配偶淋巴细胞免疫治疗反复自然流产91例分析

目的探讨反复自然流产患者,运用配偶淋巴细胞免疫治疗后,体内封闭抗体水平的变化及其临床疗效.方法对确诊为封闭抗体缺乏的RSA患者91例,用分离的配偶淋巴细胞,皮内注射法免疫治疗3～5疗程,治疗前后运用流式细胞仪测定患者体内封闭抗体水平.结果 91例RSA患者经免疫治疗后,体内封闭抗体的水平显著提高,抗配偶CD3%、抗配偶CD4%、抗配偶CD8%,分别由治疗前的-1.32±0.98、-1.39±0.80、-0.96±0.54上升为0.99±0.74、1.01±0.64、0.75±0.49(P＜0.05);妊娠成功80例,成功率为87.9%(80 / 91).结论配偶淋巴细胞免疫治疗,可以提高患者体内封闭抗体水平,有助于妊娠成功.     

反复自然流产的免疫因素分析探讨

为分析探讨反复自然流产的免疫性因素，应用补体微量淋巴细胞毒实验方法检测女性反复自然流产的封闭抗体，用ELISA法检测女性反复自然流产的抗心磷脂抗体(ACA)、抗精子抗体(ASA)共752例。结果显示，封闭抗体与反复自然流产明显相关，抗心磷脂抗体与反复自然流产有一定关系，抗精子抗体与反复自然流产无明显相关。研究表明，封闭抗体、抗心磷脂抗体是造成反复自然流产的重要免疫因素。     

封闭抗体的抗独特型抗体在反复自然流产中的应用价值

为了观察在反射自然流产（ＲＳＡ）中独特型抗体－抗独特型抗体网络的作用，分别测定正常生育组、原发性ＲＳＡ、继发性ＲＳＡ的封闭抗体效率（Ａｂ１）和抗独特型抗体（Ａｂ２），以及原发性ＲＡＳ免疫治疗前后Ａｂ２的变化。结果发现：正常生育组的Ａｂ２分别为７．５３％和１０．７０％；而原发性ＲＳＡ分别为－５５．５１％和－４２．６８％；继发性ＲＳＡ则分别为２９．９８％和－３０．００％，免疫治疗前后，原发性ＲＳＡ患者     

淋巴细胞主动免疫治疗母-胎免疫识别低下型反复性流产疗效分析

目的分析淋巴细胞主动免疫疗法治疗母-胎免疫识别低下型反复性流产（RSA）的临床疗效和作用机制。方法以临床筛查封闭抗体确诊为母-胎免疫识别低下型RSA未孕患者86例为研究对象,采用淋巴细胞主动免疫疗法治疗,将妊娠患者与同期不明原因反复性自然流产（URSA）已孕患者治疗情况对比观察疗效,对母-胎免疫识别低下型RSA患者治疗后不同归向原因进行对比分析该方法的作用机制。结果治疗后妊娠56例,妊娠成功51例,成功率91.07%,与对照组比较P〈0.01,主动免疫治疗疗效与患者年龄、反复流产次数有相关性,与注射淋巴细胞密度无相关性。结论母-胎免疫低下型RSA患者宜早期治疗,淋巴细胞主动免疫疗法是治疗母-胎免疫识别低下型RSA的有效方法。     

原因不明反复自然流产不同疗程的主动免疫治疗疗效观察

目的比较不明原因反复自然流产主动免疫治疗不同疗程的临床疗效。方法将160例APLA阴性患者分为3组,60例治疗组只治疗一疗程4次后妊娠,78例对照组每3周治疗1次,直至APLA转阳后妊娠;22例未治疗后直接妊娠,观察3组妊娠结局。APLA采用淋巴细胞毒实验进行检测。结果免疫治疗前APLA阳性率为8.57%,免疫治疗后治疗组、对照组APLA阳性率分别为41.67%、94.87%,治疗前后APLA比较差异显著（P〈0.01）。治疗组妊娠成功率为88.64%,对照组妊娠成功率为90.77%,两组比较差异不显著（P〉0.05）,未治疗组妊娠成功率为43.75%,与前两组比较差异显著（P〈0.01）。结论免疫治疗能有效刺激母体产生封闭抗体。对不明原因反复自然流产患者孕前进行一疗程4次治疗具有疗程短、疗效显著、妊娠结局好等特点。     

反复自然流产患者血清ThAb、AsAb、EMAb和AoAb检测的临床意义

目的:探讨了反复自然流产患者血清ThAb、AsAb、EMAb和AoAb水平的变化及临床意义。方法:应用放射免疫分析和斑点免疫法对84例反复自然流产患者进行了血清ThAb、AsAb、EMAb和AoAb的检测,并与35名健康孕妇作比较。结果:反复自然流产患者血清ThAb、AsAb、EMAb和AoAb的阳性率显著地高于正常孕妇组(P<0.05)。结论:检测反复自然流产患者血清ThAb、AsAb、EMAb和AoAb水平的变化对疾病的诊断和发病机制有一定的临床价值。     

反复自然流产与免疫学因素的相关性分析

为了探讨抗精子抗体（AsAb）、抗心磷脂抗体（ACA）和抗子宫内膜抗体（EMAb）在反复自然流产中所起的作用,我们检测了从2007年6月～2008年12月来我院优生优育门诊就诊的女性患者血清中AsAb、ACA和EMAb,并以正常育龄妇女作对照,现将结果报告如下。     

反复自然流产患者血浆前列环素和血栓素水平及其与抗心磷脂抗体的关系

用ＲＩＡ法检测了４６例不明原因的反复自然流产（ＲＳＡ）患者血浆６－ｋｅｔｏ－ＰＧＦ１ａ和ＴＸＢ２水平，并对其与抗心磷脂抗体（ＡＣＡ）的关系进行了研究。结果表明，ＲＳＡ患者有一定程度的血栓素升高和前列环素的降低，其中尤以ＡＣＡ阳性者更为明显，Ｔ／Ｋ比值较对照组显著增高（Ｐ＜０．０１）。体外实验尚未发现ＡＣＡ对血小板释放ＴＸＡ２有明显的促进作用，对其原因也进行了分析。本文还就ＡＣＡ阳性患者血浆ＴＸＢ２升高和６－ｋｅｔｏ－ＰＧＦ１ａ降低的机理及临床意义作了探讨。     

反复自然流产患者母胎界面SOCS3蛋白、TNF-α及IL-10的表达

目的:研究反复自然流产患者蜕膜组织中细胞因子信号转导抑制因子SOCS3,细胞因子TNF-α及IL-10的表达,并与正常妊娠作对照。方法:Western blot检测SOCS3的表达,免疫组织化学法检测细胞因子TNF-α及IL-10的表达。结果:反复自然流产组蜕膜组织中SOCS3的表达明显降低(P<0.01),差异有统计学意义,IL-10表达降低(P<0.01),TNF-α表达增高(P<0.05),差异有统计学意义。结论:与正常妊娠相比,反复自然流产组蜕膜组织中SOCS3蛋白及IL-10表达降低,TNF-α表达增高,差异有统计学意义,说明反复自然流产患者母胎界面Th1/Th2失衡,SOCS3蛋白可能通过与细胞因子的相互调控作用影响Th1/Th2平衡导致流产发生。     

Natural Killer Cell Cytotoxicity and Paternal Lymphocyte Immunization in Women with Recurrent Spontaneous Abortions

PROBLEM: Natural killer (NK)-cell cytotoxicity in women undergoing lymphocyte immunization prior to and following treatment was investigated. METHOD OF STUDY: A cohort of 33 women with a history of two or more recurrent spontaneous abortions was prospectively studied. NK-cell cytotoxicity was determined at effector-to-target ratios of 50:1 and 25:1. Peripheral blood CD56+ NK-cell, CD 19+ B-cell, CD19+/5+ B-l-cell, and CD3+ pan T-cell levels were studied by flow cytometry before and after lymphocyte immunization treatment. Maternal antipaternal T- and B-cell antibody levels were measured before and after lymphocyte immunization by flow cytometric analysis. Paternal lymphocyte immunizations were given two times with a 4-week interval. Post-lymphocyte immunization testing was done 4 weeks after the second lymphocyte immunization. The controls were 8 normal healthy women. NK assays were done twice with an interval of 8 weeks. RESULTS: NK-cell activity at effector-to-target ratios of 50:1 (P = 0.005) and 25:1 (P = 0.001) were significantly suppressed after lymphocyte immunization. CD3+ pan T-cell levels after lymphocyte immunization were significantly increased compared with levels before lymphocyte immunization (P = 0.008). CD56+ NK-cell levels were significantly suppressed after lymphocyte immunization (P = 0.016). There was no correlation between changes in NK cytotoxicity and differences in antipaternal lymphocyte antibody levels before or after lymphocyte immunization. CONCLUSION: Lymphocyte immunization suppresses NK-cell cytotoxicity and CD56+ NK-cell levels and increases the peripheral blood CD3+ T-cell population in women with recurrent spontaneous abortions.     

Allogenic Lymphocyte Immunotherapy for Unexplained Recurrent Spontaneous Abortion: A Meta‐Analysis

Allogenic lymphocyte immunotherapy (LIT) as a treatment for unexplained recurrent spontaneous abortion (URSA) is still controversial due to the lack of enough controls to evaluate its effectiveness. Eighteen randomized, placebo‐controlled trials with LIT for URSA were included in the meta‐analysis. Live birth rates for each group were extracted, and the overall odds ratio (OR) for LIT was calculated. The success rate of treatment group was significantly higher (OR 3.74, 95% CI 3.07 ~ 4.57). LIT performed before and during pregnancy had dramatically improved the live birth rate in women with URSA (OR 4.67, 95% CI 3.70 ~ 5.90). The overall OR was 5.25 (95% CI 4.16 ~ 6.64), which supports a low dose of lymphocytes for treating URSA. Our results indicate that LIT provides a significantly beneficial effect over placebo for URSA. LIT given before and during pregnancy is superior to LIT given only before pregnancy, and the lower doses per treatment (less than 100 × 10⁶ lymphocytes or 100 mL peripheral blood) achieved a better outcome.     

改良单向混合淋巴细胞培养在反复自然流产诊疗中应用

为了避免现行封闭抗体检测方法的不合理性,对其进行改进,将男方刺激细胞与妇女待测血清孵育,然后分离结合了封闭抗体的刺激细胞,将经或未经封闭抗体作用的男方刺激细胞分别与女方反应细胞在25%正常AB型血清同等培养条件下培养6d.改进后方法测得正常生育组与原发性反复自然流产组封闭效率阳性率为57.1%及12.3%,均数为7.53±10.30及—55.51±13.41.改进后方法的准确度(81.7%)、灵敏度(87.8%)及特异性(57.1%)均高于改进前.在分析白细胞免疫疗法免疫效果时发现,改进后的方法更能准确反应患者体内封闭效率逐渐上升趋势.改进后的封闭效率在评价反复自然流产治疗的临床疗效时优于改进前.     

复发性流产的免疫治疗效果分析

目的了解采用淋巴细胞对复发性流产进行主动免疫的疗效。方法采用丈夫外周血淋巴细胞治疗复发性流产,454例患者疗程结束并成功随访,妊娠至20周后者为治愈。结果 116（25.55%）例足月分娩,治愈率70.48%（未包括已孕20周内）。其间1例孕20周诊断无脑儿,1例孕26周超声示胎儿先天性左心发育不良,畸形率0.44%。结论免疫治疗是安全、有效的治疗复发性流产的方法之一,能确实解决病患实际问题。     

The Effectiveness of Allogeneic Leukocyte Immunization in Unexplained Primary Recurrent Spontaneous Abortion

PROBLEM: Unexplained primary recurrent spontaneous abortion (RSA) can be viewed as a partner-specific problem for which immunization with allogeneic leukocytes is being offered as therapy. Published data from randomized controlled trials have produced conflicting results regarding treatment effectiveness. The aim of this study was to perform a subgroup analysis of the data from a recent worldwide collaborative meta-analysis using the raw data for patients with primary RSA entered into randomized controlled trials of immunotherapy. METHODS: Data from randomized controlled trials in eight centers were included in this analysis. Individual patients were included only if they had had three or more spontaneous abortions, no previous pregnancy beyond 20 weeks' gestation, no identifiable cause for the abortions, and no evidence of antipaternal antibodies. Meta-analysis by centre and logistic regression analysis were performed to determine the overall effect of treatment in achieving live birth and to identify variables that affect the prognosis for a successful outcome. RESULTS: In the meta-analysis by center, immunotherapy significantly improved the live birth rate (common odds ratio = 1.94, 95% confidence interval (CI) = 1.20 to 3.12). In the analysis by patient, the likelihood of a successful outcome was also significantly better with treatment (relative risk = 1.46, 95% CI 1.19 to 1.69). The absolute treatment effect was 16.3% producing a number needed to treat of 6. The number of previous abortions had a significant negative correlation with live birth rate, such that for each additional pregnancy loss beyond three, the likelihood of live birth was reduced by 23%. CONCLUSION: Allogeneic leukocyte immunization is an effective treatment for unexplained primary RSA when pretreatment antipaternal antibodies are absent. Better diagnostic tests are required to identify patients who may derive maximal benefit from this therapeutic approach.     

Worldwide Collaborative Observational Study and Meta-Analysis on Allogenic Leukocyte Immunotherapy for Recurrent Spontaneous Abortion1

PROBLEM: Recurrent spontaneous abortion (RSA) is a common complication of pregnancy for which there is no known cure. Therefore, effective treatment is needed. Published results from controlled clinical trials of allogeneic leukocyte immunization of women suffering from RSA have given conflicting results. To address this controversy, the international raw data of all patients who had been entered into clinical trials that included a control group were collected and analyzed. The primary question to be answered was whether alloimmune stimulation of the female partner improves the subsequent live birth rate. METHODS: Fifteen clinical centers were identified worldwide because they controlled appropriate raw data. Consequently, nine randomized trials (seven double-blinded) were evaluated independently by two separate data analysis teams to assure conclusions were robust. One team also compared randomized trials to the results of six nonrandomized cohort-controlled studies to test for bias in nonrandomized trials. Factors predicting successful live births among couples with RSA were evaluated by logistic regression. RESULTS: Although the two independent analyses made use of different definitions and utilized different statistical methods, the results of both were similar. The live birth ratios (ratio of live births in treatment and control groups) with 95% confidence intervals (CI) were 1.16 (CI, 1.01-1.34, P = 0.031) and 1.21 (CI, 1.04-1.37, P = 0.024), respectively. The absolute differences in live birth rates between treatment and control groups were 8% and 10% in respective analyses. Results in randomized and nonrandomized trials were surprisingly similar despite significant differences in composition of control and treatment groups. Live birth rates were lower with older female partners, more than five abortions, with a positive ANA or with positive anticardiolipin antibodies. Live birth rates were higher if the female partner had prior to treatment serum antibodies to paternal leukocytes or converted from negative to positive with immunization. Approximately 0.5% of controls and 2.1% of treated patients experience side effects for a 1.6% treatment related effect. There was no evidence of an increased risk of adverse effects on the fetus. CONCLUSIONS: Two independent analyses of worldwide data on allogeneic leukocyte immunization for treatment of RSA suggest that alloimmunization may be an effective treatment. The treatment effect appears, however, to be small, and the data indicate that immunotherapy helps only 8% to 10% of affected couples. A current lack of diagnostic tests defining patients who most likely would benefit from immunotherapy, precludes the identification of a patient population that would benefit most from such treatment. The efficacy of treatment in such a subgroup could be expected to increase and could be of sufficient magnitude to allow the determination of more effective immunization protocols. This study does not exclude the possibility of a partial correction of a widely prevalent immunology defect by immunotherapy. The presence of such a defect would indicate a need for more effective therapy. The unexplained variation in pregnancy success rates of control groups among centers continues to present a statistical problem, limiting the statistical evaluation of retroactively obtained data.     

Treatment of Recurrent Spontaneous Abortions by Immunization With Paternal Lymphocytes Induces Immunosuppression by Placental Isoferritin

PROBLEM: The immunological mechanism leading to an effective vaccination of unexplained habitual aborters with paternal lymphocytes is not yet elucidated. Since previous studies revealed that immunosuppression by placental isoferritin (PLF) may play an important role in the down regulation of the immune system during pregnancy, it was of interest to investigate whether alloimmunization activates immunosuppression by PLF. METHOD: The immunosuppressive effect of PLF or anti-PLF CM-H-9 monoclonal antibody (MAb) was studied by a one-way mixed lymphocyte reaction (MLR) of alloimmunized women and their husbands. RESULTS: It was found that vaccination of the women with paternal lymphocytes resulted in in vitro immunosuppression by PLF as well as by CM-H-9 MAb, reaching the highest effect after three vaccinations (38 ± 8 and 42 ± 10%, respectively). The increase in PLF immunosuppressive effect was accompanied by the appearance of serum antipaternal human leukocyte antigen cytotoxic antibodies. However, there was no correlation between the degree of suppression and titer of antibodies. The study group was too small to reach a significant correlation between degree of immunosuppression and pregnancy outcome. CONCLUSION: Although it may be of value to measure the inhibitory effect of PLF in one-way MLR as an index of immunosuppression, further studies are needed to establish whether it is a relevant predictor of a successful pregnancy.     

Treatment of Recurrent Spontaneous Abortion by Immunization With Paternal Lymphocytes: Results of a Controlled Trial

PROBLEM: It remains unclear whether maternal immunization with paternal lymphocytes prior to conception improves the reproductive outcome in women with recurrent abortion in whom all secondary causes have been excluded. METHOD: A double-blind placebo controlled trial was instituted in women with unexplained recurrent spontaneous abortion, comparing immunization with 400 million paternal to 400 million maternal (autologous) lymphocytes. The groups were compared in a paired sequential trials chart, by logistic regression, and, in addition, a meta-analysis of this and other published trials was carried out. RESULTS: The live birth rate among pregnancies in paired couples with paternal lymphocyte immunization was 68% compared to 47% in the women who received their own cells. The results bordered on, but did not achieve, statistical significance. The women in each group were thoroughly investigated to exclude known causes of recurrent pregnancy loss and appeared to have been well matched in all variables. Women with lymphocytotoxic antibodies against paternal lymphocytes were excluded. Unlike our previous study there was not association between the time to conception and the chance of a successful outcome. Indeed, the time to conception was relatively short, 12 wk in all groups. The meta-analysis supported an overall modest favorable experience with paternal cells. CONCLUSION: The study is consistent with a general trend favoring paternal over maternal lymphocyte immunization but reinforces the need for larger multicenter controlled trials as well as more detailed biological study in humans to understand the nature of the maternal-fetal interface and its breakdown.     

Intravenous Immunoglobulin in the Prevention of Recurrent Spontaneous Abortion: The European Experience

PROBLEM: Clinical trials of the use of intravenous immunoglobulin (IvIg) in the treatment of recurrent spontaneous abortion (RSA) in Europe were reported and discussed. METHOD OF STUDY: A search of the published literature, combined with our own published and unpublished results, was performed. RESULTS: Two placebo-controlled trials have been concluded in Europe. One trial found high but equal success rates in both the IvIg and the placebo group. Another trial found that IvIg treatment may increase the success rate by 24% compared with placebo but that the result was not statistically significant, which might be due to the small number of patients. Reasons for the diverse results of the two trials were discussed. CONCLUSION: More and larger placebo-controlled trials of IvIg treatment in RSA are needed before drawing definitive conclusions.     

Intravenous Immunoglobulin Inhibits Natural Killer Cell Activity In Vivo in Women With Recurrent Spontaneous Abortion

We previously reported elevation of natural killer (NK) cells in women with recurrent spontaneous abortion (RSA) of immune etiology. In this study, we investigated the effect of intravenous immunoglobulin G (IVIg) on peripheral blood NK activity in vivo in women with RSA. Blood was drawn prior to and 7–11 days after IVIg therapy in eight women with RSA. NK activity was measured using K562 as target cells for ⁵¹Cr-release assays. Serum IgG concentrations were also measured. All received 400 mg/kg/day of IVIg for 3 consecutive days. 1) Seven of eight women became pregnant. Five delivered a live born infant. Three out of five women (60%) who delivered a live born infant showed a significant inhibition of NK cytotoxicity post IVIg and the rest did not show any changes; 2) NK cytotoxicity was significantly increased in a woman who miscarried again; 3) A woman who miscarried a chromosomally abnormal fetus showed a significant inhibition of NK cytotoxicity after IVIg; and 4) Serum IgG concentration increased significantly from 9.3 ± 3.0 mg/ml to 23.5 ± 5.1 mg/ml post IVIg therapy. IVIg effectively inhibits peripheral blood NK activity in vivo. These results are consistent with our previous finding showing that IVIg inhibits NK cell activity in vitro. Women with RSA and elevated NK cells may benefit from IVIg treatment.