Indmedica Home | About Indmedica | Medical Jobs | Advertise On Indmedica
Search Indmedica Web
Indmedica - India's premier medical portal

Journal of the Anatomical Society of India

Correlation of Anticardiolipin Antibody IgM With First Trimester Recurrent Abortions

Author(s): Kalra, S., *Tuli, A., **Goyal, U., *Choudhary, R., *Raheja, S.

Vol. 51, No. 1 (2002-01 - 2002-06)

Department of Anatomy, Maulana Azad Medical College, New Delhi.
*Lady Hardinge Medical College N. Delhi.
**Department of Obstetrics & Gynaecology, Lady Hardinge Medical College, N. Delhi.

Abstract

The study was designed to estimate the prevalence of anticardiolipin antibody IgM in patients of first trimester recurrent abortion and find out whether there is any association between the two. Assay of anticardiolipin antibody IgM was done by Enzyme Linked Immunosorbent Assay (ELISA) technique. Significantly raised levels of anticardiolipin antibody IgM (> 15 MPI units) were detected in 16.7% patients of recurrent abortion.Polyclonal binding of anticardiolipin antibody IgM was proved in the present study, since 80% of patients with raised anticardiolipin antibody IgM had other infections also i.e., toxoplasmosis, or tuberculosis. It was concluded that anticardiolipin antibody IgM is not associated with first trimester recurrent abortions.

Key words: Anticardiolipin antibody, first trimester, abortions, fetal loss

Introduction:

The IgM antibody is the largest immunoglobulin and appears first in an immune response. It constitutes approximately 10% of normal immunoglobulins and activates the complement system (Bullock et al, 1988; Mc Cance et al, 1990). It has a serum half life of approximately 10 days. Anticardiolipin antibodies have a clearly documented association with recurrent abortions and fetal wastage in patients with autoimmune diseases and in those with no apparent autoimmune disease (Buchanan et al, 1989). The autoimmune antibodies associated with lupus anticoagulant and anticardiolipin antibodies are immunoglobulin G (IgG) and immunoglobulin M (IgM). These are serum glycoproteins produced by plasma cells in response to antigens. Anticardiolipin antibody assay is more sensitive and specific for fetal loss in comparison to lupus anticoagulant (Lockshin et al 1985, 1989). First trimester loss of pregnancies is the most common type of miscarriage in women with antiphospholipid antibodies. This may be due to defective implantation and subsequently causing defective placentation (Rai et al, 1995).

Controversies exist regarding association of anticardiolipin antibody IgM with patients of first trimester recurrent abortions. Also, there is paucity of literature of Indian subjects for the same. The present study was designed to estimate the prevalence of anticardiolpin antibody IgM in patients of first trimester recurrent abortions and find out whether there is any association between the two.

Materials and Methods:

A total of one hundred and twenty pregnant women who attended antenatal clinic of Department of Obstetrics and Gynaecolgy at Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital were taken for the study. The subjects selected were of two different groups, sixty each, consisting of women with history of two or more first trimester spontaneous abortions as study group and women with one or more live birth and with no history of any first trimester spontaneous abortion were taken as controls.

Details of history, clinical examination, routine investigations including blood group, haemogram, blood sugar, kidney function test, VDRL test, TORCH test, urine routine and microscopy and ultrasonography were done. Blood was collected and levels of anticardiolipin antibody IgM was estimated by Enzyme Linked Immunosorbent Assay (ELISA) technique using ELISA kit of Gen Bio Immuno WELL R cardiolipin antibody IgM Test (quantitative). The Immuno WELL Cardiolipin Antibody (IgM) test is an enzyme immunoassay which measures anticardiolipin antibody IgM in human serum. The Immuno WELL test provides highly reproducible results expressed in units that are standardized against an internationally recognized reference preparation. Levels of anticardiolipin antibody IgM are reported as MPL units which is defined as the cardiolipin binding activity of 1 mg/ml of an affinity purified anticardiolipin antibody IgM preparation from a standard serum (Harris et al 1987).

The immuno WELL test utilizes an enzyme immunoassay microtiter plate technique for detection of antibodies. Serum is added to antigen coated microtiter wells and allowed to react. After removal of unbound antibodies, horseradish peroxidase-conjugated antihuman antibodies are allowed to react with bound antibodies. The bound peroxidase reacts with 2,2' azino-di-[3ethylbenzthiazoline sulfonate] (ABTSâ), the chromogenic substrate, developing a colour. Finally the substrate reaction is stopped and the optical density is read with a spectrophotometric microwell reader at 405 nm optical density. For calculation of results a logarithmic paper is plotted with the concentration (X) of each calibrator against the adsorbance (Y) to get a standard curve. The cardiolipin antibody (IgM) value is obtained by referring to the standard curve. Results are interpreted in MPL units as negative < 10, Insignificantly positive 10-15, Significantly positive > 15 (as per Package Insert for Calibration Samples From the Antiphospholipid Standardization Laboratory, University of Louisville).

Observations and Results:

Levels of anticardiolipin antibody IgM were evaluated in one hundred and twenty women including sixty women who had history of recurrent abortions and sixty women as controls.Significantly raised levels were found in 16.7% (n = 10) of study group and in none of the control group patients, whereas these levels were negative in 70% (n = 42) in study group patients and 90% (n = 54) in control group. (Table I and Figure I).

Table 1 Distribution of patients according to anticardiolipin antibody lgM levels

Anticardiolipin antibody lgM
(in MPL units)
Study Group
N=60
Control Group
N=60
  n (%) n (%)
Total Positive (³10) 18 (30) 6 (10)
Significantly Positive ( >15) 10 (16.7) - -
Insignificantly Positive (10-15) 8 (13.3) 6 (10)
Negative (< 10) 42 (70) 54 (90)

Total number of patients of recurrent abortions investigated for presence of anticardiolipin antibody IgM was sixty. Out of this group, 13.3% (n= 8) had history of explained recurrent abortions whereas 86.7% (n= 52) had no explained cause of recurrent abortions.In patients of explained abortions, significantly raised levels of anticardiolipin antibody IgM was 6/8 i.e., 75% whereas it was 4/52 i.e., 7.6% in patients with unexplained cause of recurrent abortions. Toxoplasmosis was observed to be the cause for recurrent abortions in six patients, henceforth these patients were included as patients with explained cause of recurrent abortions whereas two patients were found to be suffering from tuberculosis and in two patients there was no other infection diagnosed. Since, tuberculosis is not a known cause of abortion these patients were included as patients with unexplained cause of recurrent abortions. (Table II & III).

Table II Significantly raised levels of anticardiolipin antibody IgM in patients of study group

S.No. of Patient lgM (MPL Units) Any Infection
1 25 Tuberculosis
2 24 Toxoplasmosis, fever, cholecystitis
3 20 Toxoplasmosis
4 23 Toxoplasmosis
5 18 None
6 26 Toxoplasmosis
7 23 Tuberculosis
8 19 Toxoplasmosis
9 20 None
10 22 Toxoplasmosis

Table III Patients of explained and unexplained abortions with significantly raised levels of anticardiolipin antibody lgM.

missing image

Discussion:

Lockwood et al (1986) in a study on 55 patients showed that 18% of women with poor obstetric outcome i.e. two or more recurrent spontaneous abortions, still births or unexplained fetal growth retardation had raised level of anticardiolipin antibody IgM. Cowchock et al (1986) in a study on patients with unexplained recurrent abortions reported the prevalence of IgM in 9.8% of patients which is in concordance with the present study (7.6%), but IgM was raised in none of the patient with explained recurrent abortions which is in contrast to the present study in which raised levels of IgM were observed in 75% patients of explained abortions. Unander et al (1987) in a study on 99 women with recurrent abortions have reported the prevalence of anticardiolipin antibody IgM in 7% of the patients, but IgM values were low (0-7 MPL units) while in the present study it ranged between 18-26 MPL units. Higher levels of IgM in the present study can be due to the patients of toxoplasmosis, fever, tuberculosis etc. included in the study.

Lockwood et al (1989) have reported non specific binding of IgM which suggests polyclonal IgM elevations. In their study three of the five i.e. 60% anticardiolipin antibody negative patients with a false positive plasma reagin test had greatly elevated non-specific lgM binding. Two out of these three patients were human immuno deficiency virus (HIV) positive. Parazzini et al (1991) demonstrated the prevalence of IgM anticardiolipin antibody in 12 of 99 (12%) of patients with two or more unexplained recurrent abortions whereas in the present study it is 7.6%. Maclean et al (1994) in a study of 243 women with a history of two or more first trimester abortions reported 1.6% prevalence of anticardiolipin antibody IgM. Silver et al (1996) in a study to clarify the implication of IgM or low levels of IgG reported 20.4% prevalence of IgM anticardiolipin antibody in women who underwent clinically indicated testing for antiphospholipid antibodies but have not specified the number of positive cases of IgM or low levels of IgG. In the present study pregnant women with history of two or more recurrent first trimester abortions were included and were compared with pregnant women with no history of abortion. The maximum number of women i.e., 46.6% in the study group and 50% in control group were in the age group of 26-30 years. There was no significant correlation between recurrent abortion with any particular age. Parazzini et al (1991) reported the maximum number of patients i.e. 38% in the age group of 25-29 years similar to our study i.e., 26-30 years where as it was 24% in the control group.

In the present study, we observed the prevalence of anticardiolipin antibody IgM in 16.7% (n = 10) of women with two or more recurrent first trimester abortions (Table-1 & Figure 1). Our observation is well within the range reported by other authors i.e. between 1.6% and 20.4% also it is in close conformity with the reports of Lockword et al (1986), Parrazzini et al (1991) and Silver et al (1996) (Table-IV). Polyclonal binding of anticardiolipin antibody IgM as reported by Lockwood et al (1989) has been proved by the present study. Four of the five patients i.e. 80% with increased levels of anticardiolipin antibody IgM in our study had some other infection also, i.e., six patient had toxoplasmosis including one with toxoplasmosis and fever and cholecystitis and two patients had tuberculosis, suggeting the polyclonal binding of IgM.

Table IV Prevalence of raised anticardiolipin antibody lgM as reported by different authors

Author's Name in Study Group Year No. of Patients Prevalence
Cowchock et al 1986 ND 9.8%
Lockwood et al 1986 55 18%*
Unander et al 1987 99 99 7%
Parrazzini et al 1991 99 12%*
Maclean et al 1994 243 1.6%
Silver et al 1996 ND 20.4%*
Kalra et al 2002 60 16.7%

(Present study); *In conformity with present study; ND: Not Determined

In our study prevalence of increased anticardiolipin antibody IgM in patients with explained recurrent abortion was 75% (six out of eight patients) and in patients with unexplained recurrent abortion was 7.6% (4 out of 52) (Table-III) which is similar to the observation of 7% as reported by Unander et al (1987).

Raised levels of anticardiolipin antibody IgM in patients with toxoplasmosis in the present study also substantiates the observation by Norberg et al (1987) that high concentration of anticardiolipin antibody may be found transiently in patients with certain infections e.g. cytomegalovirus infection or human immunodeficiency virus infection.

Toxoplasmosis can be the etiologic agent in abortions (Ruffolo et al, 1992). In the present study, toxoplasmosis was observed as the cause of recurrent abortions in 6 out of 10 patients (60%) with significantly raised anticardiolipin antibody IgM levels. This shows that raised levels of anticardiolipin antibody IgM are not responsible for recurrent abortions but has non specific and polyclonal binding affinity, which is in conformation with the report of Harris at al (1984) and Lockwood et al (1989) that lgG anticardiolipin antibody but not IgM anticardiolipin antibody is associated with systemic thrombotic events.

References:

  1. Buchanan, R.R.C; Wardlow, J.R; Riglar, A.G; Little John, G.O; Miller, M.H. (1989). Anti-Phospholipid antibodies in Connective tissue diseases : Their relation to the Anti- Phospholipid Syndrome and forme fruste disease. Journal of Rheumatology. 16: 757-61.
  2. Bullock, B.L; Rosendahl, P.P.: Pathophysiology. In : Adaptations and alterations in functions, Glenview. II :Scott, foressman & Co. (1988)
  3. Cowchock, S; Smith, J.B; Gocial, B. (1986): Antibodies to phospholipids and nuclear antigens in patients with repeated abortions. American Journal of Obstetrics & Gynecology 155: 1002-10.
  4. Harris, E.N; Loizou, S; Englert, H. (1984): Anticardiolipin antibodies and lupus anticoagulant. Lancent 2:1099.
  5. Harris, E.N; Gharavi, A.E; Patel, S.P; Hughes, G.R.V. (1987): Evaluation of the anti-cardiolipin test : report of an international workshop held 4 April 1986, Clinical Experiment Immunology 68: 215-222.
  6. Lockshin, M; Druzin, M; Goei, S. (1985): Antibody to cardiolipin as a predictor of fetal distress or death in pregnant patients with systematic lupus erythematosus. New England Journal of Medicine. 313: 152-6.
  7. Lockshin, Druzin, M.L; Qamar T (1989): Prednisone does not prevent recurrent fetal death in women with antiphospholipid antibody. American Journal of Obstetrics & Gynecology. 160: 439-443.
  8. Lockwood, C.J; Reece, R.A; Romero, R; Hobbins, J.C. (1986): Antiphospholipid antibody and pregnancy wastage (letter). Lancent 2: 742-743.
  9. Lockwood, C.J; Romero, R; Feinberg, R.F. (1989): The prevalence and biologic significance of lupus anticoagulant and anticardiolipin antibodies in general obstetric population. American Journal of Obstetrics & Gynecology 16: 369-373.
  10. Maclean, M.A; Cumming, G.P; McCall, F; Walker, I.D; Walker, J.J. (1994).: The prevalence of lupus anticoagulant and anticardiolipin antibodies in women with a history of first trimester miscarriages. British Journal of Obstetrics & Gynecology, 101: 1023-106.
  11. McCance, K.L; Huether, S.F. Pathophysiology: The biologic basis for disease in adults and children. St. Louis: Mosby C.V., St. Louis (1990).
  12. Norberg, R; Nived, O; Sturfelt, G. (1987): Anaticardiolipin and complement activation: relation to clinical symptoms. Journal of Rheumatology. 14: 149.
  13. Package Insert for Calibration Samples. From the Anti- phospholipid Standardization Laboratory, University of Louisville.
  14. Parazzni, F; Acaia, B; Faden, D. (1991): Antiphospholipid antibodies and recurrent miscarriage. Obstetrics Gynecology 77: 854-858.
  15. Rai, R.S; Regan, L; Clifford, K. (1995): High prospective fetal loss rate in untreated pregnancies of women with recurrent miscarriage and antiphospholipid antibodies. Human Reproduction 19(12): 3301-3304.
  16. Ruffolo, E.H; Wilson, R.B; Weed, L.A. (1962): Listeria monocytogenes as a cause of pregnancy wastage. Obstetrics Gynecology 19: 533.
  17. Silver, R.M; Porte, T.F; VanLeeuwen, I; Coulam, C; Jeng, G; Scott, J.R. (1996): Anticardiolipin antibodies: Clinical consequences of low titres. Obstetrics Gynecology 87: 494500.
  18. Unander, A.M; Norberg, R; Hahn, L; Arfors, L; (1987): Anticardiolipin antibodies and complement in ninety-nine women with habitual abortion. American Journal of Obstetrics & Gynecology. 156: 114-119.

P=Total Positive Ps=Significantly Positive Pi=Insignificantly Positive N=Negative

Missing Image

Fig 1 : Distribution of patients according to anticardiolipin antibody lgM levels.

Access free medical resources from Wiley-Blackwell now!

About Indmedica - Conditions of Usage - Advertise On Indmedica - Contact Us

Copyright © 2005 Indmedica