1 GynécologieObstétrique, Hôpital Saint Antoine, 184 rue du Faubourg Saint-Antoine, 75012 Paris, 2 Laboratoire d'Hématologie, Hôpital Rothschild, Paris, and 3 Laboratoire d'Hématologie, Hôpital Saint Antoine, Paris, France
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Abstract |
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Key words: antiphospholipid/aspirin/autoantibodies/habitual abortions/prednisone
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Introduction |
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Injection of the husband's leukocytes (Recurrent Miscarriage Immunotherapy Trialists Group, 1994), or i.v.
-globulin (German RSA/IVIG group 1994; Yamada et al., 1998
) were used to prevent a new abortion in women with unexplained HA. Previously, it has been observed that 20% of autoantibody-free HA women became anticardiolipin (aCL)-positive in the next pregnancy (unpublished data) which could be the cause of the new abortion. On the basis of this observation, it was decided that glucorticoid and aspirin treatment should be used to try to prevent abortion.
The objective of this study was to determine the autoimmune profile of healthy women coming to the Department of Obstetrics and Gynecology for HA and before starting a double-blind control trial, to assess the possible prevention of a new abortion, in autoantibody-positive or -negative women, with low-dose aspirin until the end of the seventh month, without or with prednisone in the first trimester of pregnancy.
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Materials and methods |
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Biological investigations
All women were investigated for the presence of autoantibodies:
Immunoglobulins (Ig)
IgG and IgM aCL, IgG and IgM anti-ß2 glycoprotein 1 (anti-ß2GP1) and antiprothrombin antibodies (aPt) were detected by an enzyme-linked immunosorbent assay, as described previously (Abuaf et al., 1997). Briefly, 96-well microtitre plates (Maxisorp Nunc, Roskilde, Denmark) were coated with 30 ml of cardiolipin in ethanol at a concentration of 50 mg/ml (Sigma C-1649; Saint-Quentin Fallavier, France) or 120 ml of ß2GP1 at 15 mg/ml isolated from pooled normal human plasma, or 120 ml of prothrombin at 5 mg/ml (Diagnostic Stago, Asnières, France). Dilutions of a reference standard serum and known negative sera were used on every plate. Calibration sera for
G antiphospholipid (GPL) (IgG aPL) or
M antiphospholipid (MPL) (IgM aPL) units were obtained from Dr E.N.Harris, (Department of Medicine, University of Louisville, KY 40292, USA). A patient's serum with a titre of anti-ß2G or aPt was used as a standard serum to define arbitrary units; the threshold at 95 percentile was established with 130 blood donors. The patients were assigned to negative group: aCL <15 uGPL or MPL, anti-ß2G <6 uß2GP or MP and aPrt <60 uGP.
Lupus anticoagulant (LA)
Diagnosis was made on the basis of: (i) an abnormal tissue thromboplastin test using Innovin (Ortho Diagnostic, Issy les Moulineaux, France) diluted 1/100 as reagent. The test was considered to be positive when the clotting time ratio to normal pool plasma was >1.10; (ii) an abnormal activated partial thromboplastin time minus the altered incubation time performed as previously described (Robert, 1994): to be positive the difference in clotting times should be >9 s; and (iii) a positive plasma 1:1 mixing study with normal pooled plasma. This procedure for LA diagnosis met the requirement of the International Society for Thrombosis and Haemostasis (Brandt et al., 1992).
Antinuclear antibodies (ANA)
These were detected by indirect immunofluorescence on the Hep-2 cell line (larynx carcinoma cell line), a titre >1/100 was considered to be positive. Native anti-DNA antibody determination was performed by the Farr test (Amersham, Bucks, UK) with a threshold of 7 IU.
Antithyroid antibodies (aTh)
These were detected by determining the antimicrosomal and antithyroglobulin antibodies. Antimicrosomal antibodies were detected by immunofluorescence on human thyroid sections; an antibody titre >1/10 was considered as positive. Antithyroglobulin antibodies were assessed by passive haemagglutination with a threshold of 1/640.
Statistical analysis
Variables between series were compared using the 2 test or by Fisher's exact test for low values. The comparison of means was performed using Student's t-test. P < 0.05 was considered to be statistically significant.
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Results |
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The mean birth weights in women who received prednisone and aspirin or aspirin alone was similar in the two groups, 3083 ± 564.5 g and 2956 ± 431.5 g, as was the mean term delivery which was respectively 39 ± 2.0 and 38. 8 ± 1.6 weeks (not significant; Student's t-test). In the group of autoantibody-negative women treated with prednisone and aspirin, three cases of hypertension (2%) were observed and one of gestational diabetes (0.6%), and hypertension was observed in one patient (2%) with autoantibody-positive women, which is in accordance with the general population.
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Discussion |
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Prednisone and aspirin treatment was superior to aspirin treatment alone in autoantibody-negative women: the success rate was 90.7%, compared with 74.5% in patients with aspirin alone (P < 0.01). Previously, the outcome of pregnancies was followed in a similar cohort of 102 HA patients without treatment (Reznikoff-Etievant, 1991) and 58% resulted in births. This observation would mean that low-dose aspirin could foster pregnancy in autoantibody-negative patients. However, in a recent study (Tuppala et al., 1997) no difference was found in the success rate in HA women treated with either aspirin (70%) or placebo (70%).
Prednisone and aspirin treatment have the same success rate in both autoantibody-negative and autoantibody-positive women. The results presented here confirm those of a recent study (Geva et al., 1998). However, in another study (Laskin et al., 1997
), a double-blind trial in patients with two or more unexplained abortions with low autoantibodies, prednisone until delivery associated with aspirin was not significantly different from placebo: 65% live infants versus 56% with placebo (P = 0.19). The success rate in this work was much lower than in our study. There are two possible reasons: firstly, our work is not a randomized controlled trial and so the results may be overestimated. Secondly, the autoimmune profile is different in the two studies discussed above, and the same treament may not have the same efficacy in these two cohorts. In this study, prednisone does not seem to act by preventing the seroconversion of aCL as no difference was found between the seroconversion rate in the two treatment groups, aspirin alone or aspirin and prednisone. This would mean that prednisone may interfere with factors which were not investigated in this work, such as an embryotoxic factor (Hill et al., 1992
) or factors associated with human leukocyte antigens (HLA) (Christiansen, 1996
). As observed in women with aCL >30 uGPL, prednisone plus aspirin appeared to be less successful than in a group of aCL
30 uGPL, it is suggested that in the former group, after prednisone is stopped, heparin should be considered if the aCL titre rises. With lupus anticoagulant, heparin should be the treatment of choice as heparin is superior to low-dose aspirin (Kutteh et al., 1996; Di Simone et al., 1997
).
This series of 214 treated patients established that prednisone and aspirin treatment is safe, in accordance with previous studies (Geva et al., 1998). This contrasts with other studies (Laskin et al., 1997
) which described adverse side-effects (e.g. hypertension, diabetes mellitus and prematurity) in the prednisone and aspirin-treated group. This contrast may be due to the difference in the duration of prednisone treatment which was 2 months in this study, 3.5 months in Geva's study and throughout pregnancy for Laskin.
After this preliminary study, we began a double-blind trial in women with or without very low aPL; this study is in progress.
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Notes |
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References |
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Submitted on December 29, 1998; accepted on April 22, 1999.