Intravenous Immunoglobulin in Antiphospholipid Syndrome and Maternal Floor Infarction When Standard Treatment Fails: A Case Report

ABSTRACT

Obstetrical antiphospholipid syndrome (APS) is associated with maternal and fetal morbidity and mortality. Standard treatment with low-dose acetylsalicylic acid and unfractionated heparin has achieved up to a 70 to 80% likelihood of success. Conversely, up to 30% of women with APS will have further pregnancy losses, despite treatment. Intravenous immunoglobulin (IVIG) may be a promising adjuvant when standard treatment fails. We present a case of a 35-year-old woman with obstetrical APS and maternal floor infarction in prior pregnancy losses who continued to have further unsuccessful pregnancies despite standard treatment with acetylsalicylic acid and unfractionated heparin. On an investigational basis, she was prescribed concomitant IVIG and had two subsequent healthy newborns. IVIG appears to be promising in obstetrical patients with APS who are refractory to standard treatment. Prior history of maternal floor infarction may be a prognostic indicator for triple therapy for obstetrical APS.

KEYWORDS

Antiphospholipid syndrome - IVIG - maternal floor infarction

REFERENCES

• 1 Wilson W, Gharavi A E, Koike T et al.. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop.  Arthritis Rheum. 1999;  42 1309-1311
• 2 Backos M, Rai R, Baxter N et al.. Pregnancy complications in women with recurrent miscarriage associated with antiphospholipid antibodies treated with low dose aspirin and heparin.  Br J Obstet Gynaecol. 1999;  106 102-107
• 3 Kutteh W H, Rote N S, Silver R. Antiphospholipid antibodies and reproduction: the antiphospholipid antibody syndrome.  Am J Reprod Immunol. 1999;  41 133-152
• 4 Harris E N. The Second International Anticardiolipin Standardisation Workshop/The Kingston Antiphospholipid Antibody Study (KAPS) Group.  Am J Clin Pathol. 1990;  94 476-484
• 5 di Somone N, Meroni P L, de Papa N et al.. Antiphospholipid antibodies affect trophoblast gonadotropin secretion and invasiveness by binding directly and through adhered beta2-glycoprotein I.  Arthritis Rheum. 2000;  43 140-150
• 6 Branch D W, Peaceman A M, Druzin M et al.. A multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy.  Am J Obstet Gynecol. 2000;  182 122-127
• 7 Triolo G, Ferrante A, Ciccia F et al.. Randomized study of subcutaneous low molecular weight heparin plus aspirin versus intravenous immunoglobulin in the treatment of recurrent fetal loss associated with antiphospholipid antibodies.  Arthritis Rheum. 2003;  48 728-731
• 8 Yu Z, Lennon V A. Mechanism of intravenous immune globulin therapy in antibody-mediated autoimmune disease.  N Engl J Med. 1999;  340 227-228
• 9 Stephenson M D, Ensom M. An update on the role of immunotherapy in reproductive failure.  Immunol Allergy Clin North Am. 2002;  22 623-642
• 10 Benirschke K, Driscoll S G. Maternal Floor Infarction: Pathology of the Human Placenta. New York; Springer-Verlag 1967: 328-330
• 11 Mandsager N T, Bendon R, Mostello D et al.. Maternal floor infarction of the placenta: prenatal diagnosis and clinical significance.  Obstet Gynecol. 1994;  83 750-754
• 12 Donohoe S, Kingdom J CP, Mackie I J. Affinity purified human antiphospholipid antibodies bind normal term placenta.  Lupus. 1999;  8 525-531
• 13 Rand J H, Wu X X, Andree H A et al.. Pregnancy loss in the antiphospholipid antibody syndrome: a possible thrombogenic mechanism.  N Engl J Med. 1997;  337 154-160
• 14 Sebire N J, Backos M, Gaddal S E et al.. Placental pathology, antiphospholipid antibodies, and pregnancy outcome in recurrent miscarriage patients.  Obstet Gynecol. 2003;  101 258-263