Low-molecular-weight heparin for prevention of placenta-mediated pregnancy complications: protocol for a systematic review and individual patient data meta-analysis (AFFIRM)

BACKGROUND

Placenta-mediated pregnancy complications include pre-eclampsia, late pregnancy loss, placental abruption, and the small-for-gestational age newborn. They are leading causes of maternal, fetal, and neonatal morbidity and mortality in developed nations. Women who have experienced these complications are at an elevated risk of recurrence in subsequent pregnancies. However, despite decades of research no effective strategies to prevent recurrence have been identified, until recently. We completed a pooled summary-based meta-analysis that strongly suggests that low-molecular-weight heparin reduces the risk of recurrent placenta-mediated complications. The proposed individual patient data meta-analysis builds on this successful collaboration. The project is called AFFIRM, An individual patient data meta-analysis oF low-molecular-weight heparin For prevention of placenta-medIated pRegnancy coMplications.

METHODS/DESIGN

We conducted a systematic review to identify randomized controlled trials with a low-molecular-weight heparin intervention for the prevention of recurrent placenta-mediated pregnancy complications. Investigators and statisticians representing eight trials met to discuss the outcomes and analysis plan for an individual patient data meta-analysis. An additional trial has since been added for a total of nine eligible trials. The primary analyses from the original trials will be replicated for quality assurance prior to recoding the data from each trial and combining it into a common dataset for analysis. Using the anonymized combined data we will conduct logistic regression and subgroup analyses aimed at identifying which women with previous pregnancy complications benefit most from treatment with low-molecular-weight heparin during pregnancy.

DISCUSSION

The goal of the proposed individual patient data meta-analysis is a thorough estimation of treatment effects in patients with prior individual placenta-mediated pregnancy complications and exploration of which complications are specifically prevented by low-molecular-weight heparin.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (International Prospective Registry of Systematic Reviews) 23 December 2013, CRD42013006249.

Perinatal characteristics and bone cancer risk in offspring--a Scandinavian population-based study

BACKGROUND

We investigated perinatal factors in relation to bone cancer subtypes, osteosarcoma (OS), Ewing Sarcoma (ES) and chondrosarcoma (CS).

MATERIALS AND METHODS

All cases in Norway (1970-2009), Sweden (1974-2009) and Denmark (1980-2010)<43 years were included (n=914); 10 controls per case were selected from birth registries (which provided information on pregnancies) matched on birth country, sex and birth year (n=9140). Unconditional logistic regression models including sex and birth year were used to compute relative risk (RR) and 95% confidence intervals (CI).

RESULTS

Higher maternal education was associated with a 40% increase in OS risk (95% CI 1-93%). The RR for OS was 3.22 (95% CI 1.37-7.59) comparing offspring of hypertensive mothers with those of mothers with a normotensive pregnancy, and Cesarean section was associated with a 29% risk reduction (95% CI 0-50%). When gestational age, birth weight and birth length were assessed simultaneously, there were no associations with any of the bone tumor subtypes.

CONCLUSION

These results provided little evidence of an important role of pregnancy factors in the etiology of bone cancers. Higher maternal education may be associated with factors, possibly early nutrition or other correlates of socioeconomic status, that increase OS risk in offspring. The elevated OS risk associated with gestational hypertension and reduced risk associated with Cesarean section warrant replication.

A comparison of anthropometric, metabolic, and reproductive characteristics of young adult women from opposite-sex and same-sex twin pairs

BACKGROUND

Prenatal exposure to androgens has been linked to masculinization of several traits. We aimed to determine whether putative female intra-uterine exposure to androgens influences anthropometric, metabolic, and reproductive parameters using a twin design.

METHODS

Two cohorts of Finnish twins born in 1975-1979 and 1983-1987 formed the basis for the longitudinal FinnTwin16 (FT16) and FinnTwin12 (FT12) studies. Self-reported anthropometric characteristics, disease status, and reproductive history were compared between 679 same-sex (SS) and 789 opposite-sex (OS) female twins (mean age ± SD: 34 ± 1.1) from the wave 5 of data collection in FT16. Serum lipid and lipoprotein subclass concentrations measured by nuclear magnetic resonance spectroscopy were compared in 226 SS and 169 OS female twins (mean age ± SD: 24 ± 2.1) from the wave 4 of data collection in FT12 and FT16.

RESULTS

Anthropometric measures, the prevalence of hypertension and diabetes mellitus type 2 did not differ significantly between females from SS and OS twin pairs at age 34. Similarly, the prevalence of infertility, age at first pregnancy and number of induced and spontaneous abortions did not differ significantly between these two groups of women. The serum lipid and lipoprotein profile did not differ between females from SS and OS twins at age 24.

CONCLUSION

We found no evidence that androgen overexposure of the female fetus affects obesity, metabolic profile, or reproductive health in young adult females. However, these results do not exclude the possibility that prenatal androgen exposure in females could be adversely associated with these phenotypes later in life.

Poor pregnancy outcome in women with type 1 diabetes is predicted by elevated HbA1c and spikes of high glucose values in the third trimester

OBJECTIVE

To analyse data from a randomised, controlled study of prandial insulin aspart versus human insulin, both with NPH insulin, in pregnant women with type 1 diabetes for potential factors predicting poor pregnancy outcomes. RESEARCH DESIGN/METHOD: Post hoc analysis including 91 subjects randomised prior to pregnancy with known outcome in early pregnancy and 259 subjects randomised prior to pregnancy/during pregnancy of <10 weeks' gestation with known late-pregnancy outcomes. Poor early-pregnancy outcomes included fetal loss <22 gestational weeks and/or congenital malformation (n=18). Poor late-pregnancy outcomes included: composite endpoint including pre-eclampsia, preterm delivery and perinatal death (n=78); preterm delivery (n=63); and excessive fetal growth (n=88).

RESULTS

18 patients experienced a malformed/lost fetus in early pregnancy - none preceded by severe hypoglycaemia. Albuminuria in early pregnancy was a significant predictor of poor late-pregnancy outcome (composite endpoint; p=0.012). In the third trimester, elevated HbA1c, ≥ 1 plasma glucose (PG) measurement >11 mmol/L (198 mg/dL) and %PG values outside 3.9-7.0 mmol/L (70-126 mg/dL) were significant predictors of poor late-pregnancy outcomes (all p<0.05).

CONCLUSIONS

Elevated HbA1c, high glucose spikes and out-of-range %PG in the third trimester, and albuminuria in early pregnancy, are associated with poor late-pregnancy outcomes.

Pre-eclampsia and pregnancy-induced hypertension are associated with severe diabetic retinopathy in type 1 diabetes later in life

To investigate whether pre-eclampsia (PE) or pregnancy-induced hypertension (PIH) predicts the development of severe diabetic retinopathy (SDR) in type 1 diabetes. Altogether, 203 women with type 1 diabetes who were followed during pregnancy were re-examined within the Finnish Diabetic Nephropathy Study. After excluding patients with pre-pregnancy hypertension and those who had had laser treatment or whose retinopathy was graded as proliferative at the index pregnancy, 158 were prospectively studied. As a surrogate marker for SDR, retinal laser photocoagulation was used. The time from pregnancy to SDR (N = 21) or follow-up was 16 years (interquartile range, 11-19). HbA1c was repeatedly measured both during pregnancy and follow-up. Women with prior PE (26 % vs. 6 %, P = 0.003) or PIH (24 % vs. 6 %, P = 0.008) had more often incident SDR during follow-up compared to those with normotensive pregnancy. The hazard ratios (HR) remained associated with the progression to SDR after adjustment for duration of diabetes and diabetic nephropathy in a Cox regression analysis [PE: 3.5 (95 % CI 1.1-10.9); P = 0.03 and for PIH: 3.2 (1.1-9.8); P = 0.04]. The association between PIH and incident SDR did not change after inclusion of mean HbA1c, measured during pregnancy (all 3 trimesters) and serial HbA1c measurements during follow-up, 3.5 (1.1-11.8; P = 0.03). However, in a similar model, the HR for PE was no more significant 2.0 (0.6-6.8; P = NS). The results suggest that women with type 1 diabetes and a hypertensive pregnancy have an increased risk of severe diabetic retinopathy later in life.

Hoover R, Stephansson O. Perinatal characteristics and breast cancer risk in daughters: a Scandinavian population-based study

The in utero origins of breast cancer are an increasing focus of research. However, the long time period between exposure and disease diagnosis, and the lack of standardized perinatal data collection makes this research challenging. We assessed perinatal factors, as proxies for in utero exposures, and breast cancer risk using pooled, population-based birth and cancer registry data. Birth registries provided information on perinatal exposures. Cases were females born in Norway, Sweden or Denmark who were subsequently diagnosed with primary, invasive breast cancer (n = 1419). Ten controls for each case were selected from the birth registries matched on country and birth year (n = 14,190). Relative risks (RRs) and 95% confidence intervals (CIs) were estimated using unconditional regression models. Breast cancer risk rose 7% (95% CI 2-13%) with every 500 g (roughly 1 s.d.) increase in birth weight and 7% for every 1 s.d. increase in birth length (95% CI 1-14%). The association with birth length was attenuated after adjustment for birth weight, while the increase in risk with birth weight remained with adjustment for birth length. Ponderal index and small- and large-for-gestational-age status were not better predictors of risk than either weight or length alone. Risk was not associated with maternal education or age, gestational duration, delivery type or birth order, or with several pregnancy complications, including preeclampsia. These data confirm the positive association between birth weight and breast cancer risk. Other pregnancy characteristics, including complications such as preeclampsia, do not appear to be involved in later breast carcinogenesis in young women.

[Hypertensive pregnancy in diabetes--risk factors and influence on future life]

Pre-eclampsia and gestational hypertension are potentially dangerous entities causing maternal and fetal morbidity and mortality. Interestingly, the risk factors for these two conditions differ and it is thought that they also differ in their pathophysiological background. Notably, women with diabetes have an increased risk for de novo hypertension during pregnancy compared to non-diabetic subjects. However, among diabetic patients poor glycaemic control has been shown to increase the risk for pre-eclampsia. Furthermore, women with a history of pre-eclampsia suffer more often from cardiovascular disease later in life. New data regarding long-term effects of hypertensive pregnancies on late diabetic complications have been published that may be of clinical relevance in the prevention of these complications.

Fertility in people with childhood-onset type 1 diabetes

AIMS/HYPOTHESIS

To assess the number of live births in a population-based, retrospective cohort of women and men with childhood-onset type 1 diabetes, and matched controls.

METHODS

The reproductive histories of people in a Finnish cohort of 2,307 women and 2,819 men with type 1 diabetes and two matched controls (for each case) were obtained from National Population Register data. All persons with diabetes were diagnosed with the disease in 1965-1979 at the age of 17 or under. A proportional hazards model was used to model the association between the rate of live births as a function of the age of an individual and the observed covariates (sex and age at onset of diabetes).

RESULTS

Both women and men with diabetes had a smaller number of live births than the controls; the HR of having a first child for diabetic women compared with controls was 0.66 (95% CI 0.62, 0.71) and for men was 0.77 (95% CI 0.72, 0.83). In women, a birth cohort effect was detected; in more recent birth cohorts, the difference between diabetic women and controls as regards having children was significantly smaller than in earlier cohorts. Later age at onset of diabetes was associated with a higher rate of having a first child among men (p = 0.04) and having a second live birth among women (p = 0.002).

CONCLUSIONS/INTERPRETATION

Type 1 diabetes affects the number of live births in both women and men. The age at onset of diabetes is associated with the pattern of reproduction in both diabetic women and men.

Carotid artery intima-media thickness and elasticity in relation to glucose tolerance

The association between diabetes and subclinical atherosclerosis is well established. The effect of non-diabetic glucose intolerance on early atherosclerosis is not as straightforward, and the data regarding sex-related differences in this matter are limited. Therefore, our aim was to investigate these associations in men and women separately. We studied 1,304 Finnish men and women over 45 years of age who participated in the Finnish Health 2000 Survey. Ultrasonically determined carotid artery intima-media thickness and elasticity were used as markers of early atherosclerosis. Glucose tolerance was categorized according to the American Diabetes Association criteria for diabetes mellitus. Age-adjusted means for carotid artery intima-media thickness and elasticity indices were significantly (P < 0.05) associated with glucose tolerance status in both sexes. There was a trend of increasing early atherosclerosis with the worsening of glucose tolerance in men and women. These associations were weakened in both sexes after further adjustments for other cardiovascular risk factors. In women, but not in men, significant (P < 0.05) associations between glucose tolerance status and carotid artery elasticity were seen even after these further adjustments. Diabetes and non-diabetic glucose intolerance are associated with increased early carotid atherosclerosis compared with normal glucose tolerance in both sexes. Our results suggest that women with glucose intolerance may be in greater risk than men.

Pregnancy and multiple sclerosis

The relapse rate of multiple sclerosis (MS) is typically reduced during late pregnancy but increases in the postpartum period. The reasons for the increased postpartum activity are not entirely clear, but factors such as the abrupt decrease in oestrogen levels immediately after the delivery and the loss of the immunosuppressive state of pregnancy are likely of importance. There is a general view that MS does not affect the course or outcome of pregnancy.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on cardiovascular disease risk factors in menorrhagia patients: a 10-year follow-up of a randomised trial

OBJECTIVE

To compare, whether women with menorrhagia, treated with either hysterectomy or LNG-IUS, differ in their cardiovascular risk profile during 10-year follow-up.

STUDY DESIGN

A total of 236 women were randomized to treatment by hysterectomy (n=117) or LNG-IUS (n=119). Their cardiovascular risk factors were analyzed at baseline, at 5 years, and at 10 years. As 55 originally randomized to the LNG-IUS group had hysterectomy during the follow-up, all analyzes were performed by actual treatment modality.

MAIN OUTCOME MEASURES

Waist circumference, body-mass index (BMI), blood pressure, and the levels of blood lipids, serum high-sensitivity CRP (hsCRP) and tumor necrosis factor alpha (TNF-α) were measured, and the use of medication for hypertension, diabetes, hypercholesterolemia, and ischemic heart disease was analyzed.

RESULTS

After 5 years, an increase in the use of diabetes medication during the follow-up was only detected in the hysterectomy group (from 1.7% to 6.7%, P=0.008 vs from 5.1% to 8.4%, P=0.08), as well as they had significantly higher serum levels of TNF-α (108.59 pg/ml vs 49.02 pg/ml, P=0.001) and hsCRP (1.55 μg/ml vs 0.78 μg/ml, P=0.038) at 5- and 10-years. There was no difference between the groups in the use of cardiovascular medication, neither was there difference in blood pressure, waist circumference, BMI, or concentrations of blood lipids.

CONCLUSIONS

Hysterectomy seems to be associated with increased levels of serum inflammatory markers and increased diabetes medication, which in turn, may predispose individual to future cardiovascular events.

[Diuretics in pregnancy can do harm]

We describe a case with severe pre-eclampsia with poor obstetric outcome. This patient developed oliguria and received multiple doses of furosemide which probably contributed to the poor outcome. This case presentation reminds of the risks associated with pre-eclampsia in which both blood volume and utero-placental blood flow are already decreased. This condition was further worsened by diuretics.

Decreased variation of inflammatory markers in gestational diabetes

BACKGROUND

Gestational diabetes is a prediabetic state. Sub-clinical inflammation may play a role in the transition from gestational diabetes to type 2 diabetes; the role of the autonomic nervous system as a mediating system has been raised. We aimed to study the association of the sympathetic nervous system and sub-clinical inflammation in women with gestational diabetes.

METHODS

We studied 41 Caucasian women with gestational diabetes and 22 healthy pregnant and 14 non-pregnant controls. We assayed plasma noradrenaline, insulin, C-reactive protein, interleukin-6, insulin growth factor-1, serum amyloid A, steroid hormone-binding globulin, α-1 acid glycoprotein and cortisol at 2400, 0400 and 0700 h.

RESULTS

No differences existed in the concentrations of inflammatory markers between gestational diabetes and normal pregnancy but women with gestational diabetes showed loss of variation in C-reactive protein and serum amyloid A. Levels of hormone-binding globulin were lower in hypertensive compared with normotensive women with gestational diabetes at all time points and lowest at midnight when α-1 acid glycoprotein levels were higher in hypertensive women.

CONCLUSIONS

Gestational diabetes is associated with loss of natural variation of C-reactive protein and serum amyloid A, suggesting altered modulation of inflammation. Hypertension in gestational diabetes seems not to be associated with higher levels of inflammatory markers other than α-1 acid glycoprotein.

Factor V Leiden as a risk factor for preterm birth--a population-based nested case-control study

BACKGROUND

Preterm birth is a major cause of neonatal morbidity and mortality, occurring in 5-13% of deliveries in developed countries. Genetic thrombophilia can theoretically contribute to the induction of preterm delivery, but the role of thrombophilia as risk factor is unclear.

OBJECTIVES

To assess factor V Leiden, FII G20210A and other selected inherited and acquired variables as risk factors for preterm birth.

PATIENTS/METHODS

We performed a population-based nested case-control study of 100,000 consecutive pregnancies in Finland. Cases and controls were identified by combining national registers. Clinical data were obtained from medical records and standardized questionnaires. We studied 324 cases with preterm delivery at or after 22 and before 37 completed weeks of gestation, and 752 controls.

RESULTS

FV Leiden was associated with a 2.4-fold risk (95% confidence interval [CI] 1.3-4.6) of preterm birth in all pregnancies, and a 2.6-fold risk (95% CI 1.4-5.1) in singleton pregnancies. FV Leiden was especially associated with late preterm birth at or after 32 weeks of pregnancy, with an odds ratio (OR) of 2.9 (95% CI 1.5-5.6) in all pregnancies and an OR of 3.1 (95% CI 1.6-6.2) in singleton pregnancies. FII G20210A was not associated with preterm birth. Twin pregnancy (OR 12.0, 95% CI 6.0-24.1) and a history of venous thrombosis (OR 3.8, 95% CI 1.4-9.8) were associated with increased risk. High educational level and modest overweight (body mass index 25-29.9 kg m(-2) ) had protective effects.

CONCLUSIONS

Maternal carriage of FV Leiden was associated with increased risk of late but not early preterm birth. FII G20120A was not associated with preterm birth.

Hormonal and metabolic characteristics of premenopausal women with a history of preeclamptic pregnancy

OBJECTIVE

To investigate whether women with a history of preeclampsia have more signs of hyperandrogenism and insulin resistance in the premenopausal period than women with history of normotensive pregnancies.

DESIGN

Case-control study.

SETTING

University Hospital.

SAMPLE

Eighteen women with a history of preeclamptic first pregnancy and 19 women with prior normotensive first pregnancy studied 23-24 years after delivery.

METHODS

Diagnosis of metabolic syndrome was based on the International Diabetes Federation (IDF) criteria. Matsuda's whole-body insulin sensitivity index, serum concentrations of follicle-stimulating hormone (FSH), sex hormone-binding globulin, and total and free calculated testosterone were assessed. Polycystic ovary syndrome (PCOS) phenotype was defined using Rotterdam criteria.

MAIN OUTCOME MEASURES

Insulin sensitivity, metabolic syndrome and signs of hyperandrogenism.

RESULTS

Insulin sensitivity and total and free testosterone were similar in the two groups. However, in women with prior preeclampsia and FSH below the median, calculated free testosterone levels were higher than in women with prior preeclampsia and FSH above the median (median 13.4 range (8.0-22.5) vs. 7.1 (5.1-20.5), p = 0.03). Of the women with previous preeclampsia, 17% (3/18) had metabolic syndrome and 11% (2/18) PCOS, versus 11% (2/19) and 0% of the controls, respectively.

CONCLUSIONS

In women with prior preeclampsia, premenopause was not associated with insulin resistance, but signs of hyperandrogenism were present if FSH was within a premenopausal level.

Imbalance of the autonomic nervous system at night in women with gestational diabetes

AIMS

Autonomic nervous system dysfunction is observed in Type 2 diabetes. As gestational diabetes is a potent risk factor of later Type 2 diabetes, we set out to determine whether autonomic nervous system imbalance could already be observed in women with this condition. Because activity of the sympathetic nervous system tends to be relatively stable in the nocturnal hours, we performed the study at night.

RESEARCH DESIGN AND METHODS

We studied 41 women with gestational diabetes, 22 healthy pregnant controls and 14 non-pregnant controls. We assayed plasma noradrenaline at 24.00, 04.00 and 07.00 h and performed an overnight Holter recording for heart rate variability analysis. In addition, we assayed plasma adrenomedullin, a cardiovascular protective hormone.

RESULTS

Compared with non-pregnant controls, plasma noradrenaline levels were increased at 04.00 and 07.00 h in the gestational diabetic (P = 0.003) and pregnant control (P = 0.002) groups, with no difference between them. Heart rate variability, very-low-frequency and low-frequency power were lower in pregnant groups compared to the non-pregnant controls. Heart rate variability remained unchanged between specified sampling times in the gestational diabetic group, in contrast to fluctuation seen in the control groups.

CONCLUSIONS

Gestational diabetes, compared with normal pregnancy, seems not to be a state of overall sympathetic nervous system activation. At the heart level, however, an inhibitory effect on autonomic nervous system modulation was seen. Plasma noradrenaline and heart rate variability correlated well, supporting the use of this function in future studies of overall sympathetic activity during pregnancy.

Secular trend in the menopausal age in Finland 1997-2007 and correlation with socioeconomic, reproductive and lifestyle factors

BACKGROUND AND AIMS

Only few studies have studied secular trend of menopausal age during last decade. The aim of our study is to analyze secular trend of menopausal age and to evaluate the role of socioeconomic, reproductive and lifestyle factors.

MATERIAL AND METHODS

National FINRISK Study sample from years 1997 and 2007 was utilized. The sample size for 1997 was 4193 and during 2007 was 4253 women. Covariance analysis included menopausal age as dependent variable and covariates (age, study year, education, occupation, parity, age at first birth, smoking, use of alcohol, physical activity, body mass index, waist circumference and waist-hip ratio) as independent variables.

RESULTS

Median of menopausal age was 50 years in 1997 and 51 years in 2007. Differences in menopausal age by covariate were largest in smoking, education and occupation. Difference in mean menopausal age between smokers and non-smokers was larger in 2007 than in 1997 (p<0.001). Lowest educated women had lower average menopausal age during 2007 than higher educated women (p<0.001), but not in 1997. When including sociodemographic, reproductive and lifestyle factors in a model, smoking was significantly related to earlier and physical activity to later menopausal age. Study year was not significant in any model.

CONCLUSION

Education, smoking and physical activity have an important role in menopausal age determination when comparing 10-year differences in menopausal age.