European Review for Medical and Pharmacological Sciences
European Review for Medical and Pharmacological Sciences
1656
Abstract. – OBJECTIVE: Alpha Lipoic Acid
(ALA) is a safe natural molecule that exerts a se-
lective immunomodulating activity with antioxi-
dant and anti-inflammatory properties. This ran-
domized controlled clinical trial (RCT) tested the
effect of the vaginal administration with ALA or
Progesterone, in subchorionic hematoma re-
sorption in women with threatened miscarriage.
European Review for Medical and Pharmacological Sciences: 400 mg of vaginal
Progesterone or 10 mg of vaginal ALA were ad-
ministered to sixty-two pregnant women, in the
first trimester of gestation with threatened mis-
carriage and subchorionic hematoma. Controls
were patients who chose not to receive any
treatment.
RESULTS: In the ALA group the subchorionic
hematoma was reabsorbed more quickly in com-
parison with the progression detected in Prog-
esterone group (p ≤ 0.05). The other parameters
checked (pelvic pain and vaginal bleeding) did
not show any significant difference and a small-
er number of miscarriages was recorded in the
ALA group, compared to Progesterone group.
CONCLUSIONS: Our data provides the first
evidence of the efficacy of ALA, administered by
vaginal route, in the healing process of patients
with threatened miscarriage, thus supporting
the normal course of pregnancy. Clinical trial
registration number: NCT02601898 (ClinicalTri-
als.gov registry).
Key Words:
Threatened miscarriage, Vaginal alpha lipoic acid
(ALA), Vaginal progesterone, Randomized controlled
study, Subchorionic hematoma.
Introduction
Subchorionic hematoma is a gathering of
blood in the subchorial area, between the mem-
branes of the placenta and the chorion, deriving
from a subchorionic hemorrhage. This kind of
Resolution of subchorionic hematoma and
symptoms of threatened miscarriage using
vaginal alpha lipoic acid or progesterone:
clinical evidences
M. COSTANTINO1, C. GUARALDI
2, D. COSTANTINO3
1Department of Chemistry and Pharmaceutical Technologies, University of Ferrara, Ferrara, Italy 2U.O.C. Obstetrics and Gynecology, Valdagno Hospital, Vicenza, Italy 3Women’s Health Center, Ferrara, Italy
Corresponding Author: Demetrio Costantino, MD; e-mail: kostin5893@yahoo.it
hematoma can appear during the first trimester of
pregnancy (early pregnancy) and it is a typical
anomaly of this gestational period. It is due to the
partial separation of the chorion from the under-
lying decidua. Around 18% of all cases of vagi-
nal bleeding in the first trimester are caused by a
subchorionic hematoma1
, which is detected only
via ultrasound scan. It shows a normal gestation-
al sac close to an anechoic area, or echo free on a
sonographic image, of variable size, having the
typical form of a half-moon. The scan image
plays a pivotal role to analyze any improvement
or worsening. Also the clinical examination is re-
quired, because the sonographic results have to
be related to clinical symptoms (i.e. bleeding,
pelvic pain)2. The manifestation of a first-
trimester subchorionic hematoma represents a
very appropriate marker for identifying patients
at greater risk for threatened miscarriage3
, a seri-
ous problem in the first 20 weeks of pregnancy,
characterized by vaginal blood leaking, other
than spotting, and pelvic pain. The presence of a
large first-trimester subchorionic hematoma was
related to a 46% risk of adverse pregnancy out-
come, i.e. premature rupture of membranes and
spontaneous abortion4
. Consequently, its resorp-
tion is an essential goal to avoid early pregnancy
loss. Among several causes of miscarriages, up
to 80% are genetic5, but also inflammatory
processes and immunologic disorders can be
mentioned6,7
. A complex pathophysiological
mechanism underlies the event of threatened
miscarriage, where T helper (Th) cells (both Th1
and Th2), Th 17 and regulatory T (Treg) cells8,9
are involved in combination with numerous sig-
nal molecules, exerting pro- or anti-inflammatory
effects. Th1 cells are involved in cellular immu-
nity, and Th2 in humoral immunity. This classifi-
2016; 20: 1656-1663
cation reflects the type and prevalence of cy-
tokines secreted by each subset of cells10,11
. Th17
cells play a central role in giving rise to inflam-
mation9,12,13
, whereas Treg cells usually turn
down the immune response9
. Especially in the
first months of pregnancy, inflammatory process
is essential to protect the host from pathogens,
allowing the continuation of pregnancy14
. Inter-
estingly, both excessive inflammation and im-
mune suppression can prompt embryo resorp-
tion8,14
. In general, an adequate balance between
all the elements needs to be kept or restored for
the maintenance of a healthy gestation.
The therapeutic effects of Progesterone in preg-
nancy, in condition of threatened miscarriage, is
approved by therapeutic protocols, but its efficacy
is strongly put in doubt and criticized15-20
. In this
context, Alpha Lipoic Acid (ALA), a multifunc-
tional natural molecule, is revealing a very interest-
ing profile. This compound, given orally or i.v., is
safe at therapeutic doses, and exerts worthwhile bi-
ological activity, that are beneficial also for modu-
lating several mechanisms underlying threatened
miscarriage21-23
. Vaginal administration of ALA is
a new approach which can provide a direct effect
at vaginal and uterine level.
The aim of this pilot study was to preliminary
compare the therapeutic efficacy of ALA vs.
Progesterone, by vaginal administration, on sub-
chorionic hematoma resorption in women at the
first trimester of pregnancy with threatened mis-
carriage. Furthermore, also the effects on pelvic
pain and vaginal bleeding were evaluated.
Patients and Methods
Patients
Gravid women with threatened miscarriage
were enrolled from January 2015 to August 2015
at the Women’s Health Center, Azienda USL
Ferrara – Italy. The inclusion criteria were: pa-
tients age 24-40 years and in the 7th to 12th week
of physiological gestation, with pelvic pain and
with or without moderate vaginal bleeding (com-
parable to the heaviest normal menstrual flow),
and subchorionic hematoma, observed by sonog-
raphy. The exclusion criteria were: lack of fetus,
absence of fetal heart tone, uterine anomaly or
fetal anomaly, presence of multiple pregnancy,
pre-pregnancy or gestation pathologies (such as
maternal autoimmune diseases, antiphospholipid
syndrome, arterial hypertension), diagnosis of al-
lergic reaction to progesterone, therapies with
anti-coagulant or anti-hypertensive drugs. Fur-
thermore, patients with previous miscarriage (no
more than three miscarriages) underwent to ex-
amination to exclude karyotype abnormalities
and any possible clinical factor linked to recur-
rent pregnancy loss. All the patients gave an in-
formed consent before entering the study. The
protocol was approved by the Ethics Committee.
Study Design and Treatment Regimen
The study was a Randomized Controlled Trial
(RCT) with allocation concealment of patients in
two treatments groups (1:1 ratio): in one group
patients received 400 mg Progesterone (Progef-
fik®, Effik Italia srl, two vaginal soft gel per day,
before sleeping), and in the second one (case
study) 10 mg of ALA (DAV® vaginal capsules,
Lo.Li. Pharma srl, Rome, Italy, one vaginal cap-
sule per day, before sleeping). Randomization
did not involve a third group which was formed
by twenty-two patients who decided not to re-
ceive any treatment and it was used as control
(Figure 1). Treatments were given until the total
resolution of the clinical picture.
Outcomes and Follow-up
The primary outcome was the resolution of
subchorionic hematoma linked to threatened mis-
carriage. The evaluation of the hematoma signifi-
cance was done comparing its size with that one
of the gestational sac during the ultrasound ex-
amination, according to the method reported by
Nagy et al
4 which allows one to classify the sub-
chorionic hematoma as small (< 20% of the ges-
tational sac), medium (20%-50% of the gesta-
tional sac), or large (> 50% of the gestational
sac). Changes in hematoma resorption (% im-
provement/ worsening) during the treatment
were obtained for each patient by calculating the
Δ percentage between two subsequent time
points. Then the average values for each group
were compared. The secondary outcomes were
reduction/disappearance of the subjective (pelvic
pain) and objective (vaginal bleeding) symptoms.
A sheet was given to all patients to record the
evolution of these symptoms, which later had to
be statistically analysed.
Follow-up checks were performed at twenty
days (t = 1), and sixty days (t = 2) from the begin-
ning of the treatment (baseline, t = 0) and both
clinical signs and symptoms were recorded by in-
vestigators. The incidence of miscarriage was eval-
uated in both groups and the treatment was judged
successful if pregnancy went over 20 weeks.
1657
Treatment with vaginal lipoic acid for threatened miscarriage
1658
M. Costantino, C. Guaraldi, D. Costantino
Figure 1. Flow chart of participants over the course of the trial (Progesterone: P).
Parameter Group ALA n = 27 Group P n = 27 Group C n = 22 p-value
Age (years) 29.8 ± 0.7 31.2 ± 1.6 30.4 ± 1.3 n.s.
Gestational age (weeks) 8.8 ± 0.2 9.1 ± 0.3 8.9 ± 0.2 n.s.
Nulliparous (%) 13 (48%) 11 (41%) 9 (41%) n.s.
Multiparous (%) 0 00 n.s.
Previous C-section (%) 2 (7%) 3 (11%) 1 (4%) n.s.
Previous miscarriages 12 (44%) 10 (37%) 10 (66%) n.s.
-1 miscarriage 6 6 5 n.s.
-2 miscarriages 5 3 3 n.s.
-3 miscarriages 1 1 2 n.s.
Vaginal bleeding (%) 13 (48%) 14 (52%) 14 (64%) n.s.
Hematoma size n.s.
-Medium 24 (89%) 25 (92%) 20 (94%) n.s.
-Large 3 (11%) 2 (7%) 2 (9%) n.s.
Table I. Baseline patients features in the three groups.
Data are expressed as mean ± SE or as number and percentage (Progesterone: P).
Statistical Analysis
Percentages and mean values of sign and
symptoms were calculated excluding the number
of patients who miscarried. Statistical analysis of
the clinical data was performed by SPSS soft-
ware (SPSS Inc., Chicago, IL, USA) employing
Wilcoxon test for nonparametric data. A Mann-
Whitney U test, with SPSS software, was used to
make the comparison between the single groups.
The difference was considered statistically sig-
nificant if the p-value was ≤ 0.05.
Results
Among eighty-four evaluated subjects, with
threatened miscarriage, a total number of seven-
ty-six pregnant women were included in the trial
according to the inclusion criteria. Patients char-
acteristics at baseline were homogeneous in both
groups, as shown in Table I.
The outcomes were evaluated excluding the
number of patients who miscarried during the
study.
1659
Treatment with vaginal lipoic acid for threatened miscarriage
A blind investigator controlled the patients af-
ter twenty days (t = 1), and sixty days (t = 2)
from the baseline (t = 0) by vaginal ultrasound
scan to check and register the evolution of sub-
chorionic hematoma. The ALA group was found
to be statistically different from Progesterone and
control groups. The result was significant at p ≤
0.05 (Figures 2 and 3). Patients treated with
Progesterone did not show any significant differ-
ence vs. controls.
According to the inclusion criteria, pelvic pain
was present in all the patients at the baseline and
it was recorded only in 3 subjects treated with
Progesterone and in 2 subjects who did not re-
ceive treatment at the first medical examination
(t1) and nobody at the second one (t2). Also re-
garding vaginal bleeding, the effects due to the
treatments were similar.
Although not significantly different, a smaller
number of miscarriages was registered in the
ALA group: this is an interesting, positive trend,
which should be further verified in a following
trial with a large cohort of patients (Table II).
No adverse effects on foetus were detected
during the treatments and until the final check-up
of the study. Four patients in the case study
group reported sporadic episodes of mild vaginal
burning which did not require suspension or dis-
continuation of the therapy.
Figure 2. The progress of subchorionic hematoma resorp-
tion was detected by ultrasound in ALA group (n = 24),
Progesterone (P) group (n = 21) and Control group (n=17)
at different time points of treatment and the data are shown
as Δ percentage of Mean ± SEM. Percentages and mean val-
ues were calculated excluding the number of patients who
miscarried. The size of the hematoma was compared (%)
with the size of the gestational sac during the examination.
Progressive hematoma resorption during treatment was cal-
culated as Δ percentage between two subsequent time points
for each patient and the medium value for each group has
been obtained and compared.
Figure 3. A, Statistical significance of Δ (% improvement) at t = 1 for the subchorionic hematoma resorption: ALA, Proges-
terone (P) and control groups (mean ± SEM). Wilcoxon and Mann-Whitney U test were used. The ALA group was found sig-
nificantly different (p ≤ 0.05) from Progesterone and control groups. Patients treated with Progesterone did not show any sig-
nificant difference vs controls.
1660
M. Costantino, C. Guaraldi, D. Costantino
Discussion
As shown by our data, the subchorionic
hematoma has shown a faster resorption as result
of the vaginal administration with ALA, than
with Progesterone. These findings are in full
agreement with a very recent paper where the au-
thors have found an interesting effect due to the
oral administration of ALA plus Progesterone by
vaginal route vs only Progesterone24
.
Data obtained in previous researches and stud-
ies can help in explaining these clinical results,
focusing the role played by some cytokines and
T helper 1 (Th1) and T helper 2 (Th2) cells in
subchorionic hematoma formation and miscar-
riage. The cytokine network is deeply involved
in the positive or negative development of the
ongoing pregnancies25
, even though the knowl-
edge of the specific underlying mechanisms is in
evolution. Th1 cells are essential in cellular im-
munity, whereas Th2 cells are involved in hu-
moral immunity. There are some peculiarities
that distinguish them: IFN-gamma and TNF-beta
are released only by Th1, whereas IL-4 and IL-5
only by Th2. Moreover, Th1 predominantly se-
crete IL-2, TNF-alpha, TGF-beta, and other (e.g.
IL-10) in small amounts. On the other hand, Th2
release higher quantities of IL-3, IL-6, IL-9, IL-
10, IL-13, TGF-beta, but little TNF-alpha and
IL-226,27
. Th1 cells, through their cytokines, stim-
ulate macrophages, lymphocytes, and PMNs to
destroy bacterial pathogens11
. Furthermore, they
induce the development of cytotoxic T cells,
which play an essential role in the cell-mediated
immune response against the aggression of for-
eign agents such as viruses and tumor cells. This
pivotal function exerted by Th1 cells in immune
system sometimes can give rise to their over acti-
vation or misdirected attacks against some of our
own tissues, making Th1 cells central players in
autoimmune diseases and also when extraneous
cells develop11
.
Th2 cells stimulate strong antibody responses
and eosinophil accumulation and also inhibit sev-
eral functions of phagocytic cell
11
.
Saito and his team8 have suggested an intrigu-
ing explanation involving, Th1, Th2, Th17 and
regulatory T (Treg) cells in pregnancy. Th17
cells produce IL-17, an proinflammatory cy-
tokine, and exert a pivotal role in giving rise to
inflammation9,13,14
. Th 17 cells can induce patho-
genetic mechanisms in autoimmunity and acute
transplant rejection, affecting also the develop-
ment of gestation. It is worth of note that Th17
cells and their released cytokine, IL-17, might
exert a dual action on pregnancy, like IL-1. In-
deed, increased Th17 cells in pregnancy decidua
might be disadvantageous for the maintenance of
physiological process28
. On the other side, Treg
cells usually turn down the immune response9
,
playing a pivotal role in the processes of im-
munoregulation and in the induction of tolerance.
They secrete anti-inflammatory cytokines: IL-10,
IL-35, TGF-beta, which, directly or indirectly,
inhibit the release or the activity of pro-inflam-
matory cytokines. Treg cells inhibit cytotoxic ac-
tivity of natural killer (NK) cells, immunoglobu-
lin production by B cells, and dendritic cells
(DCs) maturation29,30
. Th1/Th2/Th17 and Treg
lineages are associated with each other, and, in
some cases, they are able to convert to other lin-
eages8
. Now, it holds to be true that in normal
development of pregnancy inflammation is nec-
essary for successful implantation14 but excessive
inflammation can cause embryo resorption, a
process that can be counteracted in the uterus by
Treg cells. On the whole, we have to keep in
mind both excessive inflammation and immune
Baseline 1st Medical 2nd Medical
med. exam. t0 control t1 control t2 Miscarriage
Symptoms ALA P C ALA P C ALA P C ALA P C
(n = 24) (n = 21) (n =17) (n = 24) (n = 21) (n =17) (n = 24) (n = 21) (n =17) (n = 27) (n = 27) (n = 22)
Pelvic pain 24 (100%) 21 (100%) 17 (100%) 0 (0%) 3 (14%) 2 (12%) – 0 (0%) 0 (0%) 365
Vag. bleed 13 (54%) 12 (57%) 11 (65%) 0 (0%) 0 (0%) 2 (12%) – – 0 (0%)
Table II. Effects of the treatment with ALA, Progesterone (P) or no treatment (C) on symptoms and incidence of miscarriage.
Data are given as sample size (number and percentage) of each group at different time points: t0: baseline medical examina-
tion; t1: 20 days after baseline medical examination; t2: 60 days after baseline medical examination. Percentages were calculat-
ed excluding the number of patients who miscarried.
lating this network, can play a pivotal role in
ameliorating significantly the medical condi-
tions of mothers and foetus.
Our results have shown that ALA vaginal ad-
ministration can efficiently improve the medical
picture of women with threatened miscarriage,
positively affecting the hematoma resorption. In
this context, a controlled inflammatory process
is indispensable in many steps of a healthy
pregnancy, also in the first trimester. Proges-
terone is known to exert an immunosuppressive
action, whereas ALA is able to finely modulate
the complex of cells and molecules involved
without a unidirectional activity. The use of this
careful modulation should provide the best ther-
apeutic choice to treat patients with threatened
miscarriage, reducing, also markedly, the main
clinical sign and symptoms. Our preliminary
evidences support this new approach proving
the first example on the vaginal use of ALA in
the clinical practice.
–––––––––––––––––-––– Conflict of Interest
The Authors declare that there are no conflicts of interest.
References
1) SAUEBREI EE. Early pregnancy: pre-embrionic and
embryonic periods. In: Sauebrei EE, Nguyen
KT, Nolan RL, editors. A practical guide to ultra-
sound in obstetrics and gynecology. Philadel-
phia (PA): Lippincott-Raven Publishers, 1998;
pp. 122-131.
2) PEDERSEN JF, MANTONI M. Prevalence and signifi-
cance of subchorionic hemorrhage in threatened
abortion: a sonographic study. AJR Am J
Roentgenol 1990; 154: 535.537.
3) NAGY S, BUSH M, STONE J, LAPINSKI RH, GARDÓ S.
Clinical significance of subchorionic and retropla-
cental hematomas detected in the first trimester
of pregnancy. Obstet Gynecol 2003; 102: 94-10.
4) LEITE J, ROSS P, ROSSI AC, JEANTY P. Prognosis of
very large first-trimester hematomas. J Ultra-
sound Med 2006; 25: 1441-1445.
5) KLIMAN HJ, MILANO KM. The majority of miscar-
riages are caused by genetic abnormalities. Fertil
Steril 2013; 100: S306.
6) KWAK-KIM J, YANG KM, GILMAN-SACHS A. Recurrent
pregnancy loss: a disease of inflammation and
coagulation. J Obstet Gynaecol Res 2009; 35:
609-622.
7) CHRISTIANSEN OB, NIELSEN HS, KOLTE AM. Inflamma-
tion and miscarriage. Semin Fetal Neonatal Med
2006; 11: 302-308.
suppression can cause embryo resorption8,14
. A
healthy pregnancy needs an adequate balance be-
tween all the elements, without any unidirection-
al overstimulation.
The treatment with progesterone, an immune
suppressant, to ward off the risk of miscarriage
is approved by therapeutic protocols, but its real
efficacy in preventing spontaneous abortion is
disputed15-20
. In this context, Alpha Lipoic Acid
(ALA), a safe multifunctional molecule, is re-
vealing an interesting and innovative therapeu-
tic activity. In addition to being synthesized in
small amounts by humans, ALA can be assimi-
lated in food, taken as dietary supplement and,
much better, vaginally administered in order to
directly reach the site of action. It is a powerful
antioxidant (called also the “ultimate antioxi-
dant”) because of the wide range of its actions
in regulating oxidative stress pathways and the
capability to pass through biological mem-
branes31,32
. ALA is not an immune suppressant,
but an immune modulator, which regulates
many parameters, such as the secretion of in-
flammatory cytokines, increases Treg-cell num-
ber, inhibits the production of vascular and in-
tracellular adhesion molecules (VCAM-1 and
ICAM-1), reduces the expression of CD4 on the
surface of blood mononuclear cells, and blocks
the activation and cytotoxicity of natural killer
(NK) cells21,22,33,34
. Treatments with ALA in-
hibits the expression of matrix metallopro-
teinase-9 (MMP-9)35 which is involved in the
degradation of the extracellular matrix, and it
also reduces the secretion prostaglandin E2
(PGE2)36
.
In particular, because subchorionic hematoma
appears to be due to immunological vasculitis in
the decidual vessels, vaginal treatment with ALA
may strongly support its resorption through its
immunomodulating activity.
In addition, several studies have highlighted
its efficacy in contrasting the weakening of hu-
man fetal membranes37,38
. It is ascertained that
ALA deficiency is responsible for the deficit in
development of the foetus39-41
.
Conclusions
In pregnancy there is cross talk among differ-
ent immune cells, which communicate by
means of messenger molecules (mainly cy-
tokines) strictly related in a network. In situa-
tion such as threatened abortion, ALA, modu-
1661
Treatment with vaginal lipoic acid for threatened miscarriage
1662
M. Costantino, C. Guaraldi, D. Costantino
8) SAITO S, NAKASHIMA A, SHIMA T, ITO M. Th1/Th2/Th17
and Regulatory T-Cell paradigm in pregnancy.
Am J Reprod Immunol 2010; 63: 601-610.
9) PECK A, MELLINS ED. Plasticity of T-cell phenotype
and function: the T helper type 17 example. Im-
munology 2010; 129: 147-153.
10) CARTER LL, DUTTON RW. Type 1 and Type 2: a fun-
damental dichotomy for all T-cell subsets. Curr
Opin Immunol 1996; 8: 336-342.
11) ROMAGNANI S. T-cell subsets (Th1 versus Th2).
Ann Allergy Asthma Immunol 2000; 85: 9-18.
12) CROME SQ, WANG AY, LEVINGS MK. Translational mi-
ni-review series on Th17 cells: function and regu-
lation of human T helper 17 cells in health and
disease. Clin Exp Immunol 2010; 159: 109-119.
13) ROMAGNANI S, MAGGI E, LIOTTA F, COSMI L. ANNUNZIA-
TO F. Properties and origin of human Th17 cells,
Mol Immunol 2009; 47: 3-7.
14) Mor G, Cardenas I, Abrahams V, Guller S. In-
flammation and pregnancy: the role of the im-
mune system at the implantation site. Ann N Y
Acad Sci 2011; 1221: 80-87.
15) PALAGIANO A, BULLETTI C, PACE MC, DE ZIEGLER D,
CICINELLI E, IZZO A. Effects of vaginal proges-
terone on pain and uterine contractility in pa-
tients with threatened abortion before twelve
weeks of pregnancy. Ann N Y Acad Sci 2004;
1034: 200-210.
16) TIEN JC, TAN TY. Non-surgical interventions for
threatened and recurrent miscarriages. Singa-
pore Med J 2007; 48: 1074-1090.
17) QURESHI NS. Treatment options for threatened
miscarriage. Maturitas 2009; 65 Suppl 1: S35-41.
18) DAYA S. Luteal support: progestogens for pregnan-
cy protection. Maturitas 2009; 65 Suppl 1: S29-
34;
19) DUAN L, YAN D, ZENG W, YANG X, WEI Q. Effect of
progesterone treatment due to threatened abor-
tion in early pregnancy for obstetric and perinatal
outcomes. Early Hum Dev 2010; 86: 41-43.
20) NORMAN JE, MARLOW N, MESSOW CM, SHENNAN A,
BENNETT PR, THORNTON S, ROBSON SC, MCCONNACHIE
A, PETROU S, SEBIRE NJ, LAVENDER T, WHYTE S, NORRIE
J; OPPTIMUM STUDY GROUP. Vaginal progesterone
prophylaxis for preterm birth (the OPPTIMUM
study): a multicentre, randomised, double-blind
trial. Lancet. 2016 Feb 23. pii: S0140-
6736(16)00350-0. doi: 10.1016/S0140-6736(16)
00350-0. [Epub ahead of print].
21) CREMER DR, RABELER R, ROBERTS A, LYNCH B. Safety
evaluation of alpha-lipoic acid (ALA). Regul Toxi-
col Pharmacol 2006; 46: 29-41.
22) CREMER DR, RABELER R, ROBERTS A, LYNCH B. Long-
term safety of alpha-lipoic acid (ALA) consump-
tion: a 2-year study. Regul Toxicol Pharmacol
2006; 46: 193-201.
23) ZIEGLER D, HANEFELD M, RUHNAU KJ, HASCHE H, Lo-
bisch M, Schütte K, Kerum G, Malessa R.
Treatment of symptomatic diabetic polyneu-
ropathy with the antioxidant alpha-lipoic acid: a
7-month multicenter randomized controlled trial
(ALADIN III study). Diabetes Care 1999; 22:
1296-1301.
24) PORCARO G, BRILLO E, GIARDINA I, DI IORIO R. Alpha
Lipoic Acid (ALA) effects on subchorionic
hematoma: preliminary clinical results. Eur Rev
Med Pharmacol Sci 2015; 19: 3426-3432.
25) WEGMANN TG, LIN H, GUILBERT L, MOSMANN TR. Bidi-
rectional cytokine interactions in the maternal-fe-
tal relationship: is successful pregnancy a TH2
phenomenon?. Immunol Today 1993; 14: 353-
356.
26) RAPHAEL I, NALAWADE S, EAGAR TN, FORSTHUBER TG. T
cell subsets and their signature cytokines in au-
toimmune and inflammatory diseases. Cytokine
2015; 74: 5-17.
27) GEGINAT J, PARONI M, MAGLIE S, ALFEN JS, KASTIRR I,
GRUARIN P, DE SIMONE M, PAGANI M, ABRIGNANI S.
Plasticity of human CD4 T cell subsets. Front Im-
munol 2014; 16: 630. doi: 10.3389/fim-
mu.2014.00630. eCollection 2014.
28) SANTNER-NANAN B, PEEK MJ, KHANAM R, RICHARTS L,
ZHU E, FAZEKAS DE ST GROTH B, NANAN R. Systemic
increase in the ratio between Foxp3+ and IL-17-
producing CD4+ T cells in healthy pregnancy but
not in preeclampsia. J Immunol 2009; 183: 7023-
7030.
29) SAKAGUCHI S. Naturally arising Foxp3-expressing
CD25 + CD4 + regulatory T cells in immunologi-
cal tolerance to self and non-self. Nat Immunol
2005; 6: 345-352.
30) AKBAR AN, VUKMANOVIC-STEJIC M, TAAMS LS, MACALLAN
DC. The dynamic co-evolution of memory and
regulatory CD4+ T cells in the periphery. Nat Rev
Immunol 2007; 7: 231-237.
31) SHAY KP, MOREAU RF, SMITH EJ, SMITH AR, HAGEN
TM. Alpha-lipoic acid as a dietary supplement:
molecular mechanisms and therapeutic poten-
tial. Biochim Biophys Acta 2009; 1790: 1149-
1160.
32) MILLER SL, WALLACE EM, WALKER DW. Antioxidant
Therapies: A Potential Role in Perinatal Medicine.
Neuroendocrinology 2012; 96: 13-23.
33) WANG KC, TSAI CP, LEE CL, CHEN SY, LIN GJ, YEN MH,
SYTWU HK, CHEN SJ. Alpha-Lipoic acid enhances
endogenous peroxisome-proliferator-activated re-
ceptor-gamma to ameliorate experimental au-
toimmune encephalomyelitis in mice. Clin Sci
(Lond) 2013; 125: 329-340.
34) COSTANTINO M, GUARALDI C, COSTANTINO D, DE GRAZIA
S, UNFER V. Peripheral neuropathy in obstetrics:
efficacy and safety of alpha-lipoic acid supple-
mentation. Eur Rev Med Pharmacol Sci 2014; 18:
2766-2771.
35) GOR CA A, HUK-KOLEGA H, PIECHOTA A, KLENIEWSKA P,
CIEJKA E, SKIBSKA B. Lipoic acid – biological activity
and therapeutic potential. Pharmacol Rep 2011;
63: 849-858.
36) LI G, FU J, ZHAO Y, JI K, LUAN T, ZANG B. Alpha-
lipoic acid exerts anti-inflammatory effects on
lipopolysaccharide-stimulated rat mesangial cells
1663
Treatment with vaginal lipoic acid for threatened miscarriage
via inhibition of Nuclear Factor Kappa B (NF-κB)
signaling pathway. Inflammation 2015; 38: 510-
519.
37) MOORE RM, NOVAK JB, KUMAR D, MANSOUR JM, Mer-
cer BM, Moore JJ. Alpha-lipoic acid inhibits tumor
necrosis factor-induced remodeling and weaken-
ing of human fetal membranes. Biol Reprod
2009; 80: 781-787.
38) MOORE RM, SCHATZ F, KUMAR D, MERCER BM, ABDEL-
RAHIM A, RANGASWAMY N, BARTEL C, MANSOUR JM,
LOCKWOOD CJ, MOORE JJ. Alpha-lipoic acid inhibits
thrombin-induced fetal membrane weakening in
vitro. Placenta 2010; 31: 886-892.
39) AL GHAFLI MH, PADMANABHAN R, KATAYA HH, BERG B.
Effects of alpha-lipoic acid supplementation on
maternal diabetes-induced growth retardation
and congenital anomalies in rat fetuses. Mol Cell
Biochem 2004; 261: 123-135.
40) PADMANABHAN R, MOHAMED S, SINGH S. Beneficial ef-
fect of supplemental lipoic acid on diabetes-in-
duced pregnancy loss in the mouse. Ann N Y
Acad Sci 2006; 1084: 118-131.
41) ANTONIO AM, GILLESPIE RA, DRUSE-MANTEUFFEL MJ.
Effects of lipoic acid on antiapoptotic genes in
control and ethanol-treated fetal rhombencephalic
neurons. Brain Res 2011; 1383: 13-21.