Outcome of pregnancy in patients possessing anticardiolipin antibodies MEDICAL SCIENCES (2000), 2, 91−95 © 2000 SULTAN QABOOS UNIVERSITY 1Department of Obstetrics and Gynaecology, Armed Forces Hospital, Muscat, Sultanate of Oman. 2Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, P O Box 38 Al-Khod, Muscat 123, Sultanate of Oman. 3Department of Microbiology & Immunology, College of Medicine, Sultan Qaboos University, P O Box 35 Al-Khod, Muscat 123, Sultanate of Oman. *To whom correspondence should be addressed. E mail: erichens@squ.edu.om 91 Outcome of pregnancy in patients possessing anticardiolipin antibodies Al Abri S1, Vaclavinkova V2, *Richens E R3 الحامل المرأة على للكارديوليبين المضادة األجسام أثر رتيشثن اليزابيث ,فاآالثينكوفا فالستا, العبري شيخه المذآورة المضادة األجسام يحملن اللواتي الحوامل النساء من عينة دراسة عند الحمل على للكارديوليبين المضادة جساماأل وجود أثر تحليل: الهدف:الملخص من الالزمة المعلومات معتج :الطريقة.الحاالت تلك مثل في البريدتيزولون أو باألسبرين المعالجة فاعلية تحليل . الحمل لفقدان يمرض تاريخ وجود بشرط وجود مع الطبيعي المعدلن ب للكارديوليبي المضادة األجسام وجود على الحاالت تلك اختيار ترآز . أسيوي أصل من أخرى حاالت بعأرو عربية ةمريض 21 آان نوع ج فقط،وجود أألجسام المضادة من عند أنه تبين- :نتائجال إحصائيا المعلومات بتحليل قمنا ذلك بعد ثم . أآثر أو واحدة لمرة باالجهاض مرضي تاريخ و ج نوع من مضادة أجسام وجود حالة في أما ، األخير الثلث عن مهمة زيادة ويزيد ي من الحمل، والثان يا للثلثين األول و متسا الجنين وفقدان اإلجهاض معدل هذه لعالج األسبرين من القليلة الجرعة بإستعمال أنه وتبين . الحمل في والثالث الثاني الثلثين زيادة مهمة عن زادت األول الثلث في اإلجهاض نسبة فإن معا م النسبة آانت عالج أي إعطاء عدم وعند . فقط األسبرين استعمال عند% 54 عليه آانت عما% 75 الحمل نجاح نسبة أصبحت البريدثيزولون بجانب الحاالت تبين وآذلك الحمل فقدان إحتمال من يزيد الحامل المرأة عند ج نوع من للكارديوليبين المضادة األجسام وجود أن فيه الشك مما : الخالصة . فقط% 17 المرأة عند المضادة األجسام وجود حالة في الحمل نجاح نسبة من يزيد معه الستيرويد إستخدام عن النظر بغض القليلة بالجرعة باألسبرين العالج أن إحصائيا .الحامل ABSTRACT: Objective – To analyse the outcome of pregnancy in a sample of patients with a history of fetal loss, and possessing anti- cardiolipin antibodies (ACAs), and to assess the effectiveness of therapy with aspirin and prednisolone. Method – Data on a cohort of 21 Arab and 4 other Asian patients who had one or more episodes of fetal loss associated with raised levels of ACAs were analysed retro- spectively. Statistical analysis was performed using χ2 test for assessment of isotype data and the Fischer test for assessment of the effects of therapeutic intervention. Results –Where immunoglobulin G (IgG) ACAs were found alone, abortion rates occurred at the same rate in the first and second trimesters, which was significantly higher than in the third trimester. In the few cases where IgG and immunoglobu- lin M (IgM) ACAs coexisted, the rate of pregnancy loss was significantly higher in the first trimester than the second and the third. In the group who had received both aspirin and prednisolone, 75% pregnancies were successful compared to 54% in the group receiving aspirin alone and 17% in those who received no therapy. Conclusion – The presence of IgG antibodies appears to increase the risk of abortions. Low dose aspirin, either alone or with prednisolone, appears to significantly improve the chances for successful pregnancies in patients with ACAs. Further clinical trials are needed to ascertain optimal therapeutic protocols. KEY WORDS: anticardiolipin, antibody, aspirin, prednisolone, pregnancy nticardiolipin antibodies (ACAs) are strongly as- sociated with venous and arterial thrombosis, thrombocytopenia and recurrent fetal loss.1 These findings were first observed during studies of sys- temic lupus erythematosus (SLE), a disease whose many symptoms include thrombosis. Of the spectrum of auto antibodies described in SLE, two were found to be di- rected against most negatively charged phospholipids, including cardiolipin.2 Anti-phospholipid antibodies are known to prolong in vitro phospholipid-dependent coagu- lation tests, and have been historically referred to as the lupus anticoagulant (LAC). In addition to their occurrence in patients with SLE, ACAs are found in patients with other autoimmune dis- eases, as well as in some with no apparent previous underlying disease.3 The term �antiphospholipid syndrome� is used to describe patients who present with the clinical manifestations described above, in association with ACAs or the LAC.4 ACAs may bind independently to the negatively charged phospholipid (in which case, they are called �authentic� ACAs) or they may require a cofactor, beta 2 glycoprotein-I (β2GPI).5 The role of β2GPI antibodies in fetal loss is under study.6 A A L A B R I E T A L 92 In pregnancy, the antibodies may react against the trophoblast resulting in sub-placental clots and interfere with further placentation. Necrotizing descidual vascular lesions are seen in the placenta.7 Thrombosis may occur in all trimesters of pregnancy resulting in complications such as spontaneous abortions and intrauterine growth retardation (IUGR). In this retrospective study, the outcome of preg- nancy in patients with a history of fetal loss, and possess- ing ACAs, who were attending the outpatient clinic of the obstetrics department of Sultan Qaboos University Hos- pital, has been analysed. SLE is common is this country and a minority of the patients presented with this condi- tion also. The patients received therapy either with aspirin or with aspirin combined with prednisolone. Due to non- compliance, six patients received no therapy. Like other corticosteroids, prednisolone suppresses antibody pro- duction. Low-dose aspirin acts by inhibiting the produc- tion of thromboxane A2, a vasoconstrictive prostaglandin associated with platelet aggregation and thrombocyto- penia. The data has been further examined to determine the effect of these therapeutic modalities on fetal sur- vival. METHOD During the period 1995�97, 25 patients with ACAs and pregnancy losses were seen in the outpatient clinic of SQU Hospital. Their ages ranged from 20�40 years; 21 were Omani whilst 4 were Asian expatriate. Patients who sustained pregnancy losses from other causes, such as genetic, endocrine or gynaecological abnormalities, rhesus incompatibility or sperm antibodies were excluded from the study. Table 1 shows the obstetric history of the patients; they had lost from 1�6 (mean ± SD: 2.3 ± 1.9) pregnan- cies, the abortions occurring mainly in the first and sec- ond trimester. All the patients possessed ACAs, and four patients, in addition, possessed antinuclear antibodies (ANAs). All patients were put on therapy as soon as the pregnancy was diagnosed. None had received treatment in previous pregnancies. The therapy was either aspirin, 80 mg daily, alone or in combination with prednisolone, 10�20 mg daily, according to the presence of antibodies and, in some patients, the coexistence of connective tis- sue disease. Of the 21 patients with ACAs alone, five were treated with aspirin and prednisolone and 11 with aspirin alone. Due to non-compliance the remaining five patients received no therapy. Of the four patients with both ACAs and ANAs, three received both aspirin and prednisolone (one with the addition of cyclophos- phamide) and the fourth received no therapy, again due to non-compliance (Table 2). ACAs were measured using the Kallestad system where the normal range for IgG ACA was < 23 GPL and for IgM ACA was < 11 MPL. Statistical analysis was performed using χ2 test for as- sessment of isotype data and the Fischer test for assess- ment of the effects of therapeutic intervention. RESULTS The patients were first analysed to assess the effect of therapeutic modality on the outcome of the pregnan- cies (Table 2). Among the 7 patients receiving both aspi- rin and prednisolone (five with ACAs only and two with both ACAs and ANAs), there were six (84%) successful pregnancies. One further ACA and ANA positive patient, who received cyclophosphamide in addition to aspirin and prednisolone, underwent an abortion. Among the 11 TABLE 1 Obstetric history of patients Stage of losses No. of pregnancies No. of losses No. of live births 7 3 4 1 1 0 2 2 0 3 2 1 3 3 0 4 4 0 3 3 0 2 2 0 6 3 3 3 3 0 10 2 8 3 2 1 T1 3 2 1 8 2 6 5 4 1 3 2 1 4 4 0 T2 6 3 3 2 2 0 7 4 3 T3 3 3 1 8 5 3 6 3 3 T1 &T2 7 5 2 T2 & T3 12 6 6 P R E G N A N C Y A N D A N T I C A R D I O L I P I N A N T I B O D I E S patients receiving aspirin alone, all of whom possessed ACAs only, there were five (45%) successful pregnancies. Among the 6 patients receiving no therapy, 5 with ACAs only and one with ACAs and ANAs, there was only one (16%) successful pregnancy. Despite the low numbers this suggests that combined aspirin and prednisolone therapy gives better outcome than aspirin alone, and that treatment with either modality is superior to no treat- ment. Indeed, the advantage attained with combined aspi- rin and prednisolone therapy is significantly better (χ2 =5.82, p<0.05) than with no therapy. The patients were secondly analysed to determine the relation of the ACA isotype to the stage of pregnancy disaster. This data is summarized in Table 3. It shows that overall, throughout pregnancy, the coincidence of IgM and IgG ACAs led to the highest rate of abortions and stillbirths, 78%, compared with 71% and 55% respec- tively when IgM and IgG ACAs were found separately. These differences were significant (χ2 = 3.98, p<0.05) when the presence of IgG ACAs alone is compared with the coincident presence of IgG and IgM ACAs. Analysis of the effect of ACA isotype on the trimes- ter of the pregnancy disaster shows that where IgG and IgM ACAs coincided in patients, 78% of the total abor- tions for that group occurred in the first trimester. Where IgM ACAs and IgG ACAs occurred separately in a pa- tient, 30% and 42% of the abortions respectively were in the first trimester. By contrast, where IgM and IgG ACAs were found separately in patients, 70% and 47% respec- tively of all abortions occurred in the second trimester, whereas only 11% of all abortions in the patient group with coincident IgG and IgM ACAs occurred in this tri- mester. Disasters in the third trimester of pregnancy were uncommon and occurred in 6% of pregnancies where IgG ACA occurred alone and in 9% where IgM and IgG ACA were found together. In summary, the presence of IgG ACAs led to a similar frequency of unsuccessful pregnancies in the first and second trimester, the rates being significantly higher than in the third trimester (χ2 = 12.26, p<0.001 and χ2 = 5.02, p<0.001 respectively). Where IgM ACAs occurred alone, more abortions occurred in the second than in the first trimester. The sample size was very small (3 patients, 14 pregnancies) and the increase was not significant (χ2 = 3.20, p>0.05). However, where both IgG and IgM ACAs coincided, the rate of pregnancy losses was significantly higher in the first trimester than in either the second tri- mester (χ2 = 16:20, p<0.001) or the third trimester (χ2 = 16:20, p<0.001). DISCUSSION ACAs are associated with recurrent abortion and fe- tal wastage occurs in more than 90% of untreated pa- tients with antiphospholipid syndrome and in those with autoimmune disease.8 Microinfarction of the placenta, The relationship of autoantibodies an Outcome of pregnancy A. ACA only (n=21) Aspirin + prednisolone (n=5) 4 normal deliveries 1 abortion 5 normal deliveries 4 abortions 1 stillbirth at 29 weeks Aspirin only (n=11) 1 delivery at 32 weeks with c abnormalities – died 1 normal delivery No therapy 4 abortions B. ACA and ANA (n=4) Aspirin + prednisolone (n=2) 2 normal deliveries Aspirin + prednisolone + cyclo- phosphamide (n=1) 1 abortion No therapy (n=1) 1 abortion TABLE 2 d therapeutic modality to the outcome of pregnancy Gestation period / Trimester of abortion Birthweight 38–40 weeks T1 3.00 – 3.41 kg 36–39 weeks 2.60 – 3.40 kg T1 T1 ongenital T1 40 weeks 3.50 kg T1 37 – 39 weeks 3.20 – 3.45 kg T1 T1 93 A L A B R I E T A L 94 possibly related to interference in prostaglandin metabo- lism, maybe responsible for the fetal loss, but the role of antiphospholipid antibodies, including ACAs, is not yet definitely ascertained.9 The antibody involved appears to be the �authentic� antiphospholipid antibody since ACA and LAC negative patients do not possess antibodies to (β2GPI )6 and animal models of APS in pregnancy can be induced by infusion of ACAs.10 In this study, we have examined the clinical and sero- logical characteristics of patients specifically selected for the presence of IgM and IgG ACAs and multiple fetal losses. The majority were categorized as having the an- tiphospholipid syndrome, but four of the subjects were also diagnosed with SLE and possessing ANAs. We have investigated the effect of therapeutic intervention on subsequent pregnancies and whether the ACA isotype was implicated in the trimester of the fetal loss. Previous trials reported successful pharmacological prevention of recurrent fetal loss using heparin,7 predni- solone and heparin11 prednisolone and azathioprine,12 corticosteroids either alone13 or with low-dose aspirin14 and high dose intravenous immunoglobulins.15 The clinical significance of the different ACA isopes is still under investigation. IgG-ACAs are generally con- sidered to have broader pathological sequelae.17 The iso- types occur with variable frequency and in individual patients each isotype may occur exclusively or in combi- nation with another isotype. Previous studies of fetal losses indicate that the majority have the IgG isotype (+/� IgM) with a minority having IgM alone.17 It has been suggested that where IgM ACA occurs alone, the only complaint is pregnancy loss.18 We have not been able to confirm this. In this study, we have found that 78% of all abortions occur in the first trimester and in these cases, the IgG and IgM ACA isotype are generally both present. Where the IgG isotype occurs alone, abortions occur at the same frequency in the first and second trimester, whereas, on the very limited data available, where the IgM isotype occurs alone, more abortions occur in the second trimester. CONCLUSION In our study, we used low-dose aspirin, either alone or with prednisolone. The patient numbers were low, but both in patients with the antiphospholipid syndrome and with SLE, the highest frequency of successful of preg- nancies occurred with the combined therapy. The use of aspirin alone was encouraging and it may be that aspirin is playing the most important role in the prevention of fetal loss. However, a randomised prospective controlled trial is necessary to determine the optimum therapy for preg- nancy conservation and prophylaxis.16 Further clinical trials should give more precise in- formation about optimal therapeutic protocols for the prevention of fetal loss and the management of patient at risk needs to be standardized. ACAs are rarely found in healthy populations: one study indicates 22 in 1000.8 Hence there is little benefit in the routine screening of healthy pregnant women for the presence of ACAs. REFERENCES 1. Ascherson RA, Harris EN. Anticardiolipin antibod- ies�clinical associations. Postgraduate Med J 1986, 62, 1081�7. 2. Buchanan RRC, Woodlaw JR, Riglar RJ, Littlejohn GO, Miller MH. Antiphospholipid antibodies in con- nective tissue diseases: their relation to the antiphos- pholipid syndrome and forme fruste diseases. J Rheumatol 1989, 16, 757�61. 3. Fields RA, Toubbeh H, Searles RP, Bankhurst AD. The prevalence of anticardiolipin antibodies in a healthy TABLE 3 The relationship of anticardiolipin isotype to the trimester (T) where abortion occurred IgG ACA IgM ACA IgG & IgM ACAs No of women 14 3 8 No of pregnancies 85 14 23 No abortions over entire pregnancy (T1T2T3) 47 10 18 % abortion 55 71 78 Trimester 1 Number of abortions 20 3 14 % T1 abortions/pregnancies 23 21 61 % T1 abortions/T123 abor- tions 42 30 78 Trimester 2 Number of abortions 22 7 2 % T2 abortions/pregnancies 26 50 9 % T2 abortions/T123 abor- tions 42 70 11 Trimester 3 Number of abortions 5 0 2 % T3 abortions/pregnancies 6 9 % T3 abortions/T123 abortions 11 11 P R E G N A N C Y A N D A N T I C A R D I O L I P I N A N T I B O D I E S 95 elderly population and its association with antinuclear antibodies. J Rheumatol 1989, 16, 623�5. 4. Khamashta MA, Hughes GRV. Antiphospholipid syndrome. BMJ 1993, 307, 883�4. 5. 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Immu- noglobulin G fractions from patients with antiphosphol- ipid antibodies cause fetal death in BALB/C mice: a model for autoimmune fetal loss. Am J Obstet Gynecol 1990, 163, 210�6. 10. Shoenfeld Y, Sherer Y, Blank M. Antiphospholipid syndrome in pregnancy-animal models and clinical im- plications. Scand J. Rheumatol Suppl 1999, 107, 33�6. 11. Parke A, Maier D, Hakim C, Randolph J, Andreoli J. Subclinical autoimmune disease and recurrent spon- taneous abortion. J Rheumatol 1986, 13, 1178�80. 12. Lockshin MD, Druzin ML, Goei S, Qamar T, Magid MS, Jovanovic L, et al. Antibody to cardiolipin as a predictor of fetal distress in pregnancy patients with systemic lupus erythematosus. N Eng J Med 1985, 313, 152�6. 13. Hedfers E, Lindatol G, Lindbland S. Anticardiolipin antibodies during pregnancy. J Rheumatol 1987, 14, 160-1. 14. Norberg R. Nived O, Sturfelt G. Anticardiolipin and complement activation: relation to clinical symptoms. J Rheumatol 1987, 14, 149�54. 15. Carreras CO, Perez GN, Vega HR, Casavilla F. Lu- pus anticoagulant and recurrent fetal loss: successful treatment with gammaglobulin. Lancet 1988, 2, 393�4. 16. Granger KA, Farquharson RG. Obstetric outcome in phospholipid syndrome. Lupus 1997, 6, 509�13. 17. Lopez LR, Santos ME, Espinosa LR, Rosa FGL. Clinical significance of immunoglobulin A versus im- munoglobulins G and M anticardiolipin antibodies in patients with systemic lupus erythematosus. Am J Clin Path 1992, 98, 449�54. 18. Brown HL. Antiphospholipid antibodies and recurrent pregnancy loss. Clin Obstet Gynecol 1991, 34, 17�26. Outcome of pregnancy in patients possessing �anticardiolipin antibodies METHOD RESULTS Table 1 Table 1 Stage of losses T1 DISCUSSION Table 3 The relationship of anticardiolipin isotype to the �trimester (T) where abortion occurred Trimester 1 Trimester 2 Trimester 3 CONCLUSION REFERENCES