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.

Maternal floor infarction: Management of an underrecognized pathology

“…In a case of APAS and recurrent MFI where aspirin and heparin had failed, i.v. immunoglobulin was started preconceptually and improved the outcome of two consecutive pregnancies with evidence of MFI on placental pathology …”

Evidence of an imbalance of angiogenic/antiangiogenic factors in massive perivillous fibrin deposition (maternal floor infarction): a placental lesion associated with recurrent miscarriage and fetal death

“…Risk factors for MPFD include anti-phospholipid antibody syndrome, 6, 10, 11, 98 elevated maternal serum alpha-feto-protein, 99 activated protein C resistance, 100 and long-chain-3 hydroxyacyl-CoA Dehydrogenase deficiency. 101 The composition of the deposited material has been evaluated and includes fibrin, extracellular matrix proteins (such as fibronectin, laminin, or collagen) and other proteins which are part of the coagulation system.…”

Pravastatin to prevent recurrent fetal death in massive perivillous fibrin deposition of the placenta (MPFD)

“…The beneficial effects of IVIG in preventing recurrent pregnancy loss, like those of heparin and aspirin, appear to be confined to patients who have evidence of anti-phospholipid syndrome or increased NK cell activity [57–59]. Yet, IVIG has been recommended for treatment of recurrent pregnancy losses in cases with poor prognosis [60], those who failed heparin and aspirin therapy [61] or in those with a history of MFI [20]. …”

“… sVEGFR-1, soluble vascular endothelial growth factors receptor-1; PlGF, placental growth factor; sEng, soluble endoglin. Percentile distribution was based on a published reference range [20]. …”

“…We proposed that serial determinations of angiogenic and anti-angiogenic factors could be used to monitor future pregnancies and identify patients at risk for adverse pregnancy outcome [19]. In addition, we have been interested in therapeutic interventions, given that the administration of aspirin, heparin, and intravenous immunoglobulin has not led to a consistent prevention of this recurrent condition [20–22]. Statins can reverse an anti-angiogenic state, and can prevent preeclampsia in an animal model [23–26].…”