IMMUNOLOGI

ABORTUS

dr. Oriza, SpOG

your name
 Definition of RSA (I)
• Traditionally, ≥ 3 clinical pregnancy losses before 20
weeks from the last menstrual period
- occurs in about 1/300 pregnancies.
Novak 15th ed., WILCOX et al, 1988

• Risk of subsequent pregnancy loss

– 24% after 2 clinical losses
– 30% after 3 losses
– 40~50% after 4 losses
Novak 15th ed., Regan et al, 1989

your name
Risk for subsequent pregnancy
loss
More than 4
40 -50% previous
losses 50- 60%

30% 3 previous
70%
losses

24%
2 previous
76%
losses

Pregnancy loss risk Probability of live birth

Regan et al.,your
1989name
• Pemeriksaan klinis dan terapi yang tepat perlu
dilakukan pada pasangan dengan keguguran spontan
2 kali berturut-turut, khususnya jika ada satu dari
beberapa hal berikut:
– Aktivitas jantung embrio telah terdeteksi sebelum
terjadi keguguran
– Karyotipe normal pada produk konsepsi keguguran
sebelumnya
– Usia pasangan wanita lebih dari 35 tahun
– Infertilitas

your name
 Etiology of RSA
Genetic
Genetic factor Anatomic factor Translocation 60.3%
9%
2-5% 10-15%
Anatomic
Unexplained 14% Synechia 64.3%
Unexplained Ut. Septum 14.3%
Autoimmune
Including
20%
non-APA 54.5% N = 881
thrombophilia (2005. 1.1 - 2009. 12. 31)
50% Endocrine 14% Autoimmune
factors Infections ATA 83.3%
17-20% 0.5 -5% APA 16.3%

5.1%
4%
Endocrine
Hyperthyroidism
Infection 71.4%
Ureaplasma 89.5%
Ford HB et al. Rev Obstet Gynecol 2009

50% of RSA classified as unexplained

Allo-immune etiology?
your name
 Diagnosis & management protocol of RSA
History taking
Routine lab Genital infection Antibiotics
Cervical culture
Genetic evaluation Chlamydia
• Karyotyping of U. Urealyticum
abortus Mycoplasma
• Parental karyotyping
Ultrasonographic scanning / pelvic exam
PGD Uterine anomaly? Ovulatory dysfunction?

HSG, MRI LH/FSH, E2, PRL, TSH, T3/ freeT4

Uterine anomaly (Septated uterus) Normal

Hormone therapy
Hysteroscopy
or
Laparoscopy Surgery
Immunologic evaluation

Allo-immune study Auto-immune study

Prednisolone (PDS)
NK number (CD ACA (IgG/IgM)
Low molecular weight heparin (LMWH)
16,56) LAC
IVIG
NK cytolytic activity Antithyroid Ab
your name
 Pada autoimmune abortion,
perkembangan plasenta dan
janin dipengaruhi oleh
autoantibodi ibu dan sel
autoreaktif akan
mempengaruhi jaringan
desidua dan trofoblast
Pada aloimmune abortion,
sistem imun ibu bereaksi
terhadap janin dan
menginvasi trofoblast
melalui reaksi penolakan
allogenik

your name
IMMUNOLOGY OF RECURRENT ABORTIONS

your name
Medawar & Billingham, Nature, 1953
• Four hypotheses:
– The conceptus lacks immunogenicity
– Significant lowering of the immune response
during pregnancy
– The uterus is an immunoprivileged site

– Barier imun oleh plasenta:

• Toleransi sistem imun maternal terhadap janin
yang semi-allogenic melalui mekanisme:
– Pencegahan jaringan janin dikenali sebagai benda
asing dan/atau ditolak oleh sistem imun maternal.

your name
 Hipotesis yg menjelaskan
toleransi maternal terhadap janin
• Ekspresi HLA/HLA-G oleh trophoblast
• Keseimbangan Th1/Th2
• Sel T regulator CD4+CD25+
• Lainnya
– Leukemia inhibitory factor (LIF)
– Indoleamine 2,3-dioxygenase (IDO)
– Suppressor macrophages
– Hormones
– CD95 and its ligand
– Annexin II
– Lowered complement activity
(Thellin et al, review 2000)
– Hidden trophoblast antigens
your name
 SUMMARY OF EVENTS IN ENDOMETRIAL RECEPTIVITY

‘E2’ stimulates ‘P’ activates

Physiological Biochemical Immuno Genetic

modulatory expression

Adhesion
Molecules HOXA 10
PINOPODES Cytokines Trophinin
NK cells

Receptive endometrium
Window of implantation ( 7th – 9th post ovulationyour
day)name
 “Implantation is biomarkers’
interplay”

Apposition Adhesio Invasion

n
• Integrin
• Pinopode • LIF
( αvβ3)
• L-selectin cytokine

Co-expression with integrin & LIF

your name
Nardo & Nikas et al and Aghajanova L, Stavreus-Evers et al Fert.Stert 2003
your name
your name
HLA dan the ’semi-
allogenic janin’

your name
 Human Leucocyte Antigen (HLA)
Major Histocompatibility Complex (MHC)
• Several classes of HLA genes:

– HLA class Ia (classical HLA class I antigens; on almost

all cells)
• HLA-A, HLA-B, HLA-C
– HLA class Ib (non-classical HLA class I antigens)
• HLA-E, HLA-F, HLA-G
– HLA class II (expressed on antigen presenting cells, B
cells)
• HLA-DR, HLA-DP, HLA-DQ

your name
 The classical HLA class Ia molecules are
highly polymorphic

HLA-A10 HLA-A3 HLA-A23 HLA-A11 HLA-A25 HLA-A26

HLA-B12 HLA-B5 HLA-B12 HLA-B16 HLA-B40 HLA-B8
HLA-Cw5 HLA-Cw7 HLA-Cw1 HLA-Cw8 HLA-Cw2 HLA-Cw5

HLA-A2 HLA-A28 HLA-A19 HLA-A19 HLA-A25 HLA-A24

HLA-B27 HLA-B17 HLA-B14 HLA-B15 HLA-B12 HLA-B8
HLA-Cw6 HLA-Cw5 HLA-Cw8 HLA-Cw2 HLA-Cw1 HLA-Cw4

your name
The non-classical HLA class Ib molecules are
nearly monomorphic

HLA-G HLA-G HLA-G HLA-G HLA-G

HLA-G
HLA-E HLA-E HLA-E HLA-E HLA-E
HLA-E
HLA-F HLA-F HLA-F HLA-F HLA-F
HLA-F

HLA-G HLA-G HLA-G HLA-G HLA-G HLA-G

HLA-E HLA-E HLA-E HLA-E HLA-E HLA-E
HLA-F HLA-F HLA-F HLA-F HLA-F HLA-F

your name
 Acceptance of the semi-allogenic fetus…
• No expression of polymorfic HLA class Ia and II on fetal
trophoblast cells in the placenta
• Expression of non-polymorfic HLA class Ib molecules by
trophoblast: HLA-G (and HLA-E and –F)
• This expression profile may influence the cytokine profile in
favour of maintaining pregnancy

your name
 HLA in pregnancy
Mother – HLA class Ia
Placenta – HLA class Ib
HLA-Am, -Bm, -Cm
HLA-Gm, -Em, -Fm, -Cm HLA-Am, -Bm, -Cm
HLA-Gp, -Ep, -Fp, -Cp

Human Leucocyte Antigen (HLA) system

Major Histocompatibility Complex (MHC)

DP DQ DR B C E A G F

class II class III class I

Chromosome
Fetus – HLA class Ia
6
HLA-Am, -Bm, -Cm
HLA-Ap, -Bp, -Cp HLA class Ia and II (-A, -B, -C, -DR etc): highly polymorfic

HLA class Ib (-G, -E, -F): nearly monomorphic

m = maternal
p = paternal

your name
The placenta
• Tidak mengekspresikan HLA-A and HLA-B class I
antigen yang polymorphic , hanya mengekspresikan
molekul HLA-C, HLA-G and HLA-E
• Loke dan King membagi trophoblast menjadi :
– villous trophoblast yg berkontak dengan darah maternal
pada ruang intervillous  class I negative
– extravillous trophoblast menginvasi desidua uterus 
class I positive

your name
your name
 Fungsi HLA-G
Kemungkinan peran HLA-G pada proses implantatsi:

1) Saat melekatnya blastokist ke endometrium

• HLA-G berperan pada adhesi cellular (Ødum et al
1991)

2) Invasi trophoblast pada jaringan uterus dan arteri spiralis

• HLA-G diekspresikan oleh sel endovascular
trophoblast cells dan kemungkinan berperan sebagai
modulator angiogenesis (Le Bouteiller et al)

3) Trophoblast berinteraksi dengan sel efektor imun maternal

• HLA-G berinteraksi dengan receptors sel imun

your name
 HLA and recurrent
miscarriage (RM)
• Many studies have focused on a possible increased
sharing of HLA alleles/haplotypes between the mother
and the father(/the fetus) in RM. However, ’HLA sharing’
is a controversial issue and lacks evidence.

• Specific HLA-DR alleles are associated with increased

risk of RM
– Meta-analysis (18 published/unpublished case-control studies):
HLA-DRB1*01 risk factor (OR 1.3; 95%CI 1.1-1.6)
(Christiansen et al 1999)
– HLA-DRB1*03 risk factor in patients with 4 or more
miscarriages and a significantly increasing trend with
increasing number of previous miscarriages (OR 1.4; 95%CI
1.1-1.9)(Kruse et al 2004)
your name
 HLA-G alleles / alternative splicing

Genomic DNA

-14 bp +14 bp 3’UTR polymorphism

HLA-G*010101 HLA-G*010102 HLA-G*010103

G1 (-92 bp)
mRNA isoforms G5/G6 (-92 bp)

G2(/G4) (-92 bp)

G1 G1 (+14 bp) G1 (+14 bp)

G2/G4 G2/G4 (+14 bp) G2/G4 (+14 bp)
G3 G3 (+14 bp) G3 (+14 bp)
G5 G5 (+14 bp) G5 (+14 bp)
G6 G6 (+14 bp) G6 (+14 bp)

(Hviid et al 2003, Rousseau et al 2003)

your name
Levels of sHLA-G in maternal blood (plasma)
• Maternal sHLA-G levels do not change substantially during a
normal course of pregnancy
• Soluble HLA-G levels of non-pregnant and pregnant women
seems to be very similar
• Therefore, a substantial part of the sHLA-G detected in maternal
circulation may be produced by immunocompetent cells of the
mother

• Reduced levels of sHLA-G in maternal plasma may be

associated with pre-eclampsia, spontaneous abortion and
placental abruption (sHLA-G < 9.95 ng/ml  RR 7.1; 3 trim)
(Steinborn et al 2003)

your name
your name
 Summary
MHC/HLA in reproduction

Fertilization
Mating preferences seem to be Weak evidence for
influenced by MHC/HLA diversity MHC/HLA-mediated
Early embryo development and implantation
effects on
HLA-G expression associated with cleavage
spermatogenesis
rate and implantation success
Heterozygote advantage
Heterozygotes at the
MHC/ HLA loci may provide a Maternal genome Paternal genome
broader immune response

Balance between foetal/paternal and maternal interests?

Some HLA-G/MHC polymorphisms may work in favour of the
foetus, others in favour of maternal interests?

Foetal growth and survival

Some evidence that HLA haplotypes
and HLA-G polymorphism are
associated with birth weight, risk of
abortion and immuneadaptation

Deficiency of MHC/HLA homozygotes in

isolated populations: frequency of MHC
heterozygotes in human populations higher
than expected
your name
HLA-G expression in the blastocyst/embryo

• Expression of HLA-G mRNA and sHLA-G has been

associated with an increased cleavage rate, as
compared to embryos lacking HLA-G
• The pregnancy rate in women who have embryos
transferred from cultures where sHLA-G is detected
is significantly higher than that in women who have
only embryos transferred from sHLA-G negative
cultures

your name
 What are Cytokines ?

Secreted molecules that regulate the intensity and

duration of the immune response by exerting a variety of
effects on lymphocytes and other immune cells

Cytokines are the messengers of the Immune System

just as

Hormones are the messengers of the Endocrine System

your name
 The Th1/Th2 balance

HLA-G/sHLA-G???

Successful pregnancy more often correlated with a Th2-type

response than Th1

However, the Th1/Th2 concept may be too simplisticyour name

 Implantation and Th 1 type / Th 2 type

• The normal reproductive woman has a strong tendency to

respond to foreign antigens by developing a Th 1 immune
respons  high levels of proinflamatory cytokines

• During pregnancy there is a decrease in cellular immunity and

enhancement of humoral immunity  high levels of anti-
inflamatory cytokines

• The balance between Th1 and Th2 is believed to be crucial for

determining pregnancy outcome

• For the continuous normal development of pregnancy Th1

cytokines will be suppressed whereas Th2 cytokines is
enhanced
your name
 Immune reaction during
pregnancy
Fetus with
Paternal
antigens

T helper 1 T helper 2
cell response cell response

Abortion of Protection of
The Fetus The Fetus
your name
 Embryo / Fetus

T helper 1 cell response activated

Cascade Tumor Necrosis Factor ά

Reaction Interleukin2

Natural killer Cells

Lymphokine Activated Killer Cells

Abortion of Fetus your name

 Role of cytokines in RPL
When HLA-G expression is down regulated, Th 1 cells are
activated and release cytokines-IFNȣ, TNF-α, IL-2

Cytokines inhibit human placental trophoblast cell growth and

metabolic activity.

IFN-ȣ inhibit secretion of (GM-CSF) which promotes growth,

differentiation of trophoblast during normal pregnancy.

Ratio of Th1/Th2 activity is critical for normal pregnancy.

Dysregulation of NK cytotoxicity and cytokine production

might be involved in RPL.
Expression of natural cytotoxicity receptors (NCRs)-
NKp46, NKp44, NKp30 and A2V-ATPase on CD56 NK cells
were up-regulated in RPL patients. your name
 Allo-cytotoxic T lymphocyte (CTL) response
stimulator cell responder T cell (Kapasi et al 2000)
Augmentation of the T cell
allo-CTL response receptor
HLA- HLA-
DR4 DR1 Inhibition of
IL-10  HLA-DR4
allo-CTL response
TNF- 
INF-  IL-10 
HLA-G HLA-G TNF- 
INF- 
RECURRENT MISCARRIAGE AND PRE-
ECLAMPSIA UNCOMPLICATED PREGNANCY

Th2 cytokine
Upregulation of the
production:
Th1 response,
IL-4
downregulation of
IL-5
Th2:
IL-10
IL-2
IL-13
INF-
(TNF-)
your name
 Local Immune suppression
• Is there any specific paternal antigen suppressor or
regulatory mechanism ???
• Evidence has shown that specific immuno
suppression is directed toward the paternally
encoded MHC antigens

• It seems that the mother’s T cell assume a

reversible tolerant state during pregnancy in which
the the cells no longer recognize paternal antigens
Tafuri A, Alferink J, Moller P, Hammerling J, Arnold B. T cell awareness of
paternal alloantigens during pregnancy. Science 1995;270:630-3

•
your name
• T cells were that were specific for fetal antigens were
shown to decrease in number during pregnancy
Jiang SP, Vacchio MS. Multiple mechanism of peripheral T cell tolerance to the fetal allograft. J Immunol 1998;160:3086-90

• This reversible tolerant state is caused directly by the

induction of apoptosis of maternal activated T cell by
the Fas/Fas ligand (FasL)

Mor G, Gutierrez L, Eliza M, Kahyaoglu F, Arici A. Fas-Fas ligand system induced apoptosis in human placenta and gestational trophoblastic disease. Am J Reprod Immunol 1998;40:89-95.

Bamberger A, Schulte H, Thuneke I, Erdmann I, Bamberger C, Asa S. Expression of the apoptosis-inducing Fas ligand (FasL) in human first and third trimester placenta and choriocarcinoma cells. J Clin Endocrinol Metab
1997;82:3173-5.

your name
Rogers AM, Boime I, Connolly J, Cook JR, Russell JH. Maternal-fetal tolerance is maintained despite transgene-driven trophoblast expression of MHC class I, and defects in Fas and its ligand. Eur J Immunol 1998;28:3479-87.

Huppertz B, Frank HG, Kingdom JC, Reister F, Kaufmann P. Villous cytotrophoblast regulation of the syncytial apoptotic cascade in the human placenta . Histochem Cell Biol 1998;110:495-508.
 Apoptosis
Fas ligand (FasL)-Fas interaction between decidual
cells expressing FasL-Fas bearing leukocytes
leads to apoptosis of activated leukocytes → down
regulation of production of cytokines TGF-β and IL-
10 (↓extravillous trophoblast invasion)

High expression levels of apoptosis related

genes caspase 3,6,7,8,9,10,12,BAD, BAX,
BID, FasL, Fas in women with RPL.

Apoptosis genes directly regulate embryonic

development during normal pregnancy.

your name
On other hand, it has long been know that
certain sites in the body, for example, the
eye, the testes and the brain are “immune
privileged".
They are protected from attack by the
immune system. Many factors are
involved in immune privilege, such as
tight junctions between the cells of the
tissue, little expression of class I
histocompatibility molecules, and
expression of FasL.
For instance, the corneal epithelium and
the retina of the eye, Sertoli cells of the
testis and the trophoblast of the placenta
express FasL. your name
 Natural Killer Cell

Animal studies have suggested a supportive role for NK cells in pregnancy

through production of cytokines that may stimulate placental growth.
Uterine NK cells may have a key role in the immunology of implantation and
in the regulation of decidualization.
Studies in mice have implicated a role for uterine NK cell-derived IFN-γ in
the formation and maintenance of the decidua your name
your name
your name
Such protection of the trophoblast against NK cell-mediated lysis seems to occur
through the ability of the HLA class I molecules expressed by the trophoblast to
trigger more inhibitory, rather than stimulatory, NK cell signals.
Uterine NK cells express subtypes of killer inhibitory receptors and killer activator
receptors
Expression of these HLA molecules may confer protection against NK cell-mediated
lysis, allowing trophoblastic invasion of the decidua and maintaining cytotoxicity
against invading pathogens your name
 Decidual NK cells
• Decidual NK Cells appear to be
mainly involved in alloimmune
abortion.
• Under influence of Th1 cytokines
they damage the trophoblasts.
• Patients who abort have increased
NK cell activity and NK cells of
CD3,CD 56,CD 16 types.
your name
 Macrophage

Hunt and co-workers implied that maternal macrophages assist in

the tissue remodeling that is necessary to accommodate expansion
of extraembryonic tissue, however, macrophages are scavengers of
dying cells and also actively orchestrate apoptosis of unwanted cells
during tissue remodeling.
Macrophages synthesize and secrete cytokines and growth factors,
which govern the local cellular and tissue interactions your name
 Embryo protective
Immunomodulation
- How is this brought about?
Normal Pregnancy

Progesterone(P) Receptor Activation

Progesterone Induced Blocking Factor(PIBF)

Blocks Cascade Reaction, Shift to Th type 2

Embryo Protective Immunomodulation

Protection of Embryo / Fetus your name

 Progesterone-induced Blocking
Factor (PIBF) Link between the
Endocrine and Immune System
Progesterone
Normally
Th2 Progressing
PIBF
Pregnancy

Progesterone
Miscarriage
PIBF Th1
Ru 486

Progesterone
Miscarriage
PIBF Th1
+anti-PIBF

Szekeres - Bartho J et al. Int Immunopharmyour

2001;name
1:1037-
1048.
P-receptors in Pregnancy
Lymphocytes
Normally
Progressing
γ/δ
Trophoblast Pregnancy

Ac
PIBF Th2 / Th1
+
tiv
a
tio
n

γ/δ P
PR+ + P
P  Natural Killer
Cell Activity
P

Szekeres-Bartho J et al. Int Immunopharm 2001; 1:10371-1048.

your name
 Embryo Protective Immunomodulation –
What is it?
3 Positive responses

T helper 2 cell response NK Activity

Protective Asymmetric Antibodies

Cytokines
No binding with Antigen
IL 3
IL 4 No activation of
IL 5 Complement Cascade
IL 6
IL 10
IL 13
Protection of Fetus
Raghupathy et al., (2000): Cytokine production by maternal lymphocytes during normal human
pregnancy and in unexplained recurrent spontaneous abortion. Hum. Reprod. 15(3); 713-18.
your name
 Peran Treg dalam
keberhasilan kehamilan
• Regulatory T-cell (Treg)  suatu kelompok T-
cell yang berfungsi untuk menjaga toleransi
terhadap antigen tidak berbahaya dengan
mekanisme inhibisi T-cell Sitotoksik
• Beberapa penelitian terbaru mendapatkan
adanya interaksi antara jumlah populasi Treg
dengan keberhasilan implantasi embrio, yaitu
– menurunnya jumlah Treg pada kegagalan
kehamilan
– peningkatan jumlah Treg pada keberhasilan
implantasi
– penurunan Treg kembali pada masa post-partum.

your name51
 Peran Treg dalam
keberhasilan kehamilan
• Penelitian pada wanita fertile non pregnant
didapati
• Peningkatan jumlah sel Treg pada fase folikuler
akhir  uterus siap untuk menerima embrio
sehingga dibutuhkan penurunan respon inflamasi
• Diikuti dengan penurunan drastis pada fase
sekresi  implantasi  suatu proses inflamasi

your name
 Peran Treg dalam keberhasilan
kehamilan
• Pada suatu keberhasilan kehamilan, keberadaan Treg
berperan untuk menghambat serangan sistim imun
maternal yang ditujukan pada fetal antiallogen.
• Treg berperan menjaga homeostasis immun
• Mekanisme inhibisi Treg dijalankan dengan beberapa
cara yaitu dengan:
– mensekresi IL-10 dan TGF-b1  limfokin yang berfungsi
sebagai immunosuppressant yang akan menghambat
proliferasi T-cell yang akan menyerang fetus
– merangsang sel dendritik untuk menghasilkan IDO yang
mampu melakukan katabolisme tryptophan, sehingga secara
tidak langsung juga mencegah proliferasi T-cell.
– interaksi cell-to-cell antara Treg dan T-cell Helper dan T-cell
Sitotoksik sehingga menghambat respon imun terhadap fetus.
your name53
T 17 Cells
Wanita dengan RSA didapati jumlah sel Th17 yang
lebih tinggi pada stimulasi PMBC in vitro

Selain itu juga didapai peningkatan jumlah sel Th17

dan kadar IL17A pada wanita dengan RSA baik pada
fase proliferasi maupun sekresi.

Pada acute tissue rection  peningkatan Th17

Th17 kemungkinan berperan dalam penolakan janin
dengan memproduksi berbagai sitokin proinflamasi
seperti IL17A, IL17F, IL21, IL22, IL6 dan TNFa.
your name
 T 17 Cells

Th17 dapat berubah menjadi Th1, Th2 dan Treg 

kemungkinan kemampuan th17 berubah menjadi
subpopulasi sel Thelper yg lain berperan dalam
ketidakseimbangan Th1/Th2 pada RSA

your name
 Autoimmune
• Systemic Lupus Erythmatosus (SLE)
 mengakibatkan risiko abortus 20% terutama pada 2nd
and 3rd trimester kehamilan dan dihubungkan juga dengan
antiphospholipid antibodies.

• Antiphospholipid syndrome (APA)

– 5 - 15 % of wanita dengan RSA memiliki APA
APA tampaknya menginduksi microthrombus pada
lokasi perlekatan plasenta  mengganggu vaskularitas
 mempengaruhi perkembangan embrio  menginduksi
abortus
your name
your name
Antiphospholipid antibodies(APA)
• APA adalah antibodi heterogen yang terdapat pada
sirkulasi darah perifer dan cairan peritoneal 
berikatan dengan phospholipids pada membran
platelet membrane serta serum factors lainnya , seperti
Factor III, prothrombin, Factors Xa and V and calcium
• Antiphospholipid antibodies (APA) are acquired IgG,
IgM and/or IgA immunoglobins or monoclonal
antibodies directed  against negatively charged
phospholipids associated with  a slow progressive
thrombosis and infarction in the placenta
• APA dapat mempengaruhi kehamilan sejak dari masa
blastocyst/ trophoblast stage sampai persalinan.

your name
Antiphospholipid antibodies(APA)
• Antigen APA antigens bervariasi berupa PE
phophatidylethanolamine) dan PS (phosphatidylserine)
antigens yang merupakan komponen utama membran
plasma sementara cardiolipin (CL) terbatas ditribusinya
hanya pada inner mitochondrial membrane
• APA yang sering dihubungkan dengan kegagalan
kehamilan adalah lupus anticoagulant (LA) and
anticardiolipin (aCL).
• aCL akan menyerang CL antigen complexed melalui
plasma protein co-factor, b2-glycoprotein I (b2-GPI)
• APA berikatan dengan phospholipids seperti
prothrombin, Factor Xa, protein C or S  APA
merupakan campuran antibodi terhadap b2-GPI dan
phospholipid epitopes your name
 Antiphospholipid syndrome
– An Autoimmune disorder having specific
clinical & lab criteria. Sapporo criteria
– Diagnosis requires at least one of each.
CLINICAL
1) Thrombolic events-arterial,venous,small vessel
2)Pregnancy loss- ≥3 losses at <10wks gestation,
fetal death after 10wks,premature birth at <34wks
associated with severe preeclampsia or placental
insufficiency.
LABORATORY 1) Lupus Anticoagulant
2) Anticardiolipin antibodies(IgG or IgM)
Any lab test results must be observed on at least 2 separate occasions 6 wks
yourapart
name
Antiphospholipid antibodi

Antiphospholipid antibodi (APA)

awal implantasi

Rx. membran fosfolipid

Mikrotrombus a.spiralis.

Antibodi di pembuluh darah desidua

kerusakan plasenta  RPL your name

 Antiphospholipid Antibodies
(2%Auto immune )
Incidence of APA 2%

LA, ACl in RPL 15-20%

Prevent trophoblast proliferation, cause early fetal loss by

complement activation

Cause thrombosis by interrupting fibrinolysis, inhibits the

anticoagulant pathway, causes elevated thrombin generation

LA& aCLA require plasma protein co factors interact with

placental interphase  resulting in decidual vasculopathy 
deposition of immune complexes leading to lowered perfusion
your name
Schematic representation of the coagulation pathway .

The circles depict the prothrombin–

convertase complex (FVa + FXa) that
drives coagulation by converting
prothrombin into thrombin.

• Thrombin converts fibrinogen to fibrin

and this is stabilized by the crosslinking of
fibrin polymers by FXIII.

•Thrombin is inactivated by antithrombin

III
•ATIII and fibrinogen are downregulated
in the follicular fluid of RPL patients.
your name
your name
Possible Immunological Mechanisms Involved In
RPL

HLA G molecules of trophoblast cells inter

act with killer activator receptor (KAR)of
uterine natural killer cells (NK)

Cytokines released from NK cells attack

trophoblast cells.

Inter action of HLA G with killer inhibitory cell

( KIR) has opposite effect.

Th1 cytokines induce cytotoxic activity in uterine NK

cells & cytotoxic T cells.

B cells release auto antibodies –APA,ANA,ATA

your name
your name
 Summary
Possible causes for RPL
• Secondary immune response due to dysregulation
of HLA Expressions , cytokines and exposed
paternal antigens
• Lack of immunological protection to the embryo
• Lack of appropriate expression of compliment
regulatory proteins
• Apoptosis-inducing TNF super family
members, HLA G or HLA E

your name
 IMMUNOLOGIC FACTORS

Autoimmune Alloimmune
(directed to self) (directed to foreign
tissues/cells)

-Systemic Lupus Erythmatosus An abnormal maternal

-Antiphospholipid Syndrome immune response to
fetal or placental antigen.

your name
Thank you.

your name
 Functions of HLA-G
• Several in vitro studies have shown that HLA-G and
HLA-E protect against Natural Killer-mediated cell lysis

your name
 Functions of HLA-G
Suppression of allo-reactive cytotoxic
T cells
‘Mixed Lymphocyte Reaction’ (MLR) CD4+ responder
stimulator cell responder T cell T cell
T cell
receptor Secretion of
HLA- HLA-
DR4 DR1
soluble HLA-G5
HLA-DR4
inhibitory receptor
(ILT-2, p49 ?)

HLA-G1 (Lila et al
Inhibition of T cell PNAS 2001;
K562 98:12150)
allo-proliferation

(Carosella et al. Immunol Today 1999; 20:60 / Riteau et al. J Reprod Immunol 1999; 43:203)

your name
 Maternal NK cell

KIR2DL4 Maternal monocyte/

macrophage/lymphocyte
CD94/NKG2 IL-10
ILT-2/(-4)*)

HLA-E sHLA-G
?
HLA-C HLA-G1
Inhibition of
allo-CTL
response ?
HLA-G  IL-10 ??
HLA-F (?) (influenced by TNF- 
Trophoblast cell HLA-G genotype) INF- 
HLA-G  TGF-1 
FETUS VEGF 

Augmentation of
Cell lysis allo-CTL response ?
IL-10 ??
TNF- 
INF- 
Influence, interact with or modulate
Secretion of the specific factor

your name
 Recurrent pregnancy loss
autoimmunity and pregnancy loss

Diagnosis
– Antiphospholipid antibody syndrome ACL, APS, API, APE
– Anti Nuclear Antibodies ANA
– Anti Thyroid Antibodies ATA

Treatment
– Heparin and baby aspirin
– Prednisone
– IViG

your name
 Recurrent pregnancy loss
Alloimmunity: pregnancy as an allograft

Immunosuppression in pregnancy
– Role of NK-cells
– TH1 vs. TH2 response
– HLA-G, Progesterone Blocking Factor
Diagnosis
– Embryo toxic factor
– Immunophenotype and NK-cell activity
– Cytoxicity
– HLA
Treatment
– IViG
– LIT

your name
 Thyroid Disease & RPL
*Painless thyroiditis one year
Positive TPO antibody is
after pregnancy loss can cause
associated with high
immunological changes and
incidence of RPL.
hypothyroidism

20% of TPO + will develop Auto antibodies might

subclinical hypothyroidism by cause growth inhibition of
term if untreated. trophoblast and
thrombosis.

*Investigation RPL Fertil,Steril,2005;83:821. your name

 Role of Angiogenesis

Expression levels of Insufficient or abnormal

angiogenesis related gestational angiogenesis
genes MMP-2,PAI, resulting from aberrant
Integrin, TGF-β, VEGF, expression of angiogenesis
FGF were lower in intact related genes lead to
chorionic villi derived abnormal growth of fetus or
from RPL patients. pregnancy loss.

your name
So what does HLA-G do?
Alloimmune Protection
• One function is to decrease or prevent the maternal
alloimmune attack on the fetus' paternally inherited MHC
• HLA-G inhibits both the antigen-specific cytotoxic
lymphocyte (CTL) response and decreases NK cell function
• Thus, the low variability may be sufficient to present antigen
fragments
• In comparison to MHC-I and MHC-II molecules, there has
been little evolutionary pressure for HLA-G to evolve greater
variability because of the limited number of pathogens, and
there has been pressure to not evolve variability, to avoid
maternal autoimmune reactions to the fetus

your name
So what does HLA-G do?
Autoimmune Protection
•
Autoimmune reaction occurs when the appropriate
proportion of CD4:CD8 is disrupted (Beer and
Kwak, 1999) 
• Changes in the proportion of CD4:CD8 inhibit NK
cell adhesion to HLA-G producing an
autoimmune response to the placental
trophoblast and termination of the developing
conceptus (Beer and Kwak, 1999). 
• Such losses are usually repetitive (Beer and
Kwak, 1999). your name
 Thrombophilias
• Pregnancy –a hypercoaguable state
• Factor VII, VIII & X shifts the thromboxane &
prostacyclin ratio , vasospasm& platelet aggregation
leading to micro thrombi and placental necrosis.
• Deficiency of Protein C ,S & anti thrombin III results in
Platelet aggregation, generation of thromboxane,
lowered platelet reactivity to anti aggregating response
of prostacyclin
• Hypercoaguability is aggravated by thrombophilia –
RPL

your name
 FETO-PLACENTAL
TISSUES INJURY

Maternal immune system

Immunoregulatory Th2-type Th1-type

placental factors respons respons

IFN-, TNF-α, IL-2., IL-12

Uterine PIBF
CSF-1 IL-3, IL-4, IL-10 LAK NK Cells
GM-CSF

NORMAL ABNORMAL

Successful Pregnancy Pregnancy Lost your name

Arthritis and Rheumatism
Volume 40 • Number 3 • March 1997
Copyright @ 1997 American College of
Rheumatology

Human Polyclonal and Monoclonal Anti beta2

Glycoprotein I Antibodies React In Vitro With
Endothelial Cells Through Adherent beta2
Glycoprotein I and Induce Endothelial Activation
Del Papa N, Guidali L, Sala A, Buccellati C, Khamashta MA, Ichikawa K, et al.

Anti beta2 GPI antibodies bind and activate through the adherent cofactor beta2 GPI,
likely leading to a procoagulant state. Autoimmune aPL in contrast with infective
aPL, require certain phospholipid binding proteins, such as beta2 GPI

your name
your name
 Recurrent miscarriage syndrome
Antiphospholipid and infertility
& Pregnancy
caused by blood coagulation protein or platelet
defects Antiphospholipid isotypes
ACA IgG only 37.6
ACA IgM only 30.7
ACA IgA only 6.9 70
62
ACA IgG+IgM 5.0 60
ACA IgG+IgA 1.0
50 chromosom
ACA IgA+IgM 0.0
40 anatomical
LA only 2.0 hormonal
ACA + LA 2.0 30 unexplained
Antiphosphatidylserine 4.0 20 coagulation
15
Antiphosphatidylinositol 2.0 10
10 7 6
Antiphosphatididic acid 5.0
0
Antiphosphatidylethanolamine 5.0
Antiphosphatidylcholine 6.9
Antiphosphatidylglycerol 1.0
B2-GPI 0.0 Bick RL. Clin Appl Throm
Hexagonal phospholipid 0.0 He mos ta t 2000; 63: 115your
-125name
 Mechanisme of thrombosis in APS
APS

coagulation Annexin V endothel platelet fibrinolysis

Hypercoagulable Decreased  Endothelial  activity

Cell activity fibrinolysis
state

Thrombosis

your name
your name
Protective mechanisms in pregnancy
Strict regulation of the expression of
HLA class 1 molecules in sub
population of trophoblast is supposed
to protect the semi allograft against
4 immune cells which are programmed
to attack cells expressing paternal
HLA class 1 antigens.*

Trophoblasts contain indoleamine 2,3

disoxynase(IDO , inhibits tryptophan
5 metabolism) there by inactivates T
cells

*362514Lebo tiller P.Mallet V-HLA G& preg-Reprod 1997;2:7

Role of HLA G in Human preg Reprd Bio Endo 2006;4 Supp,1:510
your name