Severe maternal morbidity in women with high BMI in IVF and unassisted singleton pregnancies.

STUDY QUESTION: Is there a synergistic risk of severe maternal morbidity (SMM) in overweight/obese women who conceived by IVF compared to normal-weight women without IVF? SUMMARY ANSWER: SMM was more common in IVF pregnancies, and among overweight/obese women, but we did not detect a synergistic effect of both factors. WHAT IS KNOWN ALREADY: While much is known about the impact of overweight and obesity on success rates after IVF, there is less data on maternal health outcomes. STUDY DESIGN, SIZE, DURATION: This is a population-based cohort study of 114 409 singleton pregnancies with conceptions dating from 11 January 2013 until 10 January 2014 in Ontario, Canada. The data source was the Canadian Assisted Reproductive Technologies Register (CARTR Plus) linked with the Ontario birth registry (BORN Information System). PARTICIPANTS/MATERIALS, SETTING, METHODS: We included women who delivered at ≥20 weeks gestation, and excluded those younger than 18 years or with twin pregnancies. Women were classified according to the mode of conception (IVF or unassisted) and according to pre-pregnancy BMI (high BMI (≥25 kg/m2) or low-normal BMI (<25 kg/m2)). The main outcome was SMM, a composite of serious complications using International Classification of Diseases, 10th revision (ICD-10) codes. Secondary outcomes were gestational hypertension, pre-eclampsia, gestational diabetes and cesarean delivery. Adjusted risk ratios (aRR) with 95% CI were estimated using log binomial regression, adjusted for maternal age, parity, education, income and baseline maternal comorbidity. MAIN RESULTS AND THE ROLE OF CHANCE: Of 114 409 pregnancies, 1596 (1.4%) were IVF conceptions. Overall, 41.2% of the sample had high BMI, which was similar in IVF and non-IVF groups. We observed 674 SMM events (rate: 5.9 per 1000 deliveries). IVF was associated with an increased risk of SMM (rate 11.3/1000; aRR 1.89, 95% CI: 1.06-3.39). High BMI was modestly associated with SMM (rate 7.0/1000; aRR 1.23, 95% CI: 1.04-1.45) There was no interaction between the two factors (P = 0.22). We noted supra-additive effects of high BMI and IVF on the risk of pre-eclampsia and gestational diabetes, but not gestational hypertension or cesarean delivery. LIMITATIONS, REASONS FOR CAUTION: We were unable to assess outcomes according to reason for treatment. Type II error (beta ~25%) may affect our results. WIDER IMPLICATIONS OF THE FINDINGS: Our results support previous data indicating a greater risk of SMM in IVF pregnancies, and among women with high BMI. However, these factors do not interact. Overweight and obese women who seek treatment with IVF should be counseled about pregnancy risks. The decision to proceed with IVF should be based on clinical judgment after considering an individual's chance of success and risk of complications. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Research Institute of the McGill University Health Centre (grant 6291) and also supported by the Trio Fertility (formerly Lifequest) Research Fund. The authors report no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Bleeding complications and antithrombotic treatment in 264 pregnancies in antiphospholipid syndrome.

Purpose The purpose of this study was to evaluate the safety of antithrombotic treatments prescribed during pregnancy in patients with antiphospholipid syndrome (APS). Methods This international, multicenter study included two cohorts of patients: a retrospective French cohort and a prospective US cohort (PROMISSE study). Inclusion criteria were (1) APS (Sydney criteria), (2) live pregnancy at 12 weeks of gestation (WG) with (3) follow-up data until six weeks post-partum. According to APS standard of care, patients were treated with aspirin and/or low-molecular weight heparin (LMWH) at prophylactic (pure obstetric APS) or therapeutic doses (history of thrombosis). Major bleeding was defined as abnormal blood loss during the pregnancy and/or post-partum period requiring intervention for hemostasis or transfusion, or during the peripartum period greater than 500 mL and/or requiring surgery or transfusion. Other bleeding events were classified as minor. Results Two hundred and sixty-four pregnancies (87 prospectively collected) in 204 patients were included (46% with history of thrombosis, 23% with associated systemic lupus). During pregnancy, treatment included LMWH ( n = 253; 96%) or low-dose aspirin ( n = 223; 84%), and 215 (81%) patients received both therapies. The live birth rate was 89% and 82% in the retrospective and prospective cohorts, respectively. Adverse pregnancy outcomes occurred in 28% of the retrospective cohort and in 40% of the prospective cohort. No maternal death was observed in either cohort. A combined total of 45 hemorrhagic events (25%) occurred in the retrospective cohort, but major bleeding was reported in only six pregnancies (3%). Neither heparin nor aspirin alone nor combined therapy increased the risk of hemorrhage. We also did not observe an increased rate of bleeding in the case of a short interval between last LMWH (less than 24 hours) or aspirin (less than five days) doses and delivery. Only emergency Caesarean section was significantly associated with an increased risk of bleeding (odds ratio (OR) 5.03 (1.41-17.96); p=.016). In the prospective cohort, only one minor bleeding event was reported (vaginal bleeding). Conclusion Our findings support the safety of antithrombotic therapy with aspirin and/or LMWH during pregnancy in high-risk women with APS, and highlight the need for better treatments to improve pregnancy outcomes in APS. PROMISSE Study ClinicalTrials.gov identifier: NCT00198068.

Studies of defective tolerance induction in NZB mice. Evidence for a marrow pre-T cell defect.

NZB mice manifest a defect in tolerance induction by deaggregated heterologous gamma globulins. We have used an adoptive transfer system to study the defect. Thymectomized, intact, or thymectomized recipients given thymic epithelial grafts were studied after lethal irradiation and reconstitution with NZB, DBA/2, or (NZB x DBA(F1 marrow depleted of mature T cells. NZB thymocytes were responsible for the tolerance defect of NZB mice. The information for the defect was present in the NZB marrow prethymocyte. That defect could only be expressed when there was further maturation in association with a thymus. However, the normal DBA/2 thymic epithelium served as well as the abnormal NZB thymic epithelium. These studies resolve existing conflicts as to whether the NZB marrow or thymus is responsible for the loss of tolerance in association with autoimmunity.

Autoantibodies in alcoholic liver disease.

PURPOSE: To test the hypothesis that since only a proportion of heavy drinkers develop significant alcoholic liver disease (ALD), an autoimmune pathogenesis is likely. PATIENTS AND METHODS: Autoimmune markers were measured in 47 patients with biopsy-proven ALD and compared to measurements in 20 alcoholics without clinical and hematologic evidence of ALD and 28 patients with autoimmune chronic active hepatitis (CAH). RESULTS: Twenty-two percent of patients with ALD were antinuclear antibody-positive, compared to 71% of patients with CAH. Approximately 60% of patients with ALD had either anti-single-stranded or anti-double-stranded DNA antibodies, slightly more than the patients with CAH. Another marker of autoimmunity, as in systemic lupus erythematosus, is the presence of IgM antibodies to autologous and heterologous lymphocytes, which are cytotoxic at 4 degrees C. Seventy-two percent of patients with CAH had positive antilymphocyte antibodies, compared to 59.6% of patients with ALD. Furthermore, more than 90% of the sera from ALD and CAH patients displayed lymphocytotoxicity. Thirty-two percent and 25.5% of CAH and ALD patients, respectively, had all three autoantibodies present. CONCLUSION: These results suggest that autoimmune mechanisms may indeed play a role in the pathogenesis of ALD in at least some patients.

The effects of low-intensity warfarin on coagulation activation in patients with antiphospholipid antibodies and systemic lupus erythematosus.

The optimal intensity of oral anticoagulant therapy for the prevention of thromboembolism in patients with antiphospholipid antibodies (APLA) and systemic lupus erythematosus is controversial. Retrospective studies have suggested that patients with APLA are resistant to oral anticoagulant therapy, with a targeted International Normalization Ratio (INR) of 2.0 to 3.0, and that a higher intensity of anticoagulation (INR: 2.6 to 4.5) is required to prevent recurrent thromboembolism. To investigate if patients with APLA are resistant to the anticoagulant effect of low intensities of warfarin therapy, we performed a randomized trial in which 21 patients with APLA and systemic lupus erythematosus were allocated to receive one of three intensities of warfarin (INR: 1.1 to 1.4, 1.5 to 1.9 or 2.0 to 2.5) or placebo for four months. The main outcome was the effect of each intensity of warfarin therapy on prothrombin fragment 1+2 level (F1+2), that was used as a marker of coagulation activation. When F1+2 levels in patients allocated to the three warfarin intensities were compared to F1+2 levels in the placebo group, there was a statistically significant decrease (p<0.05) in the patient group receiving warfarin with a targeted INR of 2.0 to 2.5 at two, three and four months, and in the patient group with a targeted of INR 1.5 to 1.9 at three months. We conclude that in patients with APLA and systemic lupus erythematosus, warfarin therapy, with a targeted INR of 2.0 to 2.5, is effective in suppressing coagulation activation, and therefore, might be effective in preventing thromboembolism.

Folic acid and homocyst(e)ine metabolic defects and the risk of placental abruption, pre-eclampsia and spontaneous pregnancy loss: A systematic review.

Placental infarction or abruption, recurrent pregnancy loss and pre-eclampsia are thought to arise due to defects within the placental vascular bed. Deficiencies of vitamin B12 and folate, or other abnormalities within the methionine-homocyst(e)ine pathway have been implicated in the development of such placental diseases. We conducted a systematic literature review to quantify the risk of placental disease in the presence of these metabolic defects. Studies were identified through OVID Medline between 1966 and February 1999. Terms relating to the measurement of vitamin B12, folic acid, methylenetetrahydrofolate reductase or homocyst(e)ine were combined with those of pre-eclampsia, placental abruption/infarction or spontaneous and habitual abortion. Human studies comprising both cases and controls and published in the English language were accepted. Their references were explored for other publications. Data were abstracted on the matching of cases with controls, the mean levels of folate, B12 or homocyst(e)ine in each group or the frequency of the homozygous state for the thermolabile variant of methylenetetrahydrofolate reductase. The definition of 'abnormal' for each exposure was noted and the presence or absence of the exposure of interest for each outcome was calculated as an absolute rate with a 95 per cent confidence interval. The crude odds ratios were calculated for each study and then pooled using a random effects model. Eighteen studies were finally included. Eight studies examined the risk of placental abruption/infarction in the presence of vitamin B12 or folate deficiency, or hyperhomocyst(e)inaemia. Folate deficiency was a prominent risk factor for placental abruption/infarction among four studies, though not statistically significant (pooled odds ratio 25.9, 95 per cent CI 0.9-736.3). Hyperhomocyst(e)inaemia was also associated with placental abruption/infarction both without (pooled odds ratio 5.3, 95 per cent CI 1.8-15.9) and with methionine loading (pooled odds ratio 4.2, 95 per cent CI 1.2-15.0), as was the homozygous state for methylenetetrahydrofolate reductase (pooled odds ratio 2.3, 95 per cent CI 1.1-4.9). Vitamin B12 deficiency was not a demonstrable risk factor. Eight studies examined blood levels among women with spontaneous abortion or recurrent pregnancy loss. The pooled odds ratios were 3.4 (95 per cent CI 1.2-9.9) for folate deficiency, 3.7 (95 per cent CI 0.96-16.5) for hyperhomocyst(e)inaemia following methionine challenge, and 3.3 (95 per cent CI 1.2-9.2) for the methylenetetrahydrofolate reductase mutation. Five case-control studies examined the relationship between pre-eclampsia and abnormal levels of vitamin B12, folate, homocyst(e)ine or methylenetetrahydrofolate reductase. Folate deficiency was not an associated risk factor (odds ratio 1.2, 95 per cent CI 0.5-2.7), but hyper-homocyst(e)inaemia was (pooled odds ratio 20.9, 95 per cent CI 3.6-121.6). Similarly, homozygosity for the methylenetetrahydrofolate reductase thermolabile variant was associated with a moderate risk of preeclampsia (odds ratio 2.6, 95 per cent CI 1.4-5.1). Some pooled data were associated with significant statistical heterogeneity, however. There is a general agreement among several observational studies that folate deficiency, hyperhomocyst(e)inaemia and homozygosity for the methylenetetrahydrofolate reductase thermolabile variant are probable risk factors for placenta-mediated diseases, such as pre-eclampsia, spontaneous abortion and placental abruption. Vitamin B12 deficiency is less well defined as an important risk factor. Due to the limited quality of these data, including insufficient matching of cases with controls, and possible laboratory measurement bias relating to pregnancy, prospective studies are needed to confirm these findings and guide future preventative and therapeutic research.

A human anti-cardiolipin autoantibody is encoded by developementally restricted heavy and light chain variable region genes.

Based on recent structural analyses of monoclonal autoantibodies, it appears that a number of these antibodies express germ-line immunoglobulin variable region (V) genes with little or no somatic mutation. In addition, our group and others have noted the identity or near identity of some autoantibody-associated V genes to V genes apparently expressed preferentially in the fetal pre-B cell repertoire. To extend these data, we now report that the heavy and light chain V genes of an anti-cardiolipin antibody derived from a healthy individual display 99% nucleotide sequence homology with V genes expressed in early B cell ontogeny. Sequence comparisons indicate the likely use of fetal-restricted V genes by this autoantibody. Taken together with other data on autoantibody V gene usage, these findings provide further evidence for overlap between the autoantibody-associated and early ontogeny expressed V gene repertoires and suggest that natural autoreactivity may be instrumental in the development and maintenance of the normal immune repertoire.

The transfer of pravastatin in the dually perfused human placenta.

HMG-CoA reductase inhibitors (statins) are contraindicated during pregnancy. However, it has been suggested that the hydrophilic property of pravastatin prevents its placental transfer to the fetus, explaining neutral effects observed in controlled studies. Using the ex-vivo placental perfusion model, placental transfer of pravastatin (50 ng/ml) was determined. The mean maximum fetal concentration was 4.4 ng/ml. The transfer of pravastatin's across the placenta appears to be limited and slow. Combined with its rapid elimination half-life of 2 h and 50% protein binding, the transfer of pravastatin from maternal to fetal compartments is substantially more limited than observed in the perfusion experiments.

Anti-DNA and antilymphocyte antibodies during acute infection with human parvovirus B19.

Sera from patients in the acute and recovery stages of parvovirus B19 infection, and from individuals with no detectable antiparvovirus antibody were examined for the presence of anti-DNA and antilymphocyte antibodies. Sixty-eight percent of individuals recently recovered from parvovirus infection had elevated levels of antidouble stranded (ds) and antisingle stranded (ss) DNA antibodies. In addition, a cytotoxic IgM antilymphocyte antibody was detected in more than 88% of these same sera. Serial specimens from volunteers experimentally infected with parvovirus B19 were also tested for these autoantibodies and it was determined that the presence of antilymphocyte IgM was dependent on the stage of infection. The antilymphocyte IgM was occasionally detectable in sera containing rubella specific IgM (11%) or varicella zoster specific IgM (25%). However, in contrast to B19 infection, these antibodies were not cytotoxic. From the results of our study, we propose that parvovirus infection of hematologically normal individuals may be accompanied by a transient, subclinical autoimmune state.

The specificity of in vivo tolerance to haptens in NZB and normal mice after exposure to hapten-modified syngeneic spleen cells.

We have evaluated hapten-specific hyporesponsiveness induced by in vivo administration of TNP-modified syngeneic spleen cells (TNP-SC). Pretreatment of non-autoimmune mice led to hyporesponsiveness to challenge with either TNP or the closely related hapten DNP coupled to Ficoll. There was also a significant reduction of the direct PFC response after challenge with TNP-HGG. In tolerized mice challenged with TNP-HGG, the IgM portion of the serum response was similarly suppressed; however, the total serum antibody as well as the indirect PFC response was not suppressed. There was no tolerance at all when the mice were challenged with DNP-HGG. Thus, exposure to TNP-SC results in an incomplete form of hapten-specific B cell tolerance. This tolerance is selective for the IgM isotype and does not extend to the cross-reactive hapten DNP on a thymic-dependent carrier, although it does extend to a DNP on a thymic-independent carrier. Autoimmune NZB mice were defective with regard to tolerance after injection of hapten-modified syngeneic spleen cells. They did manifest a reduced direct PFC response to the challenge with TNP-Ficoll, but failed to demonstrate cross-tolerance to DNP-Ficoll challenge. Moreover, they did not have suppression of the hapten-specific IgM response after challenge with TNP on the thymic-dependent carrier. These abnormalities in tolerance induction in NZB mice to modified self may help to explain the loss of self-tolerance that occurs spontaneously and is expressed as autoimmune disease.

The regulatory role of NZB T lymphocytes in the production of anti-DNA antibodies in vitro.

Murine lupus is characterized by the production of numerous autoantibodies and immune complex glomerulonephritis. Anti-DNA antibodies are the hallmark of this disorder and may be associated pathogenetically with the glomerulonephritis. The cellular mechanisms underlying the regulation of the production of anti-DNA antibodies may prove to be the fundamental abnormalities responsible for the lupus syndrome seen in these mice. By using a system of spontaneous anti-DNA antibody production in vitro, we have determined that such production is characteristic of autoimmune NZB and MRL-lpr/lpr mice but not of the nonautoimmune control strains. Additional examination of the cellular mechanisms involved in the regulation of this response in NZB mice revealed: 1) this response is markedly T cell dependent, 2) NZB T cells are essential for maximal production of this autoantibody, and 3) NZB T cells actively interfere with normal immune regulatory mechanisms that lead to the production of anti-DNA antibodies spontaneously in vitro by nonautoimmune syngeneic B lymphocytes. Although these studies of anti-DNA antibody production in vitro disagree with previous work by others they successfully reproduce the results obtained earlier in experiments performed in vivo.

Comparison of stem-cell recovery in autoimmune and normal strains.

The capacity of NZB stem cells to proliferate in vivo was evaluated in two systems which required repopulation of peripheral organs. In both types of depletion systems, stem-cell repopulation after cyclophosphamide treatment or adoptive transfer repopulation in lethally irradiated hosts, it was found that NZB stem cells were hyperproliferating. The increase in proliferating cells was most pronounced in the spleens of NZB mice treated with high-dose cyclophosphamide and in lethally irradiated F1 mice reconstituted with NZB T-cell-depleted bone marrow. Thus, upon a stimulus to repopulate, NZB marrow stem cells will hyperproliferate in peripheral organs resulting in an increase in cell number. The abnormality in the marrow cells can be observed in young NZB mice when their marrow cells are in an environment which requires recovery and division.

Clinical utility and specificity of anticardiolipin antibodies.

Established solid phase assays for anticardiolipin antibodies (aCL) are often characterized by high levels of nonspecific binding. As a result, only very high levels of aCL have been reported to be associated with a variety of clinical conditions including systemic lupus erythematosus (SLE), recurrent intravascular thrombosis and unexplained recurrent fetal loss. We have developed an ELISA replacing direct evaporation of soluble cardiolipin with cardiolipin micelles in physiological saline as the antigen binding step in the assay. Levels of IgG aCL were detected in various sera at dilutions of 1/100 to 1/3200, showing improved assay sensitivity. Assay specificity was determined using double stranded DNA and ovalbumin as irrelevant binding antigens and no crossreactivity was found. The controversial use of Tween 20 in the assay was investigated and results showed it decreases nonspecific binding without interfering in antibody detection. This assay has enabled us to identify differences in the prevalence and level of aCL antibodies in sera from healthy nonpregnant controls (0/25 positive), healthy pregnant controls (5/47 positive for IgG and 8/47 positive for IgM) and from women with unexplained recurrent fetal loss (16/62 and 14/62 positive, respectively). We support the observation that aCL are not normally distributed, and therefore nonparametric methods of statistical analysis are necessary to determine population prevalence. We confirm that aCL IgM are a relatively nonspecific finding, and extreme caution must be used in basing any clinical decisions on the presence of this antibody alone.

NZB cells actively interfere with the establishment of tolerance to BGG in radiation chimeras.

We report experiments designed to determine if the tolerance defect in NZB mice results from i) failure of NZB cells to become tolerant, or ii) the ability of NZB cells to interfere actively with the development of tolerance. The results indicate that NZB cells are primed by the tolerogen itself and actively interfere with the expression of tolerance by DBA/2 cells, which normally can be rendered tolerant.

Hemochromatotic arthropathy mimicking rheumatoid arthritis. A case with subcutaneous nodules, tenosynovitis, and bursitis.

A 63-year-old man developed symmetrical polyarthritis, subcutaneous nodules at the elbows, olecranon bursitis, and recurrent tenosynovitis. He was later discovered to have idiopathic hemochromatosis. Staining of the subcutaneous nodule revealed iron deposits. These manifestations which are common to rheumatoid arthritis may be seen in hemochromatotic arthropathy.

Comparison of response to stem cell differentiation signals between normal and autoimmune mouse strains.

Normal DBA/2 and autoimmune NZB mice were studied with regard to signals eliciting differentiation and division of bone marrow stem cells. Irradiated (NZB X DBA/2)F1 mice were repopulated with various combinations of T-depleted bone marrow from NZB and DBA/2 mice. In response to the repopulation signal of irradiation, recipients of autoimmune NZB marrow initially demonstrated expansion of LY-5+ lymphoid and hemopoietic cells, particularly of the B cell lineage. The greater the proportion of NZB marrow, the higher the percentage of lymphoid cells observed 2 wk post-repopulation. B cells (ThB-positive cells) were increased in disproportionate numbers in recipients of NZB marrow, even those that had received as little as 20% NZB bone marrow cells. However, by 2 mo, the initially observed increase in lymphoid cells in recipients of NZB marrow was no longer observed. Up to 6 mo post-repopulation, cytogenetic analysis revealed that irradiated recipients were repopulated in the same proportion of DBA/2: NZB as was in the injected marrow. Endogenous colony formation assays indicated that recipients of 100% NZB, 80% NZB, and 20% NZB marrow all had greater numbers of splenic endogenous colonies than did recipients of DBA/2 marrow alone. These studies indicated that autoimmune NZB marrow repopulated irradiated mice in the proportion in which it was injected, but there was a disproportionate early increase in cells of the B lineage as well as a disproportionate increase in splenic colony formation.

Lupus pregnancy. A prospective study of placental changes.

Eleven patients with systemic lupus erythematosus (SLE) were monitored prospectively during pregnancy. Clinical and serologic features of disease activity were recorded, and after delivery, a careful search for pathologic changes in the placenta was carried out. Seven patients delivered live infants, and 4 patients had unsuccessful pregnancies, with fetal loss occurring between 12 and 27 weeks of gestation. One of these 4 patients had active SLE at delivery, and all had circulating lupus anticoagulant and thrombocytopenia. Other serologic abnormalities, including anticardiolipin and anti-Ro antibodies, were not associated with fetal loss. The overall placental size was reduced in SLE patients compared with that in healthy controls and in diabetic controls. A variety of pathologic changes were noted, including placental infarction, intraplacental hematoma, deposition of immunoglobulin and complement, and thickening of the trophoblast basement membrane. The reduction in placental size appeared to enhance the clinical significance of these pathologic changes.