Use of D-dimer measurement to guide anticoagulant treatment in recurrent pregnancy loss associated with antiphospholipid syndrome.

PROBLEM: To examine whether the level of plasma D-dimer can guide anticoagulant treatment in recurrent pregnancy loss (RPL) associated with antiphospholipid syndrome (APS). METHODS: A total of 1096 RPL women with APS between 2012 and 2015 in a single-center hospital were randomly divided into two groups (group A, 75 mg of low-dose aspirin [LDA] daily; group B, 75 mg of LDA plus 4100 U of low molecular weight heparin [LMWH] subcutaneously daily); 1015 of the total successfully completed the trial. Plasma D-dimer level and live birth rates were estimated. RESULTS: For APS women with an elevated D-dimer level at baseline, higher live birth rates were reached in LDA plus LMWH group compared to LDA alone group (92.71% vs 61.68%, P < .0001); however, no significant differences were found between the two groups of women with a normal D-dimer level (87.08% vs 83.76%, P = .48). Women with a normal D-dimer level at all blood draw points had the highest live birth rates (92.88%), as compared with those with persistently abnormal D-dimer at all blood draw points or increased D-dimer level after treatment (P < .001). CONCLUSION: The combination therapy with LDA and LMWH is not essential for all APS women, but has proven to be beneficial for women with an elevated D-dimer level.

Increased expression of Toll-like receptor 3 in decidual natural killer cells of patients with unexplained recurrent spontaneous miscarriage.

OBJECTIVE: To investigate whether the expression of Toll-like receptor 3 (TLR3) in decidual natural killer (dNK) cells plays a role in the pathogenesis of unexplained recurrent spontaneous miscarriage (URSM). STUDY DESIGN: NK cells were isolated from human decidual tissue through magnetic cell sorting and analyzed for phenotypes through flow cytometry. TLR3 expression in dNK cells was detected by quantitative reverse-transcriptase polymerase chain reaction and western blotting. The cytotoxicity of dNK was detected using a lactate dehydrogenase release test. RESULTS: The CD56(+) dNK percentages varied between 85% and 96%. The expression of TLR3 mRNA and protein in dNK cells of URSM patients was statistically significantly higher than that in control women (p=0.005 and p=0.01, respectively). Meanwhile, the mean cytotoxicity percentage of freshly isolated dNK cells from the patients was significantly higher than that from normal controls (31.24 ± 7.46% vs. 16.20 ± 6.03%; p=0.03). CONCLUSION: The expression of TLR3 in dNK cells is abnormally higher in URSM patients, which indicates that TLR3 expression may be critical to the activation of dNK cells infiltrating the maternal-fetal interface and account for the loss of immune tolerance.

Decidual CD4+CD25+CD127dim/- regulatory T cells in patients with unexplained recurrent spontaneous miscarriage.

OBJECTIVES: To investigate the frequency and function of CD4(+)CD25(+)CD127(dim/-) regulatory T (Treg) cells in decidua of patients with unexplained recurrent spontaneous miscarriage (URSM). STUDY DESIGN: The decidual lymphocytes from patients who experienced URSM and normal pregnant women (controls) were collected by Ficoll density gradient centrifugation. CD4(+)CD25(+)CD127(dim/-) Treg cells were isolated by magnetic cell sorting. The proportion of Treg cells and IL-10, TGF-ß in Treg cells were determined by flow cytometry. Inhibitory effects of Treg cells on effecter T cells were detected with or without the presentation of anti-IL-10 antibodies and anti-TGF-ß antibodies. RESULTS: The frequency of CD4(+)CD25(+)CD127(dim/-) Treg cells was decreased in URSM decidua compared to controls (2.09%±0.86% vs. 2.97%±1.19%, p=0.005), and the expression of IL-10 and TGF-ß in Treg cells was lower in the URSM group than in the control group (p=0.04 and p=0.01, respectively). Furthermore, the suppressive effect of CD4(+)CD25(+)CD127(dim/-) Treg cells on the proliferation of effector T cells was decreased in URSM decidua (p<0.05). Suppression was mediated predominantly through IL-10 and TGF-ß in decidua. CONCLUSIONS: Decreased frequency and immunosuppressive capacity of CD4(+)CD25(+)CD127(dim/-) Treg cells was found in URSM decidua. Treg cells inhibit proliferation of effector T cells mainly via IL-10 and TGF-ß in URSM decidua.

Increased prevalence of T helper 17 (Th17) cells in peripheral blood and decidua in unexplained recurrent spontaneous abortion patients.

T helper 17 (Th17) cells and regulatory T (Treg) cells are two distinct subsets of CD4(+) T cells which have opposite effects on inflammation, autoimmunity and immunological rejection of foreign tissue. Treg cells have been shown to be important in maintaining materno-fetal tolerance, but the role of Th17 cells in human pregnancy and pathological pregnancy, especially in relation to unexplained recurrent spontaneous abortion (RSA), has not been investigated. In this study, we showed that the proportion of Th17 cells in the peripheral blood and decidua was significantly higher in unexplained RSA patients compared to normal, early pregnant women. Meanwhile, there was an inverse relationship between Th17 cells and Treg cells in the peripheral blood lymphocytes (PBL) and decidua in unexplained RSA. The expression of Th17 related factors, IL-17, IL-23 and retinoid orphan nuclear receptor (RORC), in PBL and decidua in unexplained RSA patients was significantly higher than normal, early pregnant women. This study is the first to define the occurrence of Th17 cells in unexplained RSA patients and in normal, early pregnant women. We suggest that these highly pro-inflammatory cells contribute to unexplained RSA, and the balance between Th17 cells and Treg cells may be critical to pregnancy outcomes.

Effects of letrozole and clomiphene citrate on the expression of HOXA10 and integrin alpha v beta 3 in uterine epithelium of rats.

OBJECTIVE: To compare the effects of letrozole and clomiphene citrate on the expression of HOXA10 and integrin alpha(v)beta(3) in the uterine epithelium in rats. DESIGN: Controlled prospective study. SETTING: Teaching hospital and university research laboratory. ANIMAL(S): Sixty sexually mature female Wistar-Albino rats that were 20 weeks of age. INTERVENTION(S): Letrozole, 5 mg/kg of body weight daily (20 rats); clomiphene citrate, 100 microg/kg daily (20 rats); and saline solution, 2 mL/day (20 rats). After 2 days, rats were killed and hysterectomized. MAIN OUTCOME MEASURE(S): Expression of integrin alpha(v)beta(3) and HOXA10. RESULT(S): The expression of integrin alpha(v)beta(3) in the clomiphene citrate group was statistically significantly lower than in the letrozole and saline solution groups. The expression of HOXA10 was statistically significantly higher in the saline solution group than in the letrozole group, and the letrozole group showed a statistically significantly higher expression of HOXA10 compared with the clomiphene citrate group. CONCLUSION(S): In rats, letrozole affects the expression of HOXA10 in uterine epithelium but has no effect on the expression of integrin alpha(v)beta(3), which suggests that clomiphene suppresses endometrial receptivity more than letrozole. In the future, letrozole may be an appropriate drug for ovulation induction.

The investigation on the value of repeat and combination test of ACA and anti-beta2-GPI antibody in women with recurrent spontaneous abortion.

PROBLEM: In order to investigate the value of anticardiolipin antibodies (ACA) and anti-beta2-GPI antibodies detection in screening autoimmune type recurrent spontaneous abortion and its clinic application in antiphospholipid syndrome diagnosis, we adopt repeat combined ACA and anti-beta2-GPI antibodies detection in this study. METHOD OF STUDY: Sera were collected from patients and work-up was done for detection of ACA and anti-beta2-GPI antibodies by enzyme-linked immunosorbent assay (ELISA). The work-up was done for detection of antibodies once in every 6 weeks for 14 times consecutively. RESULTS: The repeated and combined detection of ACA and anti-beta2-GPI antibodies detection could raise the positivity rate up to 21.8% (P < 0.05) in comparison with positive for ACA alone (14.1%), positive for anti-beta2-GPI alone (3.1%), and concurrently positive for both ACA and anti-beta2-GPI antibodies (4.6%). In 91 confirmed positive antiphospholipid antibodies (APA) patients, with more frequent screening for ACA and anti-beta2-GPI antibodies, more patients with APA were found. The positive rate of five and more screenings was over 81.32%, which was statistically significant (P < 0.05), in comparison with that of four or less screenings (68.13%). CONCLUSION: Our data implied that it would be appropriate to take over five or more screenings of combined ACA and anti-beta2-GPI antibodies detection in suspect patients to facilitate the positive diagnostic rate for autoimmune type RSA.