Evidence of autoantibodies against cardiac troponin I and sarcomeric myosin in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a major cause of pregnancy-related maternal heart failure that develops towards the end of pregnancy or in the months following delivery. In small retrospective case series, autoimmune responses in the pathogenesis of PPCM have been proposed upon identification of autoantibodies (AABs) to cardiac antigens. However, their clinical and prognostic relevance still remain unclear. In this study, we evaluated the presence of circulating AABs against cardiac sarcomeric myosin (MHC) and troponin I (TnI) in the sera of PPCM patients and in relation to clinical presentation. In this case-control study, 70 patients diagnosed with PPCM and 50 pregnancy-matched healthy women with normal cardiac function were enrolled. Clinical assessment, echocardiography and blood tests were performed at baseline and at 6 ± 2 months follow-up. The presence of serum AABs against MHC (anti-MHC) and TnI (anti-TnI) was determined with a custom-made enzyme-linked immunosorbent assay (ELISA). The seropositivity for these AABs was correlated with the severity of LV dysfunction and the occurrence of pericardial effusion indicative of perimyocardial inflammation at baseline. Potential impact of these AABs on disease progression was evaluated with regard to functional (left ventricular ejection fraction) and clinical improvement at follow-up. Either anti-MHC or anti-TnI or both AABs were detected in the serum of 46 % of PPCM patients and in 8 % of healthy controls. In PPCM the presence of either one of these AABs was associated with significantly lower baseline LVEF and lower rate of full cardiac recovery at follow-up. Patients who were seropositive for anti-TnI AABs showed more frequently pericardial effusion indicative of a more pronounced immune response of the peri-/myocardium in these patients. Further studies are required to clarify cellular and molecular circuits leading to elevated levels of AABs and their pathophysiological relevance for disease initiation and progression in PPCM.

Cutting edge assessment of the impact of autoimmunity on female reproductive success

There, likely, is no more controversial issue in reproductive medicine than the effects of autoimmunity on female reproductive success. Published studies are, therefore, often biased. We performed PubMed, Google Scholar and Medline searches for the years 2000-2010 under various key words and phrases, referring to effects of autoimmunity/autoimmune diseases on pregnancy/pregnancy outcomes/pregnancy rates/reproduction/reproductive outcomes/fertility/infertility/fertility treatments/infertility treatments, and a number of similar terms. Reference lists of selected manuscripts were evaluated for additional, potential references. All selected manuscripts were reviewed by at least one author (N.G.). Opinions were reached based on preferential review of only selected studies, which offered data, primarily developed in pursuit of unrelated scientific questions. Data from various medical fields point, surprisingly effectively, toward significant impacts of autoimmunity on female reproductive success. Autoimmunity not only increases miscarriage risks but also reduces female fecundity and infertility treatment success. A, likely, reason why differences of opinion have persisted is that effects are primarily observed in genetically predisposed women, with specific fragile X mental retardation 1 (FMR1) genotypes. This discovery coincides with recently increasing appreciation of the importance of the long arm of the X chromosome (Xq) in control of functional ovarian reserve (reflective of female fertility) and autoimmunity, with FMR1at Xq27.3, located at cross roads of both. Autoimmune effects on female reproductive success deserve recognition. Further investigations must not ignore patient stratification, based on ovarian FMR1 genotypes. Genetic definition of high-risk patients should lead to development of successful therapeutic interventions.

Gestational dermatosis shortly after implantation associated with parental class II HLA compatibility and maternal immune activation: preliminary report of a prospective case series

BACKGROUND

Pregnancy represents a semi-allograft, subject to similar immune responses as allogeneic organ transplants. Tolerance of pregnancy appears best with maximal class II HLA heterogeneity between mother and father, while compatibilities are associated with increased pregnancy loss and maternal autoimmunity. Tolerance abnormalities often involve skin reactions. Abnormalities in tolerance of the fetal graft may do the same.

OBJECTIVE

To define the characteristics of a newly described dermatosis in very early pregnancy.

METHODS

Prospective case series of 7 couples/12 clinical episodes.

RESULTS

The dermatosis was observed in 7 out of 285 women undergoing in vitro fertilization (IVF; 2.5%; 95% CI 0.66-4.26%) and in 12 out of 277 total IVF cycles reaching embryo transfer (4.3%; 95% CI 1.93-6.73%). Prior to IVF all women reported autoimmune clinically significant allergies. All but 1 couple demonstrated class II HLA compatibility. Two of 4 pregnancies miscarried. All rashes erupted within days from embryo implantation.

CONCLUSIONS

The 'implantation rash' reported here is uncommon but not rare. It may be the consequence of abnormal maternal immune responses to embryo implantation in women with prior immune activation, associated with class II HLA compatibility between parents. Further prospective studies are required to better define this condition.

Does fetal sex influence the risk of preterm delivery in dichorionic twin pregnancies after spontaneous conception?

OBJECTIVE

The incidence of preterm delivery has been increasing, and our aim was to estimate the influence of fetal sex on the risk of preterm delivery in dichorionic twins after spontaneous conception.

METHODS

125 spontaneously conceived dichorionic twin gestations, with viable fetuses, born after 24 weeks and delivered spontaneously before 37 weeks, were enrolled. The impact of fetal sex, previous preterm delivery, maternal age, body-mass-index, smoking, and parity on gestational age at birth were evaluated.

RESULTS

Despite similar baseline characteristics in all three groups, women with one or two male fetuses delivered significantly more often before 34 weeks than patients with two female fetuses, 48% (23/48) and 43% (19/44) vs 21% (7/33), p = .04. Regression analyses, including fetal sex, maternal age, maternal body-mass-index, smoking, previous preterm delivery and parity, revealed that only fetal sex was significantly associated with spontaneous preterm delivery (p = .03).

CONCLUSION

Fetal sex appears to be a risk factor for preterm delivery in spontaneously conceived dichorionic twin gestations. Twin pregnancies with one or two male fetuses seem to be at higher risk for spontaneous preterm delivery than those with only females.

Peripartum cardiomyopathy, an autoimmune manifestation of allograft rejection?

The timing of peripartum cardiomyopathy (PPCM) in association with pregnancy is typical of autoimmune conditions. This review addresses this fact by presenting PPCM as an organ specific autoimmune response (though not necessarily as an outright autoimmune condition), akin to autoimmune responses seen with complications of allogeneic organ transplantations. Since pregnancy represents a semi-allograft (representing paternal alloantigens), pregnancy and allogeneic organ transplants can be expected to be subject to similar allograft tolerance mechanisms, and also to share potential complications of normal allograft tolerance. This review suggests that PPCM represents a cardio-toxic autoimmune component within a more general immunological malfunction of tolerance of the fetal allograft by the maternal immune system. Treatment of PPCM with therapies, proven successful in graft versus host disease and organ rejection, may, therefore, be successful. Their success would also be confirmatory of such a concept.