The role of IVIG in the management of patients with antiphospholipid antibodies and recurrent pregnancy losses.

Intravenous immune gamma-globulin appears to have a role in the management of some autoimmune-mediated diseases. The exact mechanisms whereby IVIG is beneficial to patients with these diseases are not understood. The antiphospholipid-antibody syndrome is a recently recognized syndrome in which antibodies to negatively charged phospholipids are associated with a thrombotic diathesis, fetal wastage, and thrombocytopenia. The association between these antibodies and the clinical complaints is unknown. Recent evidence has suggested that a cofactor, a serum protein or glycoprotein (of approx 50 kDa) is essential for so-called antiphospholipid antibodies to bind to phospholipids. It may be that variations in this cofactor and its binding are some of the factors that determine whether high levels of antiphospholipid antibodies result in pathological consequences. Patients with antiphospholipid antibodies who have experienced previous fetal losses will continue to experience fetal wastage without some form of therapeutic intervention. The optimum therapy for these patients is yet to be determined, but recent isolated anecdotal reports suggest that IVIG may be of some benefit. IVIG appears to be less toxic to the mother than prednisone. The true benefit of IVIG, however, can be determined only by randomized, well controlled trials. Adequate numbers of patients could only be obtained by multicenter studies, and these should be designed to compare anticoagulation alone with anticoagulation and IVIG. Justifying a placebo group is difficult, as it is known that greater than 90% of pregnancies in women with aPL who have previously experienced fetal wastage fail to produce a live infant. It is only by doing such studies that the true role of IVIG in the management of pregnant patients with aPL can be determined.