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S Cowchock

Publications and source records attributed to S Cowchock.

At least 19 recordsLinked to original sources
PubMed1998

Treatment of antiphospholipid syndrome in pregnancy.

Women with antiphospholipid antibodies (aPL = IgG anticardiolipin and/or lupus anticoagulants) and a history of either prior thrombotic events or pregnancy loss are at high risk during pregnancy for either another fetal death or thrombosis. The treatment of choice is anticoagulation with heparin. Both standard unfractionated heparin and low-molecular-weight heparin are used for prophylactic anticoagulation during pregnancy. The half-lives of either standard heparin, or low-molecular-weight heparin, and the peak values for each after subcutaneous injection, are lower than those in nonpregnant patients. Doses and injection intervals need to be adjusted when treating a pregnant woman. Clotting tests such as the activated partial thromboplastin time (aPTT) vary greatly during pregnancy, and the aPTT is often not even prolonged when antithrombotic levels of heparin are achieved. The aPTT is not a useful test when the patient has a lupus anticoagulant. Levels of plasma heparin are therefore needed to best care for pregnant women who need anticoagulation even for prophylaxis. Low-dose aspirin is often added empirically to heparin for treatment of aPL during pregnancy, but its efficacy has not been evaluated. Intravenous infusions of gamma globulins (IVGG) have been used as additional therapy when prior treatment with heparin during pregnancy failed to save the fetus, when severe and early onset preeclampsia has complicated a prior pregnancy (in such cases efficacy is unproven), or when there is an additional medical complication (such as immune thrombocytopenia) for which IVGG is an appropriate treatment. There are some situations in which treatment with corticosteroids is the best, or the only choice. However, corticosteroids should not be combined with heparin for long-term treatment during pregnancy because the risk for vertebral fracture is so high.

Abortion, Habitual↗
PubMed1997

Do low-risk pregnant women with antiphospholipid antibodies need to be treated? Organizing Group of the Antiphospholipid Antibody Treatment Trial.

We identified 19 women who had persistently positive test results for antiphospholipid antibodies who were considered to be at low risk because they had none of the associated signs or symptoms of the antiphospholipid antibody syndrome. They had had no (10/19, 53%) or just one prior spontaneous abortion and did not have a history of thrombosis or thrombocytopenia. Many (8/19, 42%) had had a prior uncomplicated pregnancy ending in a live birth. These women were randomly assigned to receive low-dose aspirin (81 mg daily) or usual care. There were few obstetric complications recorded in either treatment group. One woman in the aspirin group had a fetal death, and one in the usual care group had a low-birth-weight infant. The frequency of complications was so low that > 600 such women would need to be entered into a randomized trial to evaluate whether low-dose aspirin would be beneficial treatment during a pregnancy. We concluded that treatment of pregnant women with antiphospholipid antibodies who are otherwise at low risk cannot be justified on the basis of the available evidence.

Antibodies, Antiphospholipid↗
PubMed1996

Prevention of fetal death in the antiphospholipid antibody syndrome.

The first treatment of pregnant women with antiphospholipid antibody syndrome (APLS) employed high doses of corticosteroids, plus low dose aspirin, with the goal of suppressing production of the autoantibody. Corticosteroids (usually prednisone), even when much lower doses are used, and even when tapered after midpregnancy, have been associated with significant maternal and obstetric risks and side effects: the most important are osteomalacia and preterm delivery (often precipitated by premature rupture of the membranes). Since the publication of a randomized trial demonstrating equivalent live birth rates of about 75% whether heparin or prednisone was used for treatment (plus low dose aspirin), the use of adjusted doses of heparin, together with low dose aspirin, has replaced prednisone for treatment of pregnant women; although prednisone may still be needed to treat manifestations of associated autoimmune disorders. A recent randomized trial has shown that the addition of heparin to aspirin is probably superior to treatment with aspirin alone. To achieve prophylactic levels of plasma heparin equivalent to those measured in patients who are not pregnant and are treated with the usual dose of standard heparin of 5000 IU every 12 h, the heparin dose required for treatment of pregnant women is usually higher. For that reason, heparin doses should be adjusted using the nadir APTT, or better plasma heparin measured by a factor Xa inhibition assay at the 2 h post-injection peak. Although low molecular weight heparin has been shown to be useful in prevention of fetal resorption in a mouse model, and appears to be equally safe for treatment of pregnant women, we still have no published data to show therapeutic equivalency, with respect to treatment of APLS-complicated pregnancy, to standard heparin preparations, and none that demonstrate any lower risk for the complication of most concern when heparin is given to pregnant women-osteopenia. Similarly, intravenous infusion of gamma globulins (IVG) appears on the basis of case reports to be effective additional treatment in cases where standard therapy has failed. Gamma globulin preparations contain anti-idiotypic antibodies that have been shown to bind to patient antiphospholipid antibodies. The place for the addition of IVG to standard therapy has not been defined, but clinically significant and corticosteroid-resistant thrombocytopenia complicating antiphospholipid antibody syndrome might be one indication for primary treatment with IVG +/- low dose aspirin. Overall, live birth rates in most treatment studies are in the range of 70-80%. The reported birth rate information, however, cannot be compared between studies. None of the studies reported have used tools such as logistic regression analysis to allow for such significant predictors of live birth as the number of prior miscarriages, maternal age, medical history, or a history of fetal death (loss of a viable and chromosomally normal fetus after the 10th gestational week).

Adrenal Cortex Hormones↗
PubMed1995

Predictive factors in recurrent spontaneous aborters--a multicenter study.

PROBLEM: Compare data from several centers relating to success rates in recurrent spontaneous miscarriage and assess the significance of indicators of subsequent pregnancy loss. METHOD: Data from 777 couples with unexplained recurrent spontaneous abortion from independent studies at seven centers were analyzed using logistic regression analysis. The following covariates were considered: age of patient, number of previous spontaneous abortions, length of previous abortions history, sub-fertility index (defined as the product of the number of spontaneous abortions and the abortion history), whether a patient was a primary or secondary aborter, and whether a patient had received leukocyte immunotherapy. RESULTS: There was a highly significant difference between the seven centers in success rates in the subsequent pregnancy and a highly significant association between success rate and each of the following covariates: the number of previous abortions, the length of the previous abortion history and the sub-fertility index. In particular, for each increase of 10 units in the value of the sub-fertility index, up to a value of 30, the odds in favor of a successful pregnancy decreased by a factor of 0.6, i.e., 40%. There was, however, little evidence of an association between the success rate in the subsequent pregnancy and age, parity, or immunization with cells from the husband. CONCLUSIONS: The sub-fertility index may be a useful measure of likelihood of success in a subsequent pregnancy.

Abortion, Habitual↗
PubMed1991

Autoantibodies and pregnancy wastage.

The established association between a relatively specific group of autoantibodies binding negatively charged phospholipids and poor pregnancy outcome has advanced treatment options for women with this diagnosis. Evidence for an association between systemic autoimmune disorders and otherwise unexplained obstetric complications, in the absence of a documented antiphospholipid antibody(s), is reviewed. The existence of autoantibodies with other specificities that could be related to fetal wastage has been suggested by associations between poor obstetric histories and nonspecific serologic abnormalities observed in women with no clinical signs of an autoimmune disorder. Because signs and symptoms of vasospasm such as Raynaud's phenomenon or placental infarction have been observed in women with a history of unexplained fetal demise, a search for autoantibodies recognizing antigens common to trophoblastic and vascular cell surfaces is suggested.

Abortion, Habitual↗
PubMed1988

False positive ELISA tests for anticardiolipin antibodies in sera from patients with repeated abortion, rheumatologic disorders and primary biliary cirrhosis: correlation with elevated polyclonal IgM and implications for patients with repeated abortion.

Non-specific binding in an ELISA test for antibodies to cardiolipin (ACA) was investigated in sera from patients with primary biliary cirrhosis, rheumatological disorders, and repeated abortion. Binding to wells without phospholipid was most frequent in ELISA assay for IgM class ACA and correlated with levels of serum polyclonal IgM in patients with repeated abortion and rheumatologic disorders (r = 0.79, 0.76). Using added polyclonal IgM we demonstrated that the increase in non-specific binding was most significant when levels of ACA were low; subtraction of binding to the unoccupied well over-corrected specific antibody estimates when a high affinity antibody was present. Absorption studies on three sera suggest that this 'non-specific' binding includes low affinity antibody binding. Elevated levels of polyclonal IgM in sera from patients with repeated abortion may account for some reports of elevated IgM class antibodies in other ELISA assays. The prevalence of a positive test for ACA in a sequential series of 412 such patients was reduced to 6.1% (95% confidence limits 4-9%) after subtraction of non-specific binding.

Abortion, Habitual↗
PubMed1986

Antibodies to phospholipids and nuclear antigens in patients with repeated abortions.

The frequency of positive tests for antibodies to nuclear antigens (antinuclear, deoxyribonucleic acid, Ro, La, Smith, and ribonucleoprotein) or to phospholipids was investigated in 82 patients with isolated repeated abortions. Patients with a positive antibody test (positive or negative deoxyribonucleic acid antibodies) appeared to be a separate subgroup of those with unexplained repeated abortions from those with antibodies to cardiolipin. A total of 13.1% of the 61 patients with unexplained repeated abortions had elevated levels of IgM and/or IgG anticardiolipin antibody, while none were found in patients with explained abortions (p less than 0.1). Enzyme-linked immunosorbent assays for antibodies binding to other phospholipids suggested that sera from patients with repeated abortions who had the lupus anticoagulant contained antibodies that were most often of the IgG class with affinity for negatively charged phospholipids. Binding of IgG but not IgM antibodies to cardiolipin correlated closely with that to other negatively charged phospholipids. The use of clotting tests for the lupus anticoagulant to screen patients with repeated abortions for associated autoantibodies is likely to significantly underestimate the extent of this clinical problem.

Abortion, Habitual↗
PubMed1984

Subclinical autoimmune disease and unexplained abortion.

Although it seems likely that some patients with unexplained repeated abortions have early or subclinical autoimmune disease, there are no reports on the incidence of autoimmune serologic abnormalities in such patients by use of a series of tests. This diagnosis would suggest a treatable etiology for reproductive loss. We performed 11 serologic autoimmune tests in sera from 14 patients with three or more unexplained abortions (group II) and compared these results to those of 16 control patients with an established diagnosis for repeated abortions (group I). The groups were similar in age, gravidity, number of spontaneous abortions and live births, and in the interval from last abortion to serum sampling. A positive antinuclear antibody test plus at least one other positive test was found in four of 14 (29%) patients in group II (p less than 0.05). The tests that identified all these patients included levels of antinuclear antibody, antibodies to DNA or extractable nuclear antigen, and low levels of complement 3.

Abortion, Habitual↗
PubMed1980

The recurrence risk for neural tube defects in the United States: a collaborative study.

To determine the recurrence risk for patients with one prior pregnancy affected with neural tube defects (NTD), the authors have pooled data from eight testing centers. In 831 pregnancies studied because one sib was affected with an NTD, the recurrence rate was 3.0%, with 95% confidence limits of 2.0-4.3%, and 99% confidence limits of 1.8-4.8%. The recurrent lesion, whether spina bifida or anencephaly, tended to be concordant with the first to a significant degree. Only 12.2% of recurrent NTD were different from the first, with 95% confidence limits of 4.1-26.2%, and 99% confidence limits of 1.7-30.9%. Both an accurate recurrence risk and the information that a recurrent NTD lesions tends to be concordant with that in the first affected child are useful in the genetic counseling of patients in the United States and in the selection of appropriate prenatal diagnostic studies.

Female↗