Intravenous immunoglobulin treatment of pregnant patients with recurrent pregnancy losses associated with antiphospholipid antibodies

Intravenous immunoglobulin for the secondary prevention of stillbirth in obstetric antiphospholipid syndrome: A case series and systematic review of literature

OBJECTIVE

To evaluate the efficacy and safety of intravenous immunoglobulin (IVIg) in secondary prevention of pregnancy complications for patients with obstetric antiphospholipid syndrome (APS) and history of stillbirth.

METHODS

We described three cases of obstetric APS patients with history of stillbirth treated with IVIg in four pregnancies. In addition, we conducted a systematic literature review on the use of IVIg in obstetric APS with history of stillbirth.

RESULTS

Three patients with obstetric APS and history of stillbirth were treated with prophylactic IVIg, in addition to standard treatment (hydroxychloroquine, low-dose aspirin, low molecular weight heparin, and prednisone), in four pregnancies (three singleton and one twin). All pregnancies resulted in live healthy newborns. Long-term follow-up re-evaluations (24-53 months) did not shown any sign or symptom of active systemic disease, and the children were healthy. The systematic literature review retrieved only three cases of use of IVIg in obstetric APS patients with history of stillbirth. All three cases resulted in live healthy newborns. Only in one case, mild thrombocytopenia occurred during treatment, although this event was unlikely to be related to IVIg.

CONCLUSION

Our experience suggests that IVIg as secondary prevention of APS-related stillbirth is associated with good pregnancy and long-term outcomes, with no relevant safety concerns. However, the literature evidence on this topic is limited to few isolated cases, and further studies are needed to clarify which obstetric APS patients may benefit the most from IVIg.

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.

The treatment of anti-phospholipid syndrome: A comprehensive clinical approach

Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.

IVIG in APS pregnancy

For more than two decades, the intravenous administration of high doses of IgG pooled from the plasma of healthy donors (immune globulin therapy, also known as ‘IVIG’) has benefited patients with a variety of autoimmune disorders. A potential therapeutic role of IVIG in the prevention of thrombosis and of miscarriages in antiphospholipid syndrome (APS) has been postulated. Multicenter randomized controlled trials attempted to define the role of IVIG in preventing pregnancy complications in APS indicate that simple anticoagulation could not be completely satisfactory, and certain patient subgroups might take advantage of IVIG therapy alone or in combination with heparin.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Intravenous immunoglobulins and antiphospholipid syndrome: How, when and why? A review of the literature

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and arterial thromboses and recurrent fetal losses, frequently accompanied by a moderate thrombocytopenia, in the presence of antiphospholipid antibodies (aPL), namely lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or anti-β2 glycoprotein-I (β2GPI) antibodies. The current mainstay of treatment for thrombotic APS is heparin followed by long-term anticoagulation, while in obstetric APS, the accepted first-line treatment consists in low-dose aspirin (LDA) plus prophylactic unfractionated or low-molecular-weight heparin (LMWH). Recently, new emerging treatment modalities, including intravenous immunoglobulins (IVIG), have been implemented to manage APS refractory to conventional therapy. The objective of this review is to summarize the currently available information on the IVIG therapy in APS, focusing on the use of IVIG in the obstetric form, CAPS and on primary or secondary thromboprophylaxis. We analyzed 35 studies, reporting the effects of IVIG in APS patients, and we discussed their results. IVIG in obstetric APS seem to be very useful in selected situations (patients not responsive to the conventional treatment, concomitant autoimmune manifestations or infections or patients in whom anticoagulation is contraindicated). IVIG treatment represents an important component of the combination therapy of CAPS and they could be useful, in addition to the standard therapy, to prevent recurrent thrombosis in APS patients refractory to conventional anticoagulant treatment. Anyway, in some cases we also found controversial results that claim the need of further well-designed studies to definitely state the efficacy and tolerability of IVIG in CAPS, obstetric and non-APS.

Treatment strategies and pregnancy outcomes in antiphospholipid syndrome patients with thrombosis and triple antiphospholipid positivity. A European multicentre retrospective study

Previous thrombosis, diagnosis of systemic lupus erythematosus (SLE) and triple antiphospholipid (aPL) antibody positivity have recently been found to be independent factors associated to pregnancy failure during conventional therapy in women with antiphospholipid syndrome (APS). This study aimed to assess the effect of various treatment strategies on pregnancy outcomes in women with APS and the risk factors for pregnancy failure. One hundred ninety-six pregnancies of 156 patients diagnosed with APS were analysed: 118 (60.2%) of these had previous thrombosis, 81 (41.3%) were diagnosed with SLE, and 107 (54.6%) had triple aPL positivity. One hundred seventy-five (89.3%) were treated with conventional therapies (low-dose aspirin [LDA] or prophylactic doses of heparin + LDA or therapeutic doses of heparin + LDA), while 21 (10.7%) were prescribed other treatments in addition to conventional therapy. The pregnancies were classified into seven risk profiles depending on the patients' risk factors - thrombosis, SLE, and triple aPL positivity - and their single, double or triple combinations. It was possible to find significant difference in outcomes correlated to treatments only in the thrombosis plus triple aPL positivity subset, and logistic regression analysis showed that additional treatments were the only independent factor associated to a favourable pregnancy outcome (odds ratio=9.7, 95% confidence interval=1.1-88.9, p-value<0.05). On the basis of this retrospective study, we found that APS pregnant patients with thrombosis and triple aPL positivity treated with additional therapy had a significant higher live-birth rate with respect to those receiving conventional therapy alone.

Pregnancy and myasthenia gravis

PURPOSE OF REVIEW

Myasthenia gravis (MG) is an acquired autoimmune disorder characterized by fluctuating ocular, limb, or oropharyngeal muscle weakness due to an antibody-mediated attack at the neuromuscular junction. The female incidence of MG peaks in the third decade during the childbearing years. A number of exacerbating factors may worsen MG, including pregnancy. When treatment is needed, it must be carefully chosen with consideration of possible effects on the mother with MG, the pregnancy, and the fetus.

RECENT FINDINGS

Decisions are complex in the treatment of women with MG contemplating pregnancy or with presentation during pregnancy. While data is largely observational, a number of characteristic patterns and issues related to risk to the patient, integrity of the pregnancy, and risks to the fetus are recognized. Familiarity with these special considerations when contemplating pregnancy is essential to avoid potential hazards in both the patient and the fetus. Use of immunosuppressive agents incurs risk to the fetus. Deteriorating MG with respiratory insufficiency poses risk to both the mother and the fetus.

SUMMARY

This article reviews available information regarding expectations and management for patients with MG in the childbearing age. Treatment decisions must be individualized based on MG severity, distribution of weakness, coexisting diseases, and welfare of the fetus. Patient participation in these decisions is essential for successful management.

When conventional treatment fails: the role of intravenous immunoglobulin in recurrent pregnancy loss secondary to antiphospholipid syndrome

Recurrent pregnancy loss (RPL) is a well-recognized complication of antiphospholipid syndrome (APS). First line therapy consists of low dose aspirin and heparin. Despite conventional therapy some women fail to achieve a successful pregnancy outcome. We describe the case of a patient who had two live births following intravenous immunoglobulin therapy despite previous failure with conventional therapy for RPL in the setting of APS. We will summarize the available literature on intravenous immunoglobulin for this indication.

Antiphospholipid Syndrome: Review

Antiphospholipid syndrome spans many medical disciplines. Classic criteria include the presence of anticardiolipin antibody or lupus anticoagulant with typical complications of thrombosis or pregnancy loss. Other common associated manifestations include livedo reticularis, thrombocytopenia, valvular heart disease, and nephropathy with renal insufficiency, hypertension, and proteinuria. Treatment of serious complications with anticoagulation is standard; generally warfarin for thrombosis and aspirin/heparin for pregnancy prophylaxis. Detailed recommendations regarding precise intensity and duration of anticoagulation are still a subject of debate.

Immunomodulatory Effects of Intravenous Immunoglobulins as a Treatment for Autoimmune Diseases, Cancer, and Recurrent Pregnancy Loss

Intravenous immunoglobulin (IVIG) is a safe preparation, made of human plasma of thousands of healthy donors. The fascinating history of gamma globulin therapy begins in 1930 when Finland treated pneumococcal pneumonia patients with equine serum, which prolonged their survival from pneumonia. Since then, significant breakthroughs were achieved by Cohn, Bruton, Imbach, and others, whose clinical contribution to the world of medicine was of great importance. Originally IVIG was used to treat immunodeficiencies. Later on the use of IVIG extended to autoimmune diseases as well. The efficacy of IVIG has been established only in several autoimmune diseases; clinical reports of trials, series, and case reports indicate significant improvement in many more autoimmune diseases. IVIG have also showed antimetastatic effects in a variety of cancer cell lines, as well as in a few case reports. The efficiency of IVIG has also been observed in recurrent pregnancy loss (RPL), either as a result of an autoimmune disease or spontaneous. Several attempts were made to discover the immunomodulatory effects of IVIG, but it is still not fully understood. Clearly IVIG has multiple mechanisms of actions, which are thought to cooperate synergistically. One of the main mechanisms of actions of IVIG is its ability to neutralize pathogenic autoantibodies via anti-idiotypic antibodies within IVIG preparation. The ability of IVIG to neutralize pathogenic autoantibodies is of great importance in many autoimmune diseases, as well as in RPL. In cancer cell lines, IVIG modulates the immune system in a few ways, including the induction of IL-12 secretion, which consequently activates natural killer cells, and the induction of expression of proapoptotic genes only in cancer cells. Side effects from IVIG are rare and mostly mild and transient. More importantly adverse effects can be minimized by administration to a selective patient population in a proper way: slow infusion rate of 0.4 g/Kg body weight IVIG for 5 consecutive days, given in monthly cycles. The only downside of IVIG therapy is its high price. Therefore, clinicians should balance efficiency versus cost in deciding whether or not to treat certain conditions with IVIG.

Treatment review and update for myasthenia gravis

Myasthenia gravis (MG) is the best understood autoimmune disease, with well-characterized humoral and cellular effector mechanisms. It is not surprising, therefore, that immunotherapies play a key role in the management of MG. Significant progress has been made over the last few decades in the treatment of patients with MG, and the number of effective avenues of therapy continue to increase. In this review, we provide an update on management options in MG, highlighting recent literature on both traditional and more novel approaches.

Current debates in antiphospholipid syndrome: the acquired antibody-mediated thrombophilia

Antiphospholipid (APL) syndrome is the most common form of acquired thrombophilia. It can cause significant morbidity and even mortality. The term "APL antibodies" represents a heterogeneous group of antibodies associated with this disorder. Currently no single assay can identify every APL antibody. Clinically relevant APL antibodies are mainly anticardiolipin antibodies (ACA) detected by solid phase enzyme-linked immunosorbent assay (ELISA) and lupus anticoagulants (LA) demonstrated by in vitro coagulation assay. However, there are some other antibodies associated with the APL syndrome (i.e., subgroup APL antibodies). ACAs, LAs, and subgroup APL antibodies represent intersecting, but non-identical, subsets of autoantibodies. Thus, those autoantibodies may coexist or may occur independently. Any organ system and any size of vessel can be affected during the clinical course of the disease. Therefore, the APL syndrome can manifest itself in a wide variety of clinical thrombotic features. Fetal loss and pregnancy morbidity represent a specific challenge. Despite tremendous advances in the understanding of the pathogenesis of APL syndrome during the past decade, the mainstay of management is still anticoagulation. However, there is no general agreement regarding the duration and intensity of anti-coagulant therapy. In this review, we focused on the current dilemmas and their present clarifications in the wide clinicopathologic spectrum of APL syndrome and APL antibody-related distinct pathologic conditions.

Neurological disorders in pregnancy

PURPOSE OF REVIEW

Neurological disorders are common in women of childbearing age and can lead to maternal death, as evident from previous reports of the Confidential Enquiry into Maternal Deaths in England and Wales. In the last report (1997-1999) alone, there were 34 deaths indirectly caused by neurological disorders.

RECENT FINDINGS

With the new developments in drugs, investigations and research, clinicians are now more able than ever before to diagnose and treat some disorders. A recent example is the French Study Group on Stroke in Pregnancy.

SUMMARY

This paper reviews the current concepts and outlines appropriate management of conditions such as epilepsy, headache, benign intracranial hypertension, myasthenia gravis, multiple sclerosis, Bell's palsy and cerebrovascular disorders.

New therapies: plasmapheresis, intravenous immunoglobulin, and monoclonal antibodies

Rheumatologic emergencies may pose a serious threat to life, and the treatment of patients with these illnesses continues to be challenging. In the last decade extensive animal and human research has led to development of new therapies. Considerable progress has been made in the therapy for RA. Newly developed biologic therapies have shown promising results in clinical studies, and two agents have already been approved by the FDA. These drugs are currently available for therapy and are under close postmarketing scrutiny to assess long-term efficacy and safety. Similar therapies are under investigation for SLE. Plasmapheresis, once used for many diseases, is now restricted mostly to conditions for which its use has been shown to be beneficial in randomized, controlled studies. Immunoadsorption is used to target specific disease-producing pathogens for removal during extracorporeal therapy. Evidence is accumulating for the use of IVIGs in several immune-mediated conditions. The outlook for some emergencies continues be grim, however, and various therapies are used based on evidence from anecdotal case reports and case series. The new therapies are relatively safe, but careful monitoring is needed, because there is potential for serious adverse events.

Nephrological and obstetric complications of the antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a disorder of hypercoagulability, characterised by thromboembolic events, repeated miscarriages and thrombocytopenia in association with circulating antiphospholipid antibodies. These antibodies are directed against epitopes on either oxidised phospholipids complexed with a glycoprotein, beta 2-glycoprotein I, or against the glycoprotein itself. Renal manifestations of the APS are varied and depend on the type of renal pathology present. The renal vasculature may be affected by either a small vessel, thrombotic microangiopathy process or by large vessel thrombosis. In patients with end stage renal disease, the prevalence of antiphospholipid antibodies may increase with time on dialysis. Anticardiolipin antibodies have been associated with a high incidence of haemodialysis access clotting, a major source of morbidity and hospitalisation in end stage renal disease patients. In renal transplant recipients, antiphospholipid antibodies may be associated with a higher incidence of primary graft non-function, particularly in patients without a history of pretransplantation haemodialysis. Complications of the APS during pregnancy span all trimesters and include intrauterine growth retardation, placental abruption, pre-eclampsia, preterm labour and recurrent fetal loss. As these women have a high risk of recurrent fetal loss, multiple treatment modalities have been investigated, including aspirin, heparin, prednisone and intravenous immunoglobulin. Various treatment strategies for the APS have been developed and are based on a combination of anticoagulant therapy with either warfarin or heparin, along with antiplatelet therapy with aspirin. Experimental treatments involving immunomodulatory therapy with intravenous immunoglobulin, apheresis and novel antibody therapy are being investigated with hopes of successful clinical applications.

Primary anti-phospholipid antibody syndrome (APS): current concepts

Primary anti-phospholipid syndrome (APS) is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating anti-phospholipid antibodies that may be responsible for thrombophilia and pregnancy morbidity. Ophthalmologic features are present in 15-88% of the patients with primary APS, thus ophthalmologists are one of the first physicians to whom the patient will present. An accurate diagnosis may save the patient from recurrent, potentially life-threatening thrombosis. In the U.S.A., an estimated 35,000 new cases of APS-related venous thrombosis occur each year in a population that is several decades younger than the patient population typically affected by thrombosis. Clinical features, such as chorea, transverse myelitis, cardiac valvular lesions, and accelerated atherosclerosis, are hypothesized to be due to a direct tissue-antibody interaction and cannot be explained purely by thrombosis. The use of recently proposed, well-defined diagnostic criteria, and better standardization of laboratory assays for the anti-phospholipid antibodies should help enable epidemiological surveys to establish the prevalence of these antibodies in patients with thrombosis and in the general population. Diagnosis of APS should be considered in all patients with recurrent systemic or ocular thrombosis in the absence of known risk factors. Several well-designed prospective studies show an increased risk of thrombosis in the presence of medium to high antibody level. With ocular involvement in as many as 88% of APS patients, an ophthalmic assessment should be an integral part of the clinical work-up of any patient with suspected or confirmed APS. The presence of isolated ocular thrombophilia with persistently elevated anti-phospholipid antibodies or lupus coagulant should confirm the diagnosis of APS. Management of these patients must be a multi-disciplinary effort with either a rheumatologist or a hematologist having the overall responsibility for coordinating treatment and monitoring the patient's immune status and anticoagulation. Treatment of isolated ocular thrombophilia in the presence of moderate to high titers of antiphospholipid antibodies should be on the same principles as patients with APS to prevent recurrent ocular or cerebral thrombosis.

Heparin-induced thrombocytopenia and thrombosis

Heparin remains the most commonly used parenteral medication in hospitalized patients. Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis syndrome or the white clot syndrome are important complications of heparin use. This article provides an in-depth review of the etiopathogenesis, clinical manifestations, diagnosis, and management options in patients with HIT. Clinical problems associated with HIT such as antiphospholipid antibody syndrome and venous gangrene are described. The management options of HIT patients during cardiac interventional procedures and coronary surgery as well as recent advances in therapeutic options are summarized.

Clinical uses of intravenous immunoglobulin in pregnancy

The obstetric literature contains numerous reports of IVIG therapy for various conditions encountered during pregnancy. The mechanisms of action of IVIG are uncertain and may vary depending on the specific disorder. Immunoglobulin G infusions appear to be well tolerated by the parturient. The occurrence of major and minor side effects is uncommon, and infectious morbidity is low. Further research will be necessary to elucidate the specific mechanisms of action of IVIG in certain disease states. Determining the exact "therapeutic agent" in IVIG for each specific disease state may allow for a more tailored approach to treatment (i.e., isolation or production of the particular antibody). Outcome assessment, long-term positive and negative effects, cost-benefit analysis, and effects on fetal and neonatal immune function require further study through randomized trials.

Use of intravenous immunoglobulin therapy in pregnancy in systemic lupus erythematosus and antiphospholipid antibody syndrome

Systemic lupus erythematosus and antiphospholipid antibody syndrome are associated with an increased risk of intrauterine growth restriction, miscarriage, stillbirth and premature delivery. Recent advances in therapy during pregnancy have improved the outcome but there is still significant fetal and maternal morbidity and mortality. Treatment of patients failing conventional therapy during the second half of pregnancy is difficult and may be complicated by the development of preeclampsia. The addition of intravenous immunoglobulin therapy offers a low risk strategy for reducing autoantibody mediated disease and improving placental function in severely compromised, growth restricted pregnancies.

The antiphospholipid antibody syndrome: an overview

The antiphospholipid antibody syndrome is characterized by the presence of maternal anticardiolipin antibodies and/or the lupus anticoagulant in association with recurrent pregnancy loss, thrombotic events, and/or thrombocytopenia. This disorder occurs rarely, but pregnant patients with antiphospholipid antibodies are at risk for adverse maternal and perinatal outcomes. This article reviews the antiphospholipid antibody syndrome, including its pathophysiology, clinical sequelae, diagnostic criteria, medical treatment, and nursing care.

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.

Clinical uses of intravenous immunoglobulin in pregnancy

Intravenous immunoglobulin was licensed for use in the United States in 1981. Currently, there are only a few Food and Drug Administration-labeled indications for intravenous immunoglobulin, but up to 50 "off-label" uses are reported in the literature. The obstetric literature contains numerous reports on intravenous immunoglobulin therapy during pregnancy. This article reviews the properties, pharmacokinetics, mechanisms of action, and side effects of intravenous immunoglobulin, as well as the reported uses of intravenous immunoglobulin during pregnancy.

[Obstetrical complications of antiphospholipid syndrome]

Spontaneous miscarriages and fetal deaths take part of the definition of the antiphospholipid syndrome. Preeclampsia, fetal distress, preterm delivery, intrauterine growth retardation, mother's or newborn's vascular thrombosis are also included in the spectrum of clinical events linked to the antiphospholipid antibodies in pregnant women. The pathogenesis is not fully understood, but involves interactions between antibodies and phospholipidic molecules that are complexed to plasmatic proteins of the coagulation, or present on endothelial cell and platelet surfaces. The poor spontaneous prognosis of pregnancy in the context of the antiphospholipid syndrome is dramatically improved by preventive treatment. Therapeutic options are not codified and are various combinations of low-dose aspirin, heparin, steroids, intravenous immunoglobulins, and fish-oil derivatives. Excellent obstetrical care is mandatory in every case.

Intravenous immunoglobulin therapy for the antiphospholipid syndrome in pregnancy

OBJECTIVE

Our purpose was to study the influence of intravenous immunoglobulin on pregnancy outcome.

STUDY DESIGN

Pregnancy outcomes were evaluated in five patients with 17 unsuccessful previous pregnancies. Each patient received 400 mg/kg immunoglobulin for 5 days monthly beginning in the first or early second trimester. Four patients with previous thromboembolic events were treated with concomitant heparin prophylaxis. Four patients received 81 mg of aspirin daily.

RESULTS

Short- and long-term decreases of anticardiolipin immunoglobulin G were noted in three patients. Four patients were delivered of healthy infants at term, one at 32 weeks' gestation with a diagnosis of fetal distress. Neither preeclampsia nor fetal intrauterine growth retardation were observed. The immunoglobulin therapy was not associated with major side effects. Significant placental histologic anomalies were not identified.

CONCLUSIONS

The observations suggest that immunoglobulin therapy may improve pregnancy outcomes beyond that observed with heparin and aspirin. A prospective trial is encouraged.