Anti beta 2glycoprotein I antibodies and lupus anticoagulant in patients with recurrent pregnancy loss: prevalence and clinical significance.

Anticardiolipin antibodies (aCL) were found to recognize beta 2glycoprotein I (beta 2GPI) structure altered by its interaction with an oxygen modified solid phase surface by gamma-ray radiation. Lupus anticoagulant (LA) has been reported to comprise anti prothrombin antibodies, anti factor X antibodies and anti beta 2GPI antibodies. The present study focuses on the possible association between antibodies against the altered beta 2GPI structure (anti beta 2GPI antibodies) and LA in patients with recurrent pregnancy loss. Moreover, the clinical significance of both subgroups of so-called antiphospholipid antibodies were investigated to cast light on the controversy of whether aCL and LA are risk factors for pregnancy losses. One hundred and ninety five women with a history of two or more unexplained consecutive miscarriages and 100 control pregnant women were tested. Lupus anticoagulant was detected by the dilute phospholipid activated partial thromboplastin time. Anti beta 2GPI antibodies were measured by the ELISA method using commercially oxygenated microtiter plates. Twenty two (11.3%) and 19 (9.7%) of the 195 recurrent aborters were, respectively, positive for LA and anti beta 2GPI antibodies. Seven (3.6%) of the aborters had both of them. None of the control pregnant women had LA. Three of the control pregnant women had anti beta 2GPI antibodies. Nine (40.9%) of 22 aborters with positive-LA had a history of miscarriages in the second trimester as compared to 8 (4.6%) of 173 aborters with negative-LA. (P = 0.000007, Odds ratio = 14.3). None of the 12 aborters with anti beta 2GPI antibodies but no LA had a history of second trimester-fetal loss. These results support the hypothesis that aCL and LA define two distinct but partly related populations and that aCL include two subtypes of antibodies, with and without LA activity. LA and anti beta 2GPI antibodies appear to be associated with pregnancy loss, with LA being linked not only to abortions in the first trimester but also to miscarriages in the second trimester.

Laparoscopic-assisted creation of a vagina.

The applicability of laparoscopy for colpopiesis using pelvic peritoneum was examined in two women with the Mayer-Rokitansky-Kuster-Hauser syndrome. Using a modification of laparoscopic guidance proved advantageous for safe dissection of the vesicorectal space and accurate suturing of the pelvic peritoneum without laparotomy. A sufficient vaginal cavity was achieved in both patients. This modification of the original procedure, featuring introduction of a laparoscope, thus provides effective and safe conditions for creation of a new vagina.

beta 2-Glycoprotein I-dependent anticardiolipin antibodies as a predictor of adverse pregnancy outcomes in healthy pregnant women.

Our aim was to elucidate prospectively whether beta 2-glycoprotein I-dependent anticardiolipin antibodies (beta 2GPI-dependent aCL; autoimmune type) can predict an adverse pregnancy outcome in healthy pregnant women and whether beta 2GPI-dependent aCL should be applied for routine screening of the pregnant population. A prospective cohort study was performed on 1600 healthy pregnant women from whom blood samples were obtained at about week 10 of gestation. We used a modified enzyme-linked immunosorbent assay with which to divide the subjects into three study groups: beta 2GPI-independent aCL positive, beta 2GPI-dependent aCL positive and aCL negative. Their subsequent pregnancy outcomes were ascertained and the three study groups were compared statistically for the following poor pregnancy outcomes: intrauterine fetal death (IUFD) after 12 gestational weeks, intrauterine growth retardation (IUGR) and pre-eclampsia. The total number of patients eligible for this study was 1125. The prevalence of beta 2GPI-dependent aCL positive was eight (0.7%), beta 2GPI-independent aCL positive was 17 (1.5%) and aCL negative was 1100 (97.8%). Beta 2-GPI-dependent aCL positivity was significantly associated with poor pregnancy outcome: 25.0% of beta 2GPI-dependent aCL-positive and 0.5% of aCL-negative patients experienced IUFD [relative risk 52.4; 95% confidence interval (CI), 12.7-216.3; P = 0.0009]; 37.5% of beta 2GPI-dependent aCL-positive and 2.9% of aCL-negative patients experienced IUGR (relative risk 18.4; 95% CI, 4.6-74.0; P = 0.001); and 50.0% of beta 2GPI-dependent aCL-positive and 4.0% aCL-negative patients experienced pre-eclampsia (relative risk 22.1; 95% CI, 5.7-85.7; P = 0.0002). In contrast, beta 2GPI-independent aCL did not show any significant association with such adverse pregnancy outcomes. beta 2GPI-dependent aCL are significantly highly associated with adverse pregnancy outcomes in healthy pregnant women and can be used for prediction purposes, whereas beta 2GPI-independent aCL cannot. Our results suggest that routine screening for beta 2GPI-dependent aCL should be introduced for the general pregnant population.

Diagnosis of fetal rubella infection with reverse transcription and nested polymerase chain reaction: a study of 34 cases diagnosed in fetuses.

OBJECTIVE: Our purpose was to develop a reliable method for prenatal diagnosis of fetal rubella infection through the detection of viral ribonucleic acid extracted from the chorionic villi, amniotic fluid, or fetal blood in pregnant women. STUDY DESIGN: Double amplification of rubella viral ribonucleic acid by nested polymerase chain reaction after reverse transcription was applied to samples from 34 women suspected of having rubella. The results were compared with those of serum antibody and levels of rubella virus-specific immunoglobulin M antibodies in fetal blood. RESULTS: Viral ribonucleic acid was revealed in 8 of 34 cases (23.5%). In the remaining 26 cases, healthy babies were born in 24, 1 was electively aborted, and 1 died in the thirty-sixth week of pregnancy of unknown causes. CONCLUSIONS: This method allowed very early detection of fetal rubella infection by sampling of chorionic villi and amniotic fluid compared with evaluation of the maternal symptoms and serum antibody levels. Fetal blood was also more useful for making a diagnosis up to the twentieth week of pregnancy than was measuring rubella virus-specific immunoglobulin M antibodies.

Human pregnancy serum suppresses the proliferative response of lymphocytes to autologous PHA-activated T lymphoblasts.

PROBLEM: We have previously demonstrated that human serum can suppress the proliferative response in autologous mixed lymphocyte reaction (AMLR) in which phytohemagglutinin (PHA)-activated T lymphoblasts act as stimulators (T-TPHA AMLR). The aim of the present work was to determine whether pregnancy serum (PS) possesses an inhibitory capacity similar or different in magnitude. METHODS: Sixteen PS were added to T-TPHA AMLR cultures and the proliferative response was compared with that in the presence of human serum. The effect of PS on the IL-2 dependent proliferation of PHA-activated T Lymphoblasts was examined as well. RESULTS: PS induced a significantly more pronounced suppression of T-TPHA AMLR than human serum (P < 0.05). One PS tested was not inhibitory but rather stimulatory. This PS was obtained from a woman who subsequently had IUGR. The inhibition is related to the existence of a serum inhibitory factor and not to the lack of a serum supporting factor. PS inhibited not only T-TPHA AMLR of the same woman but also T-TPHA AMLR of other individuals as well, implying that the inhibitor is a non-MHC restricted factor. IL-2 dependent cell proliferation was not inhibited by PS, implying that the inhibitor detected in T-TPHA AMLR is not a general cell proliferation inhibitor. CONCLUSIONS: These results suggest that a non-MHC restricted inhibitory factor present in PS may play an important biological role in regulating local immune responses in the fetal-placental unit mediated by autoreactive T cells restricted to autologous activated T lymphocytes.

Identification of a Gly862 to Ser substitution in the type I collagen gene from a single spermatozoon.

Individual spermatozoa from the father of two affected infants with osteogenesis imperfecta were separated by dilution and micromanipulation. A segment of the type I collagen gene containing the mutant region was amplified by nested polymerase chain reaction and sequenced. Among 40 individual spermatozoa, 15 specimens were identified as mutants with a substitution of guanine3208 to adenine (glycine862 to serine) while 18 and seven specimens were of the wild and mixed types respectively. Through this study, we have established a molecular procedure that can be considered as prerequisite for preimplantation diagnosis of genetic disorders with a single point mutation.

Cytogenetic effects of cryopreservation on human sperm: assessment using an improved method for analyzing human sperm chromosomes.

OBJECTIVE: To evaluate any cytogenetic effects of cryopreservation on human sperm by comparing the frequencies of sperm chromosome anomalies and sex ratios before and after freezing. METHODS: Using in vitro fertilization of zona-free hamster oocytes, analysis of sperm chromosomes was first performed on portions of fresh human semen samples. The residual semen was then analyzed for sperm chromosomes after cryopreservation for several weeks. Sperm donors were 5 healthy men aged 26-38 years. RESULTS: A total of 166 sperm karyotypes were analyzed, 94 before freezing and 72 after freezing. The results indicated no significant differences between fresh and frozen sperm in either frequencies of aneuploidy (fresh: 0%, frozen: 2.8%) or structural anomalies (fresh: 7.5%, frozen: 9.7%). The sex ratios did not differ from the expected 1:1 ratio under either condition. CONCLUSIONS: The results of these studies indicate that cryopreservation does not exert any cytogenetic mutagenicity on human spermatozoa or alter X/Y ratio of human sperm.

Anticardiolipin antibodies in patients with pregnancy loss induce factor Xa production in the presence of beta 2-glycoprotein I.

PROBLEM: Anticardiolipin antibodies (aCL) are commonly associated with recurrent pregnancy loss, though the mechanism is uncertain. Some investigators have indicated that aCL may be directed at a complex made up of cardiolipin and a blood anticoagulant, beta 2-glycoprotein I (beta 2GPI). We therefore investigated the effects of beta 2GPI-dependent aCL IgG enriched fractions, isolated from sera of patients with pregnancy losses, on blood coagulation. METHOD: beta 2GPI-dependent aCL were prepared from sera of three women with second trimester pregnancy losses, by cardiolipin affinity column chromography, following by anti-beta 2GPI affinity column chromatography. The effects of beta 2GPI and beta 2GPI-dependent aCL on the activation of factor X in vitro were examined. RESULTS: beta 2GPI inhibited the activation of factor X and beta 2GPI-dependent aCL blocked this inhibitory effect in a dose dependent manner. CONCLUSION: These results imply the possibility of beta 2GPI-dependent aCL induce hypercoagulation or thrombus by blocking the inhibitory effect of beta 2GPI on activation of factor X, which may result in pregnancy loss.

Successful pregnancy in a Churg-Strauss syndrome patient with a history of intrauterine fetal death.

Allergic granulomatosis and angiitis was first reported as a disease entity separate from polyarteritis nodosa in 1951 by Churg and Strauss. It is characterized by bronchial asthma, eosinophilia, and vasculitis and is especially rare in women of reproductive age, though, when present, may be associated with fetal mortality in pregnancy. We report a successful pregnancy in a patient who previously experienced intrauterine fetal death at 30 weeks of gestation.

Specific antiphospholipid antibodies (aPL) eluted from placentae of pregnant women with aPL-positive sera.

The mechanism by which antiphospholipid antibodies (aPL) cause recurrent pregnancy loss remains unclear. It has however been reported that aPL may affect cytotrophoblasts in vitro and thus direct placental damage might occur. Therefore, we investigated whether aPL are bound directly to placental tissues in patients with immunoglobulin G (IgG)-aPL positive sera. The material investigated comprised the placentae of six patients with a history of recurrent pregnancy loss and subclinical autoimmune disorder and one with systemic lupus erythematosus, who were treated with a combination of prednisolone and aspirin. Normal controls consisted of placentae derived from six women, negative for serum aPL, with no medical or obstetrical complication during their pregnancy. Five kinds of IgG- and IgM-antiphospholipid (anti-PS, PI, PA, PG and CL) antibodies were eluted from the placentae of both patients and controls, which were measured by enzyme-linked immunosorbent assay. IgG-aPL were detected in the placental eluates of four of seven (57%) patients, whereas IgM-aPL were not found in any. With respect to the pregnancy outcome of the four patients with IgG-aPL-positive placental eluates, one experienced intrauterine fetal death (IUFD) at 23 weeks of gestation and three demonstrated intrauterine growth retardation (IUGR). In contrast, the remaining three patients, evaluated negative for IgG-aPL in placental eluates, gave birth to one baby with IUGR and two appropriate-for-date babies. The placentae of the four mothers with IgG-aPL-positive placental eluates pathologically showed severe thrombotic findings. These results suggest that IgG-aPL can directly bind to placental tissue and might cause pathologic damage resulting in IUFD or IUGR.

Successful management of congenital protein C deficiency with recurrent pregnancy loss.

A 29-year-old woman experienced unexplained intrauterine fetal death (IUFD) three times, at 16, 27 and 27 gestational weeks. She was found to be protein C-deficient and the existence of infarction in the placenta was suspected at 20 weeks' gestation during her fourth pregnancy. Both heparin and antithrombin III were administered until delivery of a small-for-dates but live baby. Massive infarction in the placenta was evident at term. Anticoagulation with heparin is a useful treatment approach for cases of recurrent IUFD with protein C deficiency.

Preconceptional natural-killer-cell activity as a predictor of miscarriage.

There is no immunological test for the prospective identification of alloimmune causes of miscarriage. We investigated whether activity of natural killer cells was predictive of subsequent abortion in women who had had unexplained recurrent abortions and had received no treatment. 24 women with high preconceptional NK activity, defined as mean plus 1 SD of NK activity of 47 controls, had a significantly higher abortion rate in the next pregnancy than 44 women with normal levels of NK activity (71 vs 20%; relative risk 3.5; 95% CI 1.8-6.5). The preconceptional evaluation of NK activity in women with recurrent miscarriages may thus be predictive of the risk of pregnancy loss at the next conception.

beta 2-Glycoprotein I-dependent and -independent anticardiolipin antibodies in healthy pregnant women.

The purpose of this study was to determine the association between beta 2-glycoprotein I (beta 2GPI)-dependent anticardiolipin antibodies (aCL) and beta 2GPI-independent aCL and their respective relevance to adverse pregnancy outcomes. Therefore, we prospectively studied 210 normal pregnant women, utilizing a modified enzyme-linked immunosorbent assay method for beta 2GPI-dependent and -independent aCL. Seven of the 210 pregnant women (3.3%) demonstrated evidence for beta 2GPI-independent immunoglobulin G (IgG)-aCL. Two patients, who also appeared positive for beta 2GPI-dependent IgG-aCL, were proven to be false positives. Amongst the 210 patients, not one was thus positive for beta 2GPI-dependent aCL. Women with beta 2GPI-independent aCL demonstrated no adverse pregnancy outcomes. These results suggest that the presence of beta 2GPI-independent aCL is not associated with the presence of beta 2GPI-dependent aCL, though it may give rise to false positive results. Since the presence of beta 2GPI-independent aCL does not appear to be associated with adverse pregnancy outcomes, beta 2GPI-dependent assays may represent better markers of miscarriage risk.

Comparison of chorionic villus sampling and amniocentesis: current status of prenatal diagnosis in Japan.

Data were tabulated and compared for cases involving prenatal diagnostic procedures performed in the 8 years between January 1985 and December 1992. Of a total of 2781 pregnancies, 2546 cases (91.5 per cent) were diagnosed by amniocentesis, and 235 (8.5 per cent) by chorionic villus sampling (CVS). These findings reflect the fact that amniocentesis has taken deep root as the prenatal diagnostic procedure widely acknowledged by society, whereas even the existence of CVS has yet to be generally recognized. Analysis of our clinical and laboratory results and complication rates, however, suggests that CVS is a safe and accurate alternative to amniocentesis which should and can be positively presented to all patients who are candidates for prenatal diagnosis.

Specific IgG autoantibodies are potent inhibitors of autoreactive T cell response to phytohemagglutinin-activated T cells.

PHA-activated human T cells express MHC class II molecules and have been shown to stimulate autoreactive T cells in autologous mixed lymphocyte reaction (T-T AMLR). We now demonstrate that normal human serum can dramatically suppress the proliferative response in T-T AMLR. The inhibitory factor was detected in the IgG fraction, and the activity was found to be mediated through the F(ab')2 portion of the IgG molecule, implying that the inhibitor could be specific. All homologous as well as autologous sera tested contained the inhibitory activity. Human serum was also found to suppress allogenic MLR stimulated by PHA-activated T lymphocytes but not allogenic MLR stimulated by nonactivated PBMC, indicating that the mechanism of inhibition is related to PHA activation of the stimulator cells. Moreover, pretreatment of the PHA-activated T lymphocytes with human serum resulted in a significant inhibition of T-T AMLR, as opposed to pretreatment of nonactivated PBMC, indicating that PHA-activated stimulators are functionally involved in the inhibition. Cytofluorometric analysis revealed that autologous IgG specifically binds to PHA-activated T lymphocytes and not to nonactivated CD3+ T cells. Furthermore, serum absorbed by PHA-activated T lymphocytes substantially lost its inhibitory activity whereas serum absorbed by nonactivated PBMC did not, suggesting that a surface molecule(s) expressed during activation of the stimulator cells is involved in the inhibition. The addition of human serum later in the culture period (> 3 days) resulted in a marked decrease in inhibition, implying that the presence of IgG in the early recognition phase of T-T AMLR is essential for maximum inhibitory effect. These results raise the possibility that natural autoantibodies present in normal human IgG may play an important role in regulating immune response mediated by autoreactive T cells.

Clinical evaluation of immunotherapy in early pregnancy with x-irradiated paternal mononuclear cells for primary recurrent aborters.

OBJECTIVE: The purpose of this study was to evaluate the beneficial effect of immunotherapy for the treatment of recurrent abortion. STUDY DESIGN: We immunized 106 primary recurrent aborters, twice at around 5 and 7 weeks of gestation, with intradermal injection of approximately 100 to 200 million x-irradiated (50 Gy) paternal mononuclear cells. We injected another 38 primary recurrent aborters in the same manner with only 1 million such paternal cells, to examine the relationship between the paternal cell dose used for immunization and pregnancy outcome. RESULTS: The pregnancy success rate (83.0%) in patients immunized with a large number of cells was significantly higher than that (55.3%) in those immunized with a small number of cells (p < 0.001). Furthermore, the frequency of twins in the former group was high (5.7%, five of 88). CONCLUSION: This positive relationship between the paternal cell dose used for immunization in early pregnancy and the pregnancy outcome reflects the efficacy of this mode of immunotherapy for recurrent aborters.

[Pathogenesis on infertility; its immunological aspects].

Infertility is defined as a reproductive disorder in which pregnancy is established, but normal fetal growth can never be achieved due to pregnancy loss. The pathogenesis of this disorder must be understood accurately to obtain optimal results in its management. Although genetic, anatomic and hormonal factors have been implicated as to its cause, a substantial proportion of cases remain unexplained. Recently, an immunologic etiology for this disorder has been proposed for many couples with infertility due to unexplained causes. Author has evaluated patients with infertility according to two immunologic aspects, namely "autoimmune" and "alloimmune", and assessed them pathophysiologically and clinically. [Autoimmune abnormality] Autoimmune diseases, especially SLE, have been associated with pregnancy loss, with autoantibody abnormalities being speculated to be causally related to this reproductive disorder. Especially among various autoantibodies, author noticed an antiphospholipid antibody (aPL) that has been associated with micro-thrombosis, and performed the enzyme-linked immunosorbent assay. Pathophysiological evaluations performed were as follows: 1. Inhibitory effect of aPL on prostacyclin production in cultured vascular endothelial cells. 2. Existence of aPL in the elute from placental tissue. Clinical evaluations were as follows: 1. Frequency of aPL positivity among patients with infertility. 2. Correlation between frequency of aPL positivity at the placental site and the outcome of pregnancy. 3. Correlation between the selected modes of medical therapy (e.g., administration of prednisolone, aspirin, etc.) in aPL-positive cases and the outcome of pregnancy. Based on the results of the above evaluations, it was suggested that IgG-aPL can be considered a useful diagnostic and prognostic variable in women with infertility. Moreover, it was considered that the inhibition of prostacyclin production due to aPL might disturb utero-placental circulation by vasoconstriction and local vascular thrombosis in the placenta and thus lead to pregnancy loss. It was confirmed that the combination of immunosuppressive and anticoagulant therapy is, to a certain extent, an effective treatment for aPL-positive pregnant women. [Alloimmune abnormality] When normal pregnancy is viewed from an immunological standpoint, there arises a basic question of how the fetus escapes immunological rejection despite being allograft. Explanations have been based on various mechanisms of maternal immunity and some experiments were therefore attempted to elucidate the immunological mechanisms. Points of evaluation were as follows: 1. Blocking activity of serum utilizing the mixed lymphocyte reaction with lymphocytes of the husband as stimulators and those of the wife as responders. 2. Detection of HLA-class II antibody, cold-B cell antibody, and anti-idiotype antibody as blocking antibodies in the serum.(ABSTRACT TRUNCATED AT 400 WORDS)