Indications for immunological examination: habitual miscarriage of pregnancy of unknown origin; anembrion in the anamnesis; previous pregnancy with a delay in intrauterine development; intrauterine fetal death at any stage of pregnancy; autoimmune diseases and conditions; presence in the history of thrombosis of arterial and venous; thrombocytopenia; failure of in vitro fertilization (IVF).
Treatment with antibiotics, some physiotherapeutic procedures lead to a decrease in the parameters of cellular and humoral immunity. The period of recovery of immunity indices to the baseline is different from 3 to 6 months, so immunological studies should be performed before the initiation of therapy.
If all the parameters of immunity are reduced, then treatment with antibacterial agents must be combined with immunomodulating agents. To recommend pregnancy it is possible only after the parameters of cellular and humoral immunity are restored, since an adequate immune reaction of the body is necessary for the normal course of pregnancy.
Immunological tests for patients with habitual miscarriage.
Immunophenotyping of subpopulations of peripheral blood lymphocyte composition allows to reveal deviations from the norm and especially to estimate the level of activated cells that are responsible for the production of pro-inflammatory cytokines and autoantibodies.
- Definition of antibodies.
There are 5 classes of antibodies:
- IgM - are the first to appear in response to antigenic stimulation and are effective in binding and agglutination of microorganisms (antigens). They have a larger molecule than other immunoglobulins and do not penetrate the placenta to the fetus.
- IgG - antibodies, with an immune response appear after IgM, penetrate into extravascular spaces and through the placenta penetrate the fetus.
- IgA - the main antibodies contained in secretions in the intestines, lungs, urine. Their main function is to prevent the penetration of antigens from the surface into the tissue.
- IgE - normally constitute less than 1 / 10,000 of all serum immunoglobulins, but with allergies, its content multiplies more than 30 times, and the content of specific IgE more than 100 times.
- IgD - act on the surface of B cells, performing a regulatory function.
The definition of immunoglobulins of the three main classes (A, M, G) is necessary in assessing the immune status. An increase in the level of IgM occurs with a primary infection or with exacerbation of a persistent viral infection. A low level of IgA is the basis for refusing to use immunoglobulin during treatment, as anaphylactic complications are possible. The most important in obstetric practice is the definition of specific antibodies to viral, parasitic infections.
The presence of immunoglobulins of IgG class specific for the herpes simplex virus, cytomegalovirus, toxoplasm means that the patient has been in the past with these antigens and has immunity, and when the herpes simplex virus and / or cytomegalovirus infection is activated, the fetus will not be seriously affected, and if present antibodies of class IgG to toxoplasma fetus in general will not be ill with this disease.
The presence of specific IgM in the absence of IgG means that there is a primary infection. In the presence of simultaneously specific IgM and IgG antibodies most often there is an exacerbation of a chronic viral infection. It is possible that there is no exacerbation, but there is a persistent persistence of IgM antibodies.
Particular attention should be paid to patients who do not have antibodies to such infections, which during pregnancy can cause severe damage to the fetus - HSV, CMV, toxoplasmosis, rubella. These patients are called seronegative. When in contact with an infectious agent, infection occurs first and, accordingly, the production of antibodies. First, antibodies of IgM class appear, so-called conversion occurs and the patient from seronegative becomes seropositive for a specific infection. In this case, if the infection causes malformations of the fetus, it is more often than not that pregnancy is interrupted and not preserved, especially if the conversion was observed in the first trimester.
Therefore, in determining the virus carrier at the same time, it is necessary to determine the presence and class of specific antibodies.
Evaluation of interferon status seems to be an extremely important point of the survey.
Interferon-y - a group of proteins produced in response to a viral infection, as well as under the influence of lipolysaccharin, etc., are produced by macrophages of IFN-a, IFN-R fibroblasts and IFN-y T-cells (Th-1 helper). Interferons stimulate cells to isolate proteins that block the transcription of the information RNA of the virus. Interferons are more species-specific than other cytokines.
A high level of interferon in the serum disrupts the normal development of placentation, limiting the invasion of the trophoblast and exerting a direct toxic effect on the embryo. The evaluation of serum interferon, the spontaneous IFN reaction of leukocytes, the production of leukocytes by IFN-α during the induction of the virus by Newcastle disease (VBN), the production of alpha and beta IFN for immunomodulators for the selection of the most effective inducers for a particular patient (neovir, polyoxidonium, tsikloferon, ridostin, lorifane, imunofan, derinat, temarit); production of IFN-y lymphocytes during induction by phytohemagglutinin (PHA) with conclavin (ConA), staphylococcal enterotoxin (SEA).
Imbalance of the interferon system is available in almost all women with habitual miscarriages, especially with chronic viral infection and autoimmune disorders. This imbalance is manifested by a sharp increase in serum interferon or a sharp decrease in the production of all types of interferon by blood cells in response to various inducers.
- The levels of proinflammatory and regulatory cytokines are determined by enzyme immunoassay (Elisa) in serum, mucus and cervical canal cells, supernatants in vitro activated lymphocytes.
Currently, more than 30 cytokines are known. Traditionally, based on biological effects, it is customary to separate:
- interleukins - regulatory factors of leukocytes (17 of them have been studied);
- interferons - cytokines with predominantly antiviral activity;
- tumor necrosis factors that provide immunoregulatory and direct cytotoxic effects;
- colony-stimulating factors - hematopoietic cytokines;
- growth factors.
Cytokines differ in their structure, biological activity, and origin, but they share a number of similar characteristics characteristic of this class of bioregulatory molecules.
The functioning of the cytokine system is normally characterized by: the individual character of the formation and the reception of cytokines; Cascade mechanism of action; locality of functioning; redundancy; interconnectedness and interaction of components. Normally, cytokines formed by the primary immune response do not practically enter the bloodstream, do not exert systemic effects, i.e. There is a local character of their action.
Determination of high levels of cytokines in the peripheral blood always indicates a violation of the principle of locality of the functioning of the cytokine network, which is observed with intensive, long-term inflammatory, autoimmune diseases accompanied by generalized activation of cells of the immune system.
The redundancy of the cytokine system is manifested in the fact that each type of immune system cells is capable of producing several cytokines and each variety of cytokines can be secreted by different cells. In addition, for all cytokines, polyfunctionality with strong overlapping effects is characteristic. Thus, the manifestation of common and local signs of inflammation causes a number of cytokines: il-1, il-6, il-8, TNFa, colony-stimulating factors.
In the proliferation of T-lymphocytes, il-2, il-4, il-7, il-9, il-13, il-15, TNFa participate. This duplication ensures the reliability of the functioning of the cytokine cascade. Under the influence of specific antigens T-helper differentiation occurs in two subpopulations: Th1 and Th2, differing in antigens of the main histocompatibility complex and produced cytokines. Th1 secretes predominantly pro-inflammatory cytokines, and Th2-regulatory, causing mainly humoral reactions of hemopoiesis, angiogenesis.
The generalized nature of the release of cytokines is manifested by a number of systemic effects. It is known that lethality in septic shock is determined not so much by the action of endotoxin as by the increased level of pro-inflammatory cytokines that arise in response to its administration.
The most important antagonists of pro-inflammatory cytokines are regulatory cytokines - il-4, il-10.
Thus, the cytokine system for all diversity is a single and integrated network, the disturbances in which can lead to a breakdown in self-regulation, a change in the direction of the immune response, which becomes particularly important in the early stages of embryo development.
Therefore, it is extremely important that all cytokine parameters are within the normal range before the onset of pregnancy. The normal course of pregnancy is largely determined by the ratio of immunomodulating and immunosuppressive effects in the endometrium, trophoblast, and subsequently in the placenta, in the regulation of which the components of the cytokine system directly participate.
Autoimmunity - a mirror image of tolerance, indicates the loss of tolerance by the body, immunity to its own antigens. Normally, the immune system inhibits the autoreactivity of lymphocytes through regular mechanisms. Violation of them can lead to autoimmune pathology. The literature describes many options for the development of autoimmunity. It is assumed that the intracellular viral infection changes the antigenic nature of the "own" cell, as a result of which antibodies against the "own" cell may appear. It is possible that microorganisms have common antigens with the human body, in this case there is an insufficient elimination of all autoreactive B lymphocytes and the occurrence of autoantibodies. Assume the presence of genetic influences at the level of B-lymphocytes, subpopulations of T-cells, macrophages, target tissues and hormones.
Autoimmune diseases are more common and more severe in women. In recent years, the attention of the world's scientists has been focused on autoimmune processes in the human body and, in particular, in obstetric practice. A great deal of research has been done to understand the significance of these disorders, including obstetric pathology.
The most significant autoimmune disorder for obstetric practice is the antiphospholipid syndrome. The incidence of antiphospholipid syndrome among patients with habitual miscarriage ranges from 27-42%.
The definition of lupus anticoagulant is carried out by hemostasis methods. In obstetrical practice, great importance is the lupus anticoagulant. It is believed that the detection of lupous anticoagulant in blood is a qualitative manifestation of the effect of certain levels of autoantibodies to phospholipids (cardiolipin, phosphatidylethanol, phosphatidylcholine, phosphatidylserine, phosphatidylazitol, phosphotidic acid) on the state of hemostasis.
The risk group for the presence of autoantibodies to phospholipids is the following category of patients who have anamnesis: habitual miscarriage of pregnancy of unknown origin, intrauterine fetal death in the second and third trimesters of pregnancy, arterial and venous thromboses, cerebrovascular diseases, thrombocytopenia of unknown origin, false positive reactions to syphilis, early toxicosis of the second half of pregnancy, intrauterine growth retardation, autoimmune diseases.
Anticardiolipin antibodies, antibodies to other phospholipids, phosphoethanolamine, phosphotidylcholine, phosphatidylserine and phosphotidic acid are determined by Elisa enzyme immunoassay.
According to the researchers, the same pool of cells of the immune system produces not only antibodies to phospholipids, but also other antibodies: anti-DNA antibodies, antinuclear antibodies, antithyroid, antispermic. It is believed that these antibodies account for up to 22% of habitual miscarriages of immune genesis and about 50% of infertility of unclear genesis and IVF failures.
These antibodies can be directed both against the double DNA molecule, and single, and also against polynucleotides and histones. Most often they are detected in autoimmune diseases, but there may be antibodies without the manifestation of an autoimmune disease. Other researchers do not share this view. According to their research data, these autoantibodies are non-specific, often transient, there are no scientific data explaining the mechanism of their action in the habitual miscarriages. According to studies, these antibodies must be borne in mind, since they can be markers of autoimmune trouble, and although there is as yet no scientific explanation for the mechanism of their action, pregnancy always proceeds with complications in the form of placental insufficiency, intrauterine growth retardation.
In recent years, work has appeared on the importance of antibodies to hormones. A pool of cells producing antibodies CD 19 + 5 +. Activation of these cells leads to the appearance of autoantibodies to hormones that are essential for the normal course of pregnancy: estradiol, progesterone, chorionic gonadotropin, thyroid hormones, growth hormone.
With an excess of CD19 + 5 +, due to the presence of autoantibodies to hormones, a number of clinical manifestations of this syndrome are observed: insufficiency of the luteal phase, inadequate response to ovulation stimulation, resistant ovary syndrome, premature ovarian aging and premature menopause. When autoantibodies appear, the effect of activated CD19 + 5 + leads to disturbances in early implantation, to necrosis and inflammation in decidua, to a disruption of fibrinoid formation, to excessive deposition of fibrin. In IVF, these patients have slow division and fragmentation of embryos, a slow increase in the level of chorionic gonadotropin in pregnancy, damage to the yolk sac, subchorial hematomas.
In our clinic, we can only identify antibodies to the chorionic gonadotropin and attach great importance to this aspect in the habitual miscarriage of pregnancy.
The same pool of cells produces autoantibodies to neurotransmitters, including serotonin, endorphins and enkephalins. When these antibodies are present, ovarian resistance to stimulation is noted, blood circulation in the uterus is reduced, endometrial thinning is observed, depression often occurs, fibromyalgia, sleep disturbances, including night sweats, panic attacks, etc.
Unfortunately, many methods for identifying autoantibodies are not standardized, they require a more precise mechanism of action. Practical doctors should be aware of the existence of this area of research when miscarriages of an unknown genesis are sent to specialized laboratories and departments, rather than solving this problem by prescribing no-shpy and progesterone.
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