Elsevier

Clinical Immunology

Volume 208, November 2019, 108259
Clinical Immunology

Heparin and aspirin combination therapy restores T-cell phenotype in pregnant patients with antiphospholipid syndrome-related recurrent pregnancy loss

https://doi.org/10.1016/j.clim.2019.108259Get rights and content

Highlights

  • Th1 responses increase in patients with APS-RPL at the time of early pregnancy.

  • LMWH/aspirin combination therapy corrects Th1/Th2 imbalance in APS-RPL patients.

  • Patients with miscarriages continue to exhibit Th1 polarization at the time of abortion.

  • Restoring T-cell Phenotype is a new immunomodulatory mechanism of LMWH/aspirin combination

Abstract

Recurrent pregnancy loss (RPL) is the most common manifestation of anti-phospholipid syndrome (APS), and activated CD4+ T cells are involved in its pathogenesis. Treatment with low-molecular weight heparin (LMWH) and aspirin combination improves pregnancy outcome, however, its mechanism of action is unclear. We investigated the effect of this therapy on Th1/Th2 cells in 89 patients with APS-RPL. The results showed that serum cytokine levels, T cell phenotypes, and transcription factors' gene expression levels representing Th1 responses were higher, whereas those representing Th2 responses were lower in patients with APS-RPL at the time of early pregnancy. This Th1-bias was reversed in patients who had live birth after receiving the combination therapy at the time of delivery. Patients with miscarriages continued to exhibit Th1-bias. In conclusion, these data support a role of Th1-bias in the pathogenesis of APS-RPL and suggest restoring T-cell phenotype as a new immunomodulatory mechanism of LMWH/aspirin combination.

Introduction

Recurrent pregnancy loss (RPL) is a major manifestation of anti-phospholipid syndrome (APS) [1]. Pathogenesis of APS-related RPL (APS-RPL) remains unclear. Thrombosis and hypercoagulable state were believed to mediate APS-RPL [2]. However, accumulating evidence suggests a pivotal role of immune dysfunction in the pathogenesis of APS-RPL [3,4]. For example, a recent study showed activated CD4+ T cells in pregnant patients with lupus and/or anti-phospholipid antibodies [5]. Studies in patients and animal models also suggest a perturbed T-helper 1 (Th1)/Th2 cytokine homeostasis in APS [6,7]. Some studies have suggested a Th1-bias [8], while others have reported a shift to Th2 cytokines in APS [9]. However, the exact in vivo abnormalities in Th1/Th2 responses in APS-RPL are mostly unclear.

Numerous studies have shown that Th2 cytokines interleukin (IL)-4 and IL-10 are overexpressed, whereas the expression of Th1 cytokines IL-2 and interferon (IFN)-γ is reduced in the striatum and peripheral blood of normal pregnant women [10]. Thus, Th2-bias of the maternal immune response is generally considered to maintain pregnancy [11]. Such state of immune tolerance is perturbed in humans and animals with APS with a polarization towards a Th1 response [12]. This altered immune response is believed to damage the placental villi and embryonic tissues, affecting the development and implantation of fertilized eggs as well as the growth and development of embryos, consequently leading to adverse pregnancy outcomes including miscarriage and premature birth [13].

Combination therapy of LMWH and aspirin has been shown to improve pregnancy outcome in patients with APS-RPL and is considered to be the standard of care for APS-RPL [14]. Despite being the pillars of APS-RPL treatment, their precise mechanisms of action are not completely understood. This study evaluated the relationship between Th1/Th2 cells and APS-RPL. We further investigated the effect of combination therapy with LMWH and aspirin on Th1/Th2 cell profile in patients with APS-RPL. Our data suggest that the Th1/Th2 imbalance is restored in patients treated with LMWH/aspirin combination therapy.

Section snippets

Patients

We enrolled a cohort of patients, who visited Peking University Shenzhen Hospital between August 2016 and November 2018, with a history of APS-RPL. All patients fulfilled the 2006 revised International Sapporo Classification of Antiphospholipid Syndrome (APS) [15]. Patients with uterine malformations, chromosomal abnormalities, endocrine factors, reproductive tract inflammation, and other autoimmune diseases, such as systemic lupus erythematosus (SLE), were excluded from this study. Patients

Therapeutic effect of LMWH and aspirin combination therapy

Of 120 human subjects we enrolled, none had other comorbidities or thrombotic events. Before this pregnancy, all 89 patients with APS-RPL had 3–6 gravidities and 2–6 miscarriages. Anti-β2 glycoprotein I antibody (anti-β2GPI) was present in 55% patients, anti-cardiolipin antibody (aCL) in 39%, and lupus anticoagulant (LA) in 19% (Table 1). None of 31 healthy controls had history of adverse pregnancy outcome(s) and anti-phospholipids.

Of the 89 patients receiving combination therapy, 72 patients

Discussion

T helper cells have been implicated in the induction and regulation of experimental APS-RPL [16,17]. However, data on different Th subsets in patients with APS-RPL are scarce [18,19]. In the present study, we measured serum levels of cytokines and enumerated the number of circulating Th1 and Th2 cells during the time of early pregnancy and the time of delivery or abortion in patients with APS-RPL and at equivalent timepoints in healthy pregnant women. More importantly, we performed a long term

Author contributions

MYW designed the research, created figures, and wrote the manuscript. PZ analyzed data. SYY collected clinical data. GMZ and JYL performed laboratory experiments. DN assisted with figure preparation and edited English language. CSG assisted with research design. QWW was responsible for the supervision of subject recruitment and patient care. RRS assisted with research design and data interpretation, and revised the completed manuscript. All authors reviewed the results and approved the final

Funding

This work was supported by grants from Sanming Project of Medicine in Shenzhen (No. SZSM201612009), the Science and Technology Program for Basic Research in Shenzhen (No. JCYJ20160427190358849, No. JCYJ20170307112009204, No. JCYJ20170818153602439), and Traditional Chinese Medicine Bureau of Guangdong Province (No.20183011).

Study approval

This study was approved by the Ethical Review Committee of Peking University Shenzhen Hospital, and informed consent was obtained from all pregnant patients.

Declaration of Competing Interest

None declared.

Acknowledgements

We are grateful to all the patients who participated in this study and clinical staff who helped with recruitment.

References (48)

  • M. Kemp et al.

    Antiphospholipid syndrome in obstetrics

    Lupus.

    (2018)
  • F.A. Di Prima et al.

    Antiphospholipid syndrome during pregnancy: the state of the art

    J. Prenat. Med.

    (2011)
  • P.L. Meroni et al.

    Obstetric and vascular antiphospholipid syndrome: same antibodies but different diseases?

    Nat. Rev. Rheumatol.

    (2018)
  • K. Oku et al.

    Pathophysiology of thrombosis and pregnancy morbidity in the antiphospholipid syndrome

    Eur. J. Clin. Investig.

    (2012)
  • S. Hong et al.

    Longitudinal profiling of human blood transcriptome in healthy and lupus pregnancy

    J. Exp. Med.

    (2019)
  • I. Krause et al.

    Anti-idiotype immunomodulation of experimental anti-phospholipid syndrome via effect on Th1/Th2 expression

    Clin. Exp. Immunol.

    (1999)
  • S. Visvanathan et al.

    Cellular immunity to beta 2-glycoprotein-1 in patients with the antiphospholipid syndrome

    J. Immunol.

    (1999)
  • T. Tolomeo et al.

    T cells demonstrate a Th1-biased response to native beta2-glycoprotein I in a murine model of anti-phospholipid antibody induction

    Autoimmunity.

    (2009)
  • M. Marzi et al.

    Characterization of type 1 and type 2 cytokine production profile in physiologic and pathologic human pregnancy

    Clin. Exp. Immunol.

    (1996)
  • M. Karakantza et al.

    Type 1 and type 2 cytokine-producing CD4+ and CD8+ T cells in primary antiphospholipid syndrome

    Ann. Hematol.

    (2004)
  • L. Andreoli et al.

    EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome

    Ann. Rheum. Dis.

    (2017)
  • N. Hattori et al.

    T cells that are autoreactive to beta2-glycoprotein I in patients with antiphospholipid syndrome and healthy individuals

    Arthritis Rheum.

    (2000)
  • M. Blank et al.

    Transfer of experimental antiphospholipid syndrome by bone marrow cell transplantation. The importance of the T cell

    Arthritis Rheum.

    (1995)
  • B. Jakiela et al.

    Signs of impaired immunoregulation and enhanced effector T-cell responses in the primary antiphospholipid syndrome

    Lupus.

    (2016)
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