic review and meta-analysis

Purpose

A systematic review and meta-analysis was conducted comparing the presence of anti-phospholipid (anti-PL) antibodies between women of reproductive age, without diagnosis of antiphospholipid syndrome, who experienced at least two implantation failures following in vitro fertilization and embryo transfer (IVF-ET), and either women who had a successful implantation after IVF-ET or women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET.

Methods

Systematic search of the literature and meta-analysis of the relevant studies studying presence of antiphospholipid antibodies in women experiencing at least two implantation failures in IVF-ET as compared to either women who had a successful implantation after IVF-ET or/and women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET. Six hundred ninety-four published reports were retrieved; 17 of them fulfilled the inclusion criteria set.

Results

Presence of either any type of anti-phospholipid or anticardiolipin antibodies or lupus-anticoagulant in women experiencing at least two implantation failures in IVF-ET was associated with increased implantation failure compared to women who had a successful implantation after IVF-ET (relative risk, RR: 3.06, 5.06 and 5.81, respectively). Presence of either anticardiolipin or lupus-anticoagulant or anti-beta₂ glycoprotein-I or anti-phosphatidylserine antibodies in women experiencing at least two implantation failures in IVF-EΤ was associated with increased implantation failure compared to unselected healthy fertile women with no history of IVF-ET (RR:13.92, 6.37, 15.04 and 164.58, respectively).

Conclusion

The prevalence of antiphospholipid antibodies, particularly that of anti-beta₂ glycoprotein-I and anti-phosphatidylserine antibodies, in women experiencing at least two implantation failures in IVF-ET without diagnosis of antiphospholipid syndrome is significantly greater than either in women who had a successful implantation after IVF-ET or women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET.

Trial registration number

PROSPERO ID: CRD42018081458

Management and the pregnancy outcomes of patients positive for anti-parietal cell antibody

BACKGROUND

Autoimmunity is related to poor obstetric outcomes in previous studies.

OBJECTIVE

To evaluate the management and the pregnancy outcomes of patients positive for anti-parietal cell antibody (APCA).

METHODS

We retrospectively evaluated obstetric, neonatal outcomes and Beksac Obstetrics Index (BOI) of pregnancies with APCA positivity. Coexisting Methylentetrahydrofolate reductase (MTHFR) polymorphisms, other autoimmune antibody positivities, or thrombophilias were also evaluated in terms of obstetric outcomes.

RESULTS

Of 39 pregnancies, three resulted in abortions (7.6%). The median gestational week and birthweight was 37 weeks and 2795 g. The median APGAR scores were 8, 9, and 9 for first, fifth, and tenth minute, respectively. Analysis involving additional risk factors showed no significant difference between the groups, evaluating APCA titers, MTHFR polymorphisms, or thrombophilia status. Significant difference was only observed for the fifth minute APGAR scores between the groups with other autoantibody positivities (p= 0.036). Despite lack of significant differences, patients with positivity for more than one autoimmune antibody had lower APGAR scores for the first and tenth minute, respectively (p= 0.727; p= 0.083). BOI analysis showed a statistically significant difference between the groups, demonstrating that more than one "antibody positivity" indicated a worse obstetric history.

CONCLUSIONS

Patients with more than one autoantibody positivity, including APCA, must be considered as high-risk patients.

Pregnancy outcomes of the patients with anti-smooth muscle antibody positivity

BACKROUND AND AIMS

To evaluate the management and the pregnancy outcomes of patients positive for anti-smooth muscle antibody (ASMA).

METHODS

We retrospectively evaluated the pregnancy outcomes of the patients with ASMA positivity compared to patients without any known autoantibody positivity and/or autoimmune diseases. We have also evaluated the obstetric outcomes of the patients with ASMA positivity in terms of existence of MTHFR polymorphisms, other hereditery thrombophilias and other autoantibody positivities.

RESULS

In this study, 40 ASMA positive patient were evaluated and compared with 80 control cases. Gestational week at delivery, birthweight and APGAR scores for the 1st, 5th, 10th were significantly lower at patients with ASMA positivity (p< 0.01; p< 0.01; p< 0.01; p< 0.01; p: 0.030 respectively). Further analysis regarding to existence of additional risk factors revealed no significant difference between each pair of groups in terms of any obstetric outcome.

CONCLUSIONS

ASMA positivity may be associated with adverse pregnancy outcomes.

Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review

Most investigators currently advocate prophylactic-dose heparin plus low-dose aspirin as the preferred treatment of otherwise healthy women with obstetric antiphospholipid syndrome, whilst women with a history of vascular thrombosis alone or associated with pregnancy morbidity are usually treated with therapeutic heparin doses in association with low-dose aspirin in an attempt to prevent both thrombosis and pregnancy morbidity. However, the protocols outlined above fail in about 20 % of pregnant women with antiphospholipid syndrome. Identifying risk factors associated with pregnancy failure when conventional therapies are utilized is an important step in establishing guidelines to manage these high-risk patients. Some clinical and laboratory risk factors have been found to be related to maternal-foetal complications in pregnant women on conventional therapy. However, the most efficacious treatments to administer to high-risk antiphospholipid syndrome women in addition to conventional therapy in order to avoid pregnancy complications are as yet unestablished. This is a comprehensive review on this topic and an invitation to participate in a multicentre study in order to identify the best additional treatments to be used in this subset of antiphospholipid syndrome patients.

Human Chorionic Gonadotropin Influences Systemic Autoimmune Responses

Immunopathological outcomes in Systemic Lupus Erythematosus (SLE; or lupus) are believed to be autoantibody-mediated. Conditions which promote a Th2 skew (such as pregnancy) should encourage antibody production, worsening antibody-mediated diseases while ameliorating Th1/Th17-mediated diseases. Although an increased propensity toward autoreactivity can be observed in pregnant lupus patients and in pregnant lupus-prone mice, whether a unique human pregnancy-specific factor can contribute to such effects is unknown. This study assessed whether human chorionic gonadotropin (hCG, a pregnancy-specific hormone of diverse function) at physiological concentrations could mediate stimulatory influences on immune parameters in non-pregnant, lupus-prone mice, in light of the hormone's ameliorating effects on Th1-mediated autoimmunity in murine models. Results demonstrate that administration of hCG heightened global autoreactivity in such mice; antibodies to dsDNA, RNP68, Protein S, Protein C, β2-glycoprotein 1, and several phospholipids were enhanced, and hormone administration had adverse effects on animal survival. Specifically in splenic cell cultures containing cells derived from lupus-prone mice, hCG demonstrated synergistic effects with TLR ligands (up-modulation of costimulatory markers on B cells) as well as with TCR stimuli (enhanced proliferative responses, enhanced levels of cytokines, and the phosphorylation of p38). In both instances, enhanced synthesis of lupus-associated cytokines was observed, in addition to the heightened generation of autoantibodies reactive toward apoptotic blebs. These results suggest that selective transducive, proliferative, and differentiative effects of hCG on adaptive immune cells may drive autoreactive responses in a lupus environment, and may also potentially provide insights into the association between the presence of higher hCG levels (or the administration of hCG) with the presence (or appearance) of humoral autoimmunity.

Antibodies directed against annexin A2 and obstetric morbidity

Acquired and inherited thrombophilia have both been reported to be associated with an increased risk of obstetric complications in early or later stages of pregnancy. Annexin A2 (ANXA2) is strongly expressed in vascular and placental tissues and plays a crucial role in fibrinolysis. The aim of the present study was to evaluate the prevalence of antibodies directed against ANXA2 in patients with recurrent miscarriage or obstetric complications. Anti-ANXA2 antibodies (aANXA2) were detected by ELISA in the sera from 46 women with obstetric morbidity, mainly recurrent miscarriage. The cut-off value for positivity was defined as 3 standard deviations above the mean optical density (OD) obtained in the sera from 42 female blood donors. The prevalence of aANXA2 in patients and healthy individuals was 15.2% and 2.3%, respectively. A statistically significant difference was observed between the 2 groups in terms of aANXA2 IgG titers (p=0.01). The highest aANXA2 levels were observed in sera from 2 patients with recurrent miscarriage and one patient with preeclampsia. aANXA2 could play a role in thrombotic mechanisms leading to recurrent pregnancy loss and placental vascular disease. Further studies are needed to determine whether ANXA2 is critical for maintenance of placental integrity.

Pravastatin improves pregnancy outcomes in obstetric antiphospholipid syndrome refractory to antithrombotic therapy

BACKGROUND

Administration of conventional antithrombotic treatment (low-dose aspirin plus low-molecular weight heparin [LDA+LMWH]) for obstetric antiphospholipid syndrome (APS) does not prevent life-threatening placenta insufficiency-associated complications such as preeclampsia (PE) and intrauterine growth restriction (IUGR) in 20% of patients. Statins have been linked to improved pregnancy outcomes in mouse models of PE and APS, possibly due to their protective effects on endothelium. Here, we investigated the use of pravastatin in LDA+LMWH-refractory APS in patients at an increased risk of adverse pregnancy outcomes.

METHODS

We studied 21 pregnant women with APS who developed PE and/or IUGR during treatment with LDA+LMWH. A control group of 10 patients received only LDA+LMWH. Eleven patients received pravastatin (20 mg/d) in addition to LDA+LMWH at the onset of PE and/or IUGR. Uteroplacental blood hemodynamics, progression of PE features (hypertension and proteinuria), and fetal/neonatal outcomes were evaluated.

RESULTS

In the control group, all deliveries occurred preterm and only 6 of 11 neonates survived. Of the 6 surviving neonates, 3 showed abnormal development. Patients who received both pravastatin and LDA+LMWH exhibited increased placental blood flow and improvements in PE features. These beneficial effects were observed as early as 10 days after pravastatin treatment onset. Pravastatin treatment combined with LDA+LMWH was also associated with live births that occurred close to full term in all patients.

CONCLUSION

The present study suggests that pravastatin may improve pregnancy outcomes in women with refractory obstetric APS when taken at the onset of PE or IUGR until the end of pregnancy.

Pregnancy and autoimmune connective tissue diseases

Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.

[Pregnancy in systemic autoimmune diseases: Myths, certainties and doubts]

Systemic autoimmune diseases especially affect young women during childbearing age. The aim of this review is to update systemic lupus erythematosus, antiphospholipid syndrome and systemic sclerosis management during pregnancy. These diseases present variable maternal and fetal risks. Studies show that an appropriate disease control and a reasonable remission period prior to pregnancy are associated with satisfactory obstetric outcomes. Antiphospholipid autoantibodies profile, anti-Ro/anti-La antibodies, pulmonary pressure and activity evaluation are crucial to assess the pregnancy risk. Monitoring requires a multidisciplinary team, serial analytic controls and Doppler ultrasound of maternal and fetal circulation. Evaluation of the activity of the disease is essential.

Antiphospholipid antibodies and the risk of severe and non-severe pre-eclampsia: the NOHA case-control study

BACKGROUND

pre-eclampsia (PEecl) can be defined as non-severe (NS-PEecl) or severe (S-PEecl). Our study aimed to determine the incidence of antiphospholipid antibodies (aPLs) in women with a past history of NS-PEecl or S-PEecl.

PATIENTS AND METHODS

This case-control study includes 195 control women, 199 NS-PEecl patients and 143 S-PEecl patients whose plasma samples were collected 6 months after their first delivery. Each plasma was tested for lupus anticoagulant (LA), anticardiolipin (aCL) and antiβ2GP1 antibodies, as well as antibodies against phosphatidylserine/prothrombin complex (aPS/PT) and domain I of the β2GP1.

RESULTS

When compared with the control group no significant associations were found for the NS-PEecl group after adjustment of confounding variables. For the S-PEecl group, there was an association with antiβ2GP1 immunoglobulin G (IgG) (OR 16.91, 95% CI 3.71-77.06), as well as age, obesity, smoking and multiparity. Antiβ2GP1-domain I IgG was associated with aCL, antiβ2GP1 and aPS/PT IgG in the three groups. aPS/PT IgG was associated with aCL IgG, and aPS/PT IgM was associated with aCL and antiβ2GP1 IgM in the three groups.

CONCLUSION

S-PEecl is a distinct entity from NS-PEecl and is mainly associated with the presence of antiβ2GP1 IgG. Antiβ2GP1 domain I correlates with other aPL IgG tests, and aPS/PT may be promising in patients for whom LA tests cannot be interpreted.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Primary prophylaxis to prevent obstetric complications in asymptomatic women with antiphospholipid antibodies: a systematic review

OBJECTIVE

Obstetric complications are common in patients with antiphospholipid syndrome. However, the impact of antiphosholipid antibodies (aPL) in the pregnancy outcomes of asymptomatic aPL carriers is uncertain. The aim of this systematic review is to assess whether primary prophylaxis is beneficial to prevent obstetric complications during pregnancy in asymptomatic women positive for aPL who have no history of recurrent pregnancy loss or intrauterine fetal death.

METHODS

Studies evaluating the effect of prophylactic treatment versus no treatment in asymptomatic pregnant aPL carriers were identified in an electronic database search. Design, population and outcome homogeneity of studies was assessed and meta-analysis was performed. The pooled Mantel-Haenszel relative risk of specific pregnancy outcomes was obtained using random effects models. Heterogeneity was measured with the I(2) statistic. All analyses were conducted using Review Manager 5.3.

RESULTS

Data from five studies involving 154 pregnancies were included and three studies were meta-analysed. The risk ratio and 95% confidence interval (CI) of live birth rates, preterm birth, low birth weight and overall pregnancy complications in treated and untreated pregnancies were 1.14 (0.18-7.31); 1.71 (0.32-8.98); 0.98 (0.07-13.54) and 2.15 (0.63-7.33),respectively. Results from the meta-analysis revealed that prophylactic treatment with aspirin is not superior to placebo to prevent pregnancy complications in asymptomatic aPL carriers.

CONCLUSION

This systematic review did not find evidence of the superiority of prophylactic treatment with aspirin compared to placebo or usual care to prevent unfavourable obstetric outcomes in otherwise healthy women with aPL during the first pregnancy.

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.

[Pregnancy and inflammatory rheumatic diseases]

Pregnancy in women with rheumatic diseases represents a challenge for patients and physicians and requires optimal shared decision-making strategies. However, the majority of women can have a successful pregnancy and the vast majority of babies are born healthy. Specific preconception care should be offered to women with rheumatic diseases to optimize and increase the chances of a successful pregnancy. A careful assessment of possible risks and the justified use of antirheumatic drugs before, during and after pregnancy are key issues.

Obstetrical antiphospholipid syndrome: from the pathogenesis to the clinical and therapeutic implications

Antiphospholipid syndrome (APS) is an acquired thrombophilia with clinical manifestations associated with the presence of antiphospholipid antibodies (aPL) in patient plasma. Obstetrical APS is a complex entity that may affect both mother and fetus throughout the entire pregnancy with high morbidity. Clinical complications are as various as recurrent fetal losses, stillbirth, intrauterine growth restriction (IUGR), and preeclampsia. Pathogenesis of aPL targets trophoblastic cells directly, mainly via proapoptotic, proinflammatory mechanisms, and uncontrolled immunomodulatory responses. Actual first-line treatment is limited to low-dose aspirin (LDA) and low-molecular weight heparin (LMWH) and still failed in 30% of the cases. APS pregnancies should be a major field in obstetrical research, and new therapeutics are still in progress.

Group B streptococcal colonization and the risk of pre-eclampsia

To determine if there was an association between recto-vaginal group B streptococcus (GBS) colonization and pre-eclampsia, two cross-sectional studies were conducted using statewide hospital databases. The first study analysed data from the state of Florida, USA, and included 190 645 women who were discharged in 2001. This dataset was used to generate the hypothesis that GBS colonization is associated with pre-eclampsia. The second study tested the GBS hypothesis using the records of 577 153 women who delivered in 2004 or 2005 in Texas, USA. Adjusted odds ratios (aOR) for the outcome of pre-eclampsia comparing GBS-positive to GBS-negative women were calculated using logistic regression. The aOR for the association between GBS carriage and pre-eclampsia was 0·71 [95% confidence interval (CI) 0·65–0·77] in the Florida dataset. In the Texas dataset, the overall prevalence of GBS carriage was 14·1% while the overall prevalence of pre-eclampsia was 4·0%. GBS carriers were 31% less likely than non-carriers to have pre-eclampsia (aOR 0·69, 95% CI 0·66–0·72) in Texas. In two large statewide analyses, GBS carriage was inversely associated with pre-eclampsia. A sensitivity analysis revealed that misclassification of GBS status is not a likely explanation of our findings.

[Pregnancy and kidney diseases]

The prevalence of chronic kidney disease in women of childbearing age reaches approximately 0.2%. Under physiological conditions pregnancy results in important hemodynamic changes on the maternal organism. In the case of chronic kidney disease these adaptations often are only partial. Physiological changes of immune response during pregnancy may contribute to the progress of renal disease. Regardless of the underlying kidney disease, one can assume that the better the glomerular filtration rate and blood pressure are the more favorable the course of pregnancy will be with the chance for a healthy child and stable renal function. To achieve this goal, a close interaction is required between gynecologist, nephrologist, and other specialists in a center with appropriate experience.

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.

Lupus and pregnancy: integrating clues from the bench and bedside

Adequate pregnancy care of women with systemic lupus erythematosus (SLE) rests on three pillars: a coordinated medical-obstetrical care, an agreed and well-defined management protocol and a good neonatal unit. Pregnancy should be planned following a preconceptional visit for counselling. Women with severe active disease or a high degree of irreversible damage, such as those with symptomatic pulmonary hypertension, heart failure, severe restrictive pulmonary disease or severe chronic renal failure should best avoid pregnancy. Treatment is based on hydroxychloroquine, low-dose steroids and azathioprine. Patients with antiphospholipid antibodies/syndrome should receive low-dose aspirin +/- low molecular weight heparin. The addition and the dose of heparin depend on the clinical profile of the patient, i.e. a previous history of miscarriage, foetal loss, placental insufficiency or thrombosis. A close surveillance, with monitoring of blood pressure, proteinuria and placental blood flow by Doppler studies helps the early diagnosis and treatment of complications such as preeclampsia and foetal distress. Postpartum follow-up is important.

Antiphospholipid Syndrome during pregnancy: the state of the art

Obstetric complications are the hallmark of antiphospholipid syndrome. Recurrent miscarriage, early delivery, oligohydramnios, prematurity, intrauterine growth restriction, fetal distress, fetal or neonatal thrombosis, pre-eclampsia/eclampsia, HELLP syndrome, arterial or venous thrombosis and placental insufficiency are the most severe APS-related complication for pregnant women. Antiphospholipid antibodies promote activation of endothelial cells, monocytes and platelets, causing an overproduction of tissue factor and thromboxane A2. Complement activation might have a central pathogenetic role. These factors, associated with the typical changes in the hemostatic system during normal pregnancy, result in a hypercoagulable state. This is responsible of thrombosis that is presumed to provoke many of the pregnancy complications associated with APS. Obstetric care is based on combined medical-obstetric high-risk management and treatment with the association between aspirin and heparin. This review aims to deter- mine the current state of the art of APS by investigating the knowledge achievements of recent years, to provide the most appropriate diagnostic and therapeutic management for pregnant women suffering from this syndrome.

Association of anticardiolipin antibodies with preeclampsia: a systematic review and meta-analysis

OBJECTIVE

To systematically review the evidence of the association of anticardiolipin antibodies with preeclampsia.

DATA SOURCES

PubMed and LILACS were perused up to June 2009, citations were searched using the ISI Web of Knowledge database, textbooks and reference lists were reviewed, and experts were contacted. Search terms included "antiphospholipid syndrome," "Hughes' syndrome," "anticardiolipin antibodies," "antiphospholipid antibodies," "anti-cardiolipin," "preeclampsia," and "pre-eclampsia."

METHODS OF STUDY SELECTION

Inclusion criteria were: cohorts, case-control, or controlled cross-sectional studies; healthy pregnancy as controls; no autoimmune diseases; immunoglobulin (Ig)G, IgM anticardiolipin antibody of at least 20 units by enzyme-linked immunosorbent assay, or both; and end-point preeclampsia.

TABULATION, INTEGRATION, AND RESULTS

Our search generated 68,528 entries and 64 full-text articles were reviewed. Twelve studies were included in the meta-analysis. Pooled odds ratio (OR) for association of anticardiolipin antibodies with preeclampsia was 2.86 (95% confidence interval [CI], 1.37-5.98). Pooled OR for anticardiolipin antibodies and severe preeclampsia was 11.15 (95% CI 2.66-46.75). Funnel plot showed minor asymmetry, and the Egger test was not significant (P=.359). Meta-regression identified study design and size as related to heterogeneity.

CONCLUSION

Moderate-to-high levels of anticardiolipin antibodies are associated with preeclampsia, but there is insufficient evidence to use anticardiolipin antibodies as predictors of preeclampsia in clinical practice.

Antiphospholipid syndrome

The antiphospholipid syndrome causes venous, arterial, and small-vessel thrombosis; pregnancy loss; and preterm delivery for patients with severe pre-eclampsia or placental insufficiency. Other clinical manifestations are cardiac valvular disease, renal thrombotic microangiopathy, thrombocytopenia, haemolytic anaemia, and cognitive impairment. Antiphospholipid antibodies promote activation of endothelial cells, monocytes, and platelets; and overproduction of tissue factor and thromboxane A2. Complement activation might have a central pathogenetic role. Of the different antiphospholipid antibodies, lupus anticoagulant is the strongest predictor of features related to antiphospholipid syndrome. Therapy of thrombosis is based on long-term oral anticoagulation and patients with arterial events should be treated aggressively. Primary thromboprophylaxis is recommended in patients with systemic lupus erythematosus and probably in purely obstetric antiphospholipid syndrome. Obstetric care is based on combined medical-obstetric high-risk management and treatment with aspirin and heparin. Hydroxychloroquine is a potential additional treatment for this syndrome. Possible future therapies for non-pregnant patients with antiphospholipid syndrome are statins, rituximab, and new anticoagulant drugs.

Obstetric antiphospholipid syndrome: current uncertainties should guide our way

The subject of obstetric antiphospholipid syndrome (APS) has been reviewed dozens of times, and there is little doubt that the international APS community has done well in bringing APS to the attention of clinicians around the world. However, the evolution of clinical practice, at least in the US, also has convinced us that our field would benefit from further clinical study. For example, the number of women diagnosed with 'APS', but who do not meet the revised Sapporo criteria, seems to have increased. It is now common practice for women with recurrent miscarriage or prior fetal death to be treated with heparin, even in the presence of indeterminate or low titer antiphospholipid antibody (aPL) levels and even after only one positive test. In part, this common practice derives from confusion on the part of many clinicians and patients regarding the diagnosis of APS as well as the clinical and laboratory criteria for the syndrome. In part, this derives from the common practice of so-called 'empiric treatment' in US reproductive medicine, often driven as much by patients as by clinicians. This brief commentary focuses on areas of uncertainty that we see as deserving of new or renewed study for the sake of improving our understanding of APS and best patient care.