The role of immunization treatment in preventing recurrent abortion.

Published reports of controlled studies of immunization treatment in recurrent abortion have not shown any ability of either third-party cells or the husband's cells to prevent further abortions, whereas preliminary results of ongoing studies speak in favor of a beneficial effect of third-party cells. However, the lack of significant differences so far does not prove that immunotherapy in habitual abortion is ineffective, because all of these studies include too few patients in each group to give any conclusive results. Only a mega-trial could evaluate the efficacy and side effects of leukocyte immunotherapy. Such controlled studies are needed to clarify the true benefits, risks, and limitations of immunization treatment in recurrent abortion. Factors such as appropriate inclusion criteria, the time relationship between immunization and the next pregnancy, the number of immunizations required, the cell source and cell doses need to be established. Until this additional information is available this treatment should not be considered routinely indicated. This approach should be restricted to a few centers in order to provide maximal possibilities for collection and evaluation of the data.

Opinions on treatment of women with habitual abortion based on investigations for blocking antibody and autoantibodies.

Three hundred and thirty-seven women with habitual abortion of unknown etiology were studied for cellular reactivity and blocking antibody in one-way mixed lymphocyte culture. Their sera were investigated for anti-cardiolipin antibodies, antinuclear antibodies, and antibodies against DNA, and the activated partial thromboplastin time (APTT) and complement levels of their plasma were determined. Increased anti-cardiolipin antibody levels were demonstrated in 77 (22%) of the 337 women, all of whom were considered healthy and had no signs of autoimmune disease. Most patients with high anti-cardiolipin antibody levels displayed lowered values of complement factor C4. According to our experiences, the mere occurrence of anti-cardiolipin antibody in women with habitual abortion is no absolute cause for treatment with prednisolone, not even in cases with greatly elevated anti-cardiolipin values. Therapy with prednisolone and acethylsalicylic acid (ASA) during pregnancy should be given to those women who have high levels of anti-cardiolipin antibodies concomitant with high APTT values, low values of complement C4, and strong blocking antibody. Anti-cardiolipin antibody has been investigated during pregnancy in 136 normal pregnant women, 11 of whom (8%) were positive at any sampling occasion, but only one of whom (1%) had high levels. Evidently the development of anti-cardiolipin antibody is no normal feature of pregnancy among Swedish women and thus the high frequency found among healthy Swedish women with habitual abortion remains unexplained. We have introduced an immunization program of leukocyte transfusions in habitual abortion. The development of previously absent blocking antibody seems to be a valuable prognostic sign of possible success for immunization therapy against habitual abortion.

The results of investigations for blocking antibody and autoantibodies help to choose between different immunological treatments for recurrent abortion.

Immunologic investigations were performed on 337 healthy women with unexplained habitual abortion. Their sera were investigated for antinuclear antibodies (ANA), antibodies against DNA, and anti-cardiolipin antibodies, and the activated partial thromboplastin time (APTT) and complement levels of their plasma were determined. Cellular reactivity and blocking antibody were studied in one-way mixed lymphocyte culture (MLC). None of the women had any signs of autoimmune disease. However, in 77 of the 337 women (22%) increased anti-cardiolipin antibody levels were found, in 19 (7%) above 10 units. Most patients with high anti-cardiolipin antibody levels had lowered values of complement factor C4. We consider the mere occurrence of anti-cardiolipin antibody in women with habitual abortion to be no absolute cause for treatment with prednisolone, and this is true even in cases with very elevated anti-cardiolipin values. Treatment with prednisolone and acetylsalicylic acid (ASA) during pregnancy should be given to only those women who have high levels of anti-cardiolipin antibodies concomitant with high APTT values, and low values of complement C4. Anti-cardiolipin antibody was also investigated during pregnancy in 136 normal pregnant women. Eleven of them (8%) were positive at any of four sampling occasions, but only one (1%) had high levels. These data differ significantly from those of the habitual aborters. Thus the development of anti-cardiolipin antibody is no normal feature of pregnancy in Swedish women and so the high frequency found among healthy Swedish women with habitual abortion remains unexplained. We have introduced an immunization programme of third party leukocyte transfusions in habitual abortion.(ABSTRACT TRUNCATED AT 250 WORDS)

Anticardiolipin antibodies and complement in ninety-nine women with habitual abortion.

Immunologic investigations were performed on sera from 99 women with habitual abortion (three or more consecutive miscarriages). All were considered healthy and clinical investigations had not revealed any cause for the miscarriages. Sixty-eight were considered to have primary habitual abortion whereas 31 had secondary habitual abortion. Increased anticardiolipin antibody levels were found in 42 patients. None had a primary diagnosis of systemic lupus erythematosus, but at follow-up studies one of them fulfilled the diagnostic criteria of systemic lupus erythematosus. Ten sera, all from patients with primary habitual abortion, showed high anticardiolipin antibody values (greater than or equal to 10 units) concomitant with significantly lower levels of complement factor C4 than those found in sera with moderate or normal anticardiolipin antibody levels. There was no indication of genetic defects explaining the low C4 values, which could be explained at least in part by an activation of complement by the classical pathway.

Transfusions of leukocyte-rich erythrocyte concentrates: a successful treatment in selected cases of habitual abortion.

Forty-nine women who suffered recurrent spontaneous abortion of unknown etiology were studied for cellular reactivity and blocking antibody in one-way mixed lymphocyte culture before and after their receipt of three transfusions of leukocyte-rich erythrocyte concentrates from third-party donors. Those 38 of the 49 women who had no blocking antibody all developed significant blocking activity after the transfusion series. Twenty-five of them have become pregnant since, and only one aborted again. The blocking activity demonstrable in 11 of 49 women was increased after the transfusions. Subsequently five of them became pregnant, and all aborted again. We later found that these five women, who considered themselves to be in perfect health, all had serologic signs of autoimmune disease. We advise against transfusion treatment of women who habitually abort without preceding immunologic investigation, because a population of habitual aborters may contain women with yet undiagnosed autoimmune disease, who would be worse off after blood transfusion. We conclude from our results that a selected population of habitual aborters, that is, those without blocking antibody, benefits from transfusion treatment.

Blood transfusions generate/increase previously absent/weak blocking antibody in women with habitual abortion.

Women who suffered recurrent spontaneous abortions of unknown cause were studied for cellular reactivity and blocking antibody in a one-way mixed lymphocyte culture. A defined group of 20 women whose serum displayed no blocking capacity was given three transfusions of leukocyte-rich erythrocyte concentrates. Serum from all women displayed significant blocking capacity 2 months after the third transfusion. Because blocking antibody seems to be one of the necessary prerequisites for successful pregnancy, leukocyte transfusions from third-party donors ought to be an effective cure for habitual abortion in selected cases.

Habitual abortion: parental sharing of HLA antigens, absence of maternal blocking antibody, and suppression of maternal lymphocytes.

The immunologic responsiveness of eight women who habitually abort has been investigated. All shared an HLA-A or B antigen with their husbands. Sharing of an HLA-DR antigen was found in seven couples, one of which also had a second DR antigen in common. The probability for this high frequency of HLA-DR sharing is negligible (p = 0.0004), as calculated from the antigen frequencies among Europeans. Cells from the woman with two shared DR antigens displayed a minor response to her husband's cells but reacted strongly to control cells, whereas the other women's cells reacted normally to cells from both their husbands and controls in one-way mixed lymphocyte culture (MLC). Only minor cytotoxicity was displayed by women's cells in a direct cell-mediated lympholysis (CML) assay, but they mounted normal cytotoxic responses against both husbands' cells and control cells in an amplified CML assay. The sera from six of the habitually aborting women displayed no blocking activity in one-way MLC, and seven of them had no cytotoxic antibodies. Cells from all habitual aborters were suppressed in two-way MLC by cells from husbands and most controls. We hypothesize that increases in HLA compatibility between mother and fetus and in maternal susceptibility to suppressive influences are in some way linked to a deficiency in the development of antifetal antibody during pregnancy. As a consequence, the fetus may be deprived of the protection by maternal blocking antibody, which may allow maternal cytotoxic reactions to cause abortion.

Functional maturity of cord blood B lymphocytes: Staphylococcus aureus Cowan 1 induces IgG secretion in the human neonate.

Lymphocytes from newborn infants and adults were investigated with the polyclonal B cell activators Staphylococcus aureus Cowan 1, soluble protein A, and pokeweed mitogen (PWM). In cord blood lymphocytes (CBL), protein A and PWM induced only meagre IgM responses, whereas Cowan 1 bacteria induced synthesis of both IgM and IgG in quantities comparable to adult levels. We were also able to establish the neonatal origin of the Ig producing cells. Thus, cord blood lymphocytes seem to be functionally mature enough to produce any Ig class, provided they are given the right stimulus.

Easily suppressed lymphocytes and absence of cytotoxic antibody in three women with habitual abortion.

This investigation involves 3 women with habitual abortion and 2 women with multiple normal pregnancies. Extensive clinical investigations failed to reveal any cause for the abortions. All husbands were ABO-compatible with their respective wives. The women shared three, two, and zero of five identified HLA-A antigens with their respective husbands. None of the women had any cytotoxic antibody. Lymphocytes from all three women reacted normally in one-way mixed lymphocyte cultures to their husbands' alloantigens. Cell-mediated lympholysis was similar in couples with habitual abortion and in those with repeated normal pregnancies. The women's lymphocytes' proliferation was significantly suppressed by lymphocytes from their husbands and by those from most male controls in two-way mixed lymphocyte culture and double chamber experiments. Two women with 6 and 5 live-born children, respectively, served as controls. Their lymphocytes were not suppressed by lymphocytes from their respective husbands or by those from most male controls in two-way mixed lymphocyte cultures. Their reactions in one-way mixed lymphocyte cultures and in cell-mediated lympholysis, however, did not differ from those of the women with habitual abortion.

Evidence for a spontaneous activity and a weak helper function in cord blood lymphocytes.

Human lymphocytes from cord blood (CBL) and adult peripheral blood were studied for suppressive and stimulatory effects. Using a double chamber assay we found that via soluble substance(s) cells from approximately 90% of all cord bloods and about 25% of the tested adults could diminish the proliferative response and the IgM and IgG plaque-forming cell numbers of phytohemagglutinin (PHA) stimulated adult cell cultures. CBL were spontaneously suppressive, whereas cells from 'suppressive adults' required activation with PHA to exert suppression. Co-cultures of T cells and B cells were stimulated with pokeweed mitogen. Cord B lymphocytes were able to secrete not only IgM but also IgG. The Ig response of CBL was weaker than that of adult cells, which argues for an immaturity of cord helper T lymphocytes, and possibly also of cord B lymphocytes.

Ontogeny and postnatal persistence of a strong suppressor activity in man.

We report here on the ontogeny and postnatal persistence of an inhibited human immune response in which lymphocytes from human newborns strongly suppress the proliferation of adults' lymphocytes stimulated by phytohemagglutinin (PHA) or alloantigens in vitro. For this research we used a 2-way mixed lymphocyte culture (MLC) supplemented with PHA, with sex chromosomes acting as markers for dividing male and female cells, or alternatively a double chamber system. The proliferation of maternal lymphocytes was significantly suppressed by fetal lymphoid cells from the liver as early as the 8th week of gestation and by those from fetal blood at the 14th week or later during gestation. This strong suppressor activity persisted in 11-mo-old infants but usually disappeared after that time.