Modern management of eclampsia

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains an important cause of maternal mortality and morbidity. Despite being recognised since antiquity, consistent management practices are still lacking. Given that the aim of good care is to prevent seizures, it is disappointing that in the majority of cases the first eclamptic convulsion occurs after admission to hospital. This indicates that either the women who are likely to have a convulsion were not identified accurately, or the treatment given was ineffective. The answer to poor management of eclampsia lies in better education and training of all obstetricians, anaesthetists, midwives, and general practitioners in the diagnosis and treatment of severe pre-eclampsia and eclampsia. Protocols for the management of fluid balance, antihypertensive and anticonvulsant therapies should be available and reviewed regularly. The universal adoption of such guidelines in all obstetric units would substantially reduce elements of substandard care which have repeatedly been identified in the triennial reports of the confidential enquiries into maternal deaths in the UK.

Uterine ultrasonographic changes with gonadotropin-releasing hormone agonists

OBJECTIVES

Our purpose was to assess the changes in uterine volume and uterine artery pulsatility index in response to gonadotropin-releasing hormone agonist treatment in women undergoing hysterectomy for nonfibroid-related uterine bleeding.

STUDY DESIGN

A double-blind, placebo-controlled randomized trial of 51 women awaiting hysterectomy in a gynecology outpatient clinic was conducted. The women were treated for 8 weeks with either leuprolide acetate depot or placebo. Vaginal ultrasonographic examinations were performed before and after treatment. The paired t test was used for statistical analysis.

RESULTS

In those allocated to therapy with gonadotropin-releasing hormone agonist the mean uterine volume decreased by 34% and the uterine artery pulsatility index increased from 2.25 to 2.7. No significant changes were seen in the placebo group. The intersonographer variability was low and there was a high correlation between uterine size as measured by ultrasonography before hysterectomy and that measured postoperatively.

CONCLUSIONS

Treatment with gonadotropin-releasing hormone agonists leads to uterine shrinkage and an increase in the uterine artery pulsatility index even in the absence of uterine fibroids.

Trends in incidence of and mortality from invasive cancer of the uterine cervix in Scotland (1975-1994)

OBJECTIVE

I. To identify major trends in the incidence of and mortality from invasive cancer of the cervix uteri in Scotland during the twenty year period 1975-1994; II. to consider the extent to which these trends may have been shaped by the introduction of systematic cervical screening.

DESIGN

Analysis of annual age standardised and age specific rates for incidence and mortality, based on data collected by the Scottish Cancer Registry and the General Register Office for Scotland.

SETTING

Scotland.

SUBJECTS

Women registered with the Scottish Cancer Registry as having developed invasive cancer of the cervix during the period of interest.

RESULTS

Annual all ages incidence rates of invasive cervical cancer show little overall change over the period 1975-1989, but exhibit a pronounced decline from 1990 onwards. All-ages mortality rates show clear evidence of decline during the period 1975-1994, the rate for 1994 being some 30% lower than that for 1975. Annual age-specific incidence rates show different patterns by age group, with clear evidence of decreasing trends in the age range 50-64 years but different patterns in younger and older age groups. Most age groups show steep declines in incidence from 1990 onwards. Age specific mortality rates for 1975-1994 exhibit the most pronounced decreasing trends in the age range 50-64 years. The trends identified are broadly similar to those experienced in England and Wales over an approximately comparable period.

CONCLUSIONS

The overall (all ages) incidence of invasive cervical cancer in Scotland changed little during the period 1975-1989, but declined sharply from 1990 onwards. The most pronounced decline in incidence across the period 1975-1994 appears to have taken place in the age range 50-64 years. This decline has been accompanied by a commensurate fall in mortality in the same age range. These reductions in incidence and mortality may be attributable in part to increased coverage of cervical screening programmes during the period of interest. Evidence from other studies suggest that, without the increased coverage of cervical screening achieved during this period incidence rates in Scotland might have been seen to increase.

Antioxidants and inflammatory cell response in preeclampsia

There is widespread evidence of inflammatory cell and antioxidant activity in preeclampsia. However, it is difficult to disentangle the pathological changes from the normal physiological responses to the pathological process. The site at which the measurements are taken, and the severity of disease, alter the results. The interaction between the mother and the fetus needs to be considered separately, especially when the genetics of preeclampsia is considered. It is clear that within the placenta, there is an increase in tumor necrosis factor-alpha (TNF-alpha) and lipid peroxide production. These changes are associated with a reduction in the various placental antioxidants. This suggests there may be a failure of the normal fetal protection systems. Lipid peroxidation is also increased in the peripheral blood, as well as IL-6, IL-8, and TNF-alpha, which are of monocytic origin. Stimulated monocytes produce free radicals, which can cause oxidative damage. Maternal cells protect themselves with both plasma and intracellular antioxidants. There is an imbalance between oxidant and antioxidant activity in preeclampsia. Changes in membrane oxidation can lead to changes in the membrane stability. Genetic difference in the production of TNF-alpha and nitric oxide may also modify the disease process, demonstrating the role for "moderator genes."

How should we approach the management of pelvic pain?

Pelvic pain is a common debilitating condition. Most investigations are invasive, expensive and usually negative. Although a positive diagnosis of endometriosis justifies a recognized treatment programme, the majority of women with negative investigations are left without a diagnosis and often accused of psychological abnormalities. The reasons for the negative investigations are just as likely to be due to the inadequate techniques of the operator as the lack of pathological signs. The early use of menstrual suppression with GnRH analogue allows pain relief sooner in the majority of sufferers and separates those with pain related to the menstrual cycle, from whatever cause, from those whose pain is not related to pelvic physiology and who would not benefit from further medication or operative therapy. The majority, who have obtained relief from the analogue therapy, then have time to discuss alternative long-term treatments without the feeling of desperation that chronic monthly pelvic pain can produce.

The rise in caesarean section rate: the same indications but a lower threshold

OBJECTIVE

To investigate the reasons for the rise in caesarean section rate and note any change in indications.

DESIGN

A retrospective, descriptive study comparing the years 1962 and 1992.

SETTING

A large city centre teaching hospital.

RESULTS

There was an overall increase in the caesarean section rate from 6-8% in 1962 to 18.1% in 1992. No single cause contributed more than 30% towards this increase. The main indications in both years were similar: failure to progress (42.2% vs 36.7%) and fetal indications (18.1% vs 18.9%). The largest relative increases were in the malpresentation group (10.8% vs 16%) and previous caesarean section (4.5% vs 15.2%).

CONCLUSIONS

These results suggest that there has been a lowering in the overall threshold concerning the decision to carry out a caesarean section rather than changes in obstetric management. Obstetricians and the women in their care have to decide whether the current balance between risk and benefit is acceptable or whether they wish to alter the underlying philosophy if any significant reduction is to be sustained.

Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia

OBJECTIVE

To compare the efficacy and acceptability of the levonorgestrel intrauterine system and norethisterone for the treatment of idiopathic menorrhagia.

DESIGN

A randomised comparative parallel group study.

SETTING

Gynaecology outpatient clinic in a teaching hospital.

PARTICIPANTS

Forty-four women with heavy regular periods and a measured menstrual blood loss exceeding 80 ml.

METHODS

Twenty-two women had a levonorgestrel intrauterine system inserted within the first seven days of menses, and 22 women received norethisterone (5 mg three times daily) from day 5 to day 26 of the cycle for three cycles.

MAIN OUTCOME MEASURES

The main outcome measure was the change in objectively assessed menstrual blood loss after three months of treatment.

RESULTS

When menstrual blood loss at three months was expressed as a percentage of the control, the levonorgestrel intrauterine system reduced menstrual blood loss by 94% (median reduction 103 ml; range 70 to 733 ml), and oral norethisterone by 87% (median reduction 95 ml; range 56 to 212 ml). After three cycles of treatment 76% of the women in the levonorgestrel intrauterine system group wished to continue with the treatment, compared with only 22% of the norethisterone group.

CONCLUSIONS

Both the levonorgestrel intrauterine system and oral norethisterone in this regimen provided an effective treatment for menorrhagia in terms of reducing menstrual blood loss to within normal limits. The levonorgestrel intrauterine system was associated with higher rates of satisfaction and continuation with treatment, and thus offers an effective alternative to currently available medical and surgical treatments for menorrhagia.

Sympathetic nerve discharge in normal pregnancy and pregnancy-induced hypertension

BACKGROUND

Microneurographic assessment of processed bursts that represent multi-unit nerve discharge has suggested that sympathetic hyperactivity occurs in pregnancy induced hypertension and pre-eclampsia in comparison with normal pregnancy.

OBJECTIVE

To examine the differences between peripheral sympathetic outputs in pregnancy-induced hypertension and normal pregnancy by directly measuring single impulses of neural discharge.

DESIGN

We compared the sympathetic neural discharge at rest and its reflex responses in subjects with pregnancy-induced hypertension and normal pregnancy and re-examined their progress at least 6 weeks post partum. The patients with pregnancy-induced hypertension were hospital in-patients for whom the diagnosis could be strictly defined and the normally pregnant women were recruited to match the former.

METHODS

Standard microneurography was performed to quantify single impulses of action potentials, together with the processed multi-unit bursts from fibres innervating the leg muscles. We measured neural discharge with vascular vasoconstrictive properties, heart rate and finger arterial blood pressure at rest and their responses to standard isometric hand-grip exercise and cold pressor tests.

RESULTS

As expected, patients with pregnancy-induced hypertension (n = 13) had higher levels of finger arterial blood pressure than did women with normal pregnancies (n = 11). The number of single impulses of action potentials (per min and per 100 cardiac beats) in resting patients with pregnancy-induced hypertension was more than three times greater than that in resting women with normal pregnancies, and the number of multi-unit bursts was twofold greater. After delivery of their child, sympathetic activity and heart rate in nine patients decreased, but finger arterial blood pressure decreased in patients with pregnancy-induced hypertension only.

CONCLUSIONS

From results of cross-sectional and longitudinal studies, pregnancy-induced hypertension is associated with a greater resting sympathetic output than that of women with normal pregnancies. Follow-up data after parturition suggest that this hyperactivity is not the only cause of hypertension.

Evidence for the existence of a novel pregnancy-associated soluble variant of the vascular endothelial growth factor receptor, Flt-1

Angiogenesis is essential in physiological processes including ovulation, implantation and pregnancy. One of the most potent regulators is the cytokine vascular endothelial growth factor (VEGF). We provide evidence for a novel pregnancy-associated soluble variant of the VEGF receptor Flt-1. VEGF ranged from undetectable to 157.3 pg/ml (mean 49.9 pg/ml, SD 48.4 pg/ml) in plasma samples from normal volunteers (n = 10), but was undetectable in plasma from pregnant women (n = 12) and amniotic fluid (n = 10). Recoveries of spiked VEGF were poor in pregnancy-related samples, indicating the presence of VEGF-binding activity which was confirmed using biosensor and chromatographic techniques. Partial purification and protein sequencing indicated a novel soluble form of Flt-1 with a subunit size of 150 kDa. Normally present as a multimeric structure of approximately 400-550 kDa, complexes of 600-700 kDa were formed following binding of multiple VEGF molecules. Reverse transcriptase polymerase chain reaction of Flt-1 in placenta, amnion, chorion, human umbilical vein endothelial cells and cord blood samples produced bands of the predicted sizes but failed to identify any additional RNA species, and possible reasons for this are discussed. Soluble Flt-1 may be important in regulating the actions of VEGF in angiogenesis and trophoblast invasion and may have therapeutic implications in diseases with inappropriate angiogenesis such as proliferative retinopathies and cancer.

Erythrocyte glutathione balance and membrane stability during preeclampsia

This study aimed to determine whether oxidative damage to the erythrocyte occurs in preeclampsia, and relates to disease severity. The oxidative status of intact erythrocytes from preeclamptic patients and normal pregnant women was determined using spin echo 1H-NMR, which measures both the concentration and redox state of intracellular glutathione. Previous studies of preeclampsia have only measured total glutathione levels. Membrane fragility was determined from the degree of lysis caused by incubation in hypotonic saline. Erythrocytes from moderate-severe preeclamptic patients underwent more lysis than erythrocytes from control pregnant women (p < .05) or mild preeclamptic patients. It is suggested that increased lysis results from oxidative damage to the erythrocyte membrane, causing a decrease in membrane fluidity and reducing its ability to withstand osmotic changes. Intracellular glutathione was more oxidized in erythrocytes from pregnant women compared to nonpregnant controls (p < .05), and there was a less significant trend toward more oxidized glutathione with increasing severity of preeclampsia. The moderate-severe group showed a clear division in glutathione redox status: some patients had very oxidized glutathione while others had a normal redox balance. This novel finding suggests that some patients may be unusually susceptible to erythrocyte glutathione oxidation, possibly leading to general cellular damage, in particular HELLP Syndrome.

A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations

OBJECTIVES

We aimed to compare a new primary care outcome measure-the Patient Enablement Instrument (PEI)-against two established satisfaction measures [the Medical Interview Satisfaction Scale (MISS) and the Consultation Satisfaction Questionnaire (CSQ)]. Specifically, we sought (i) to test whether enablement and satisfaction are related or separate concepts; and (ii) to assess whether the internal consistency of the PEI might be enhanced by the inclusion of items from the satisfaction instruments.

METHODS

Questionnaire forms containing the three instruments in a variety of combinations were distributed to a total of 818 patients attending for routine surgery consultations in three urban general practices of varying socio-economic mix. The main outcome measures were: scores on the PEI; scores on the CSQ, the MISS and their individual components; rank correlations between scores on the PEI and scores on the CSQ, the MISS and their component subscales; and Cronbach's alpha coefficient for the PEI.

RESULTS

Overall mean scores, expressed as percentages of maximum scores attainable, were 44.1% for the PEI, 76.9% for the CSQ and 77.6% for the MISS. Rank correlations between PEI scores and scores for the complete CSQ and MISS instruments were 0.48 (P < 0.01) and 0.47 (P < 0.01), respectively. Correlations of PEI scores with individual component scores on the CSQ were generally lower and ranged from 0.14 to 0.53; correlations of PEI scored with MISS component scores were also generally lower and ranged from 0.21 to 0.53. Internal consistency of the PEI items (assessed by Cronbach's alpha coefficient) was lowered when items from the CSQ or MISS were added.

CONCLUSIONS

The study shows that 'enablement' is a primary care outcome measure which is related to but is different from general satisfaction.

Oxidation of erythrocyte glutathione by monocytes stimulated with interleukin-6. Analysis by 1H spin echo NMR

1H spin echo NMR was used to follow the release of reactive oxygen species (ROS) from human monocytes by monitoring erythrocyte glutathione status, which is sensitive to applied oxidative stress. This allowed the ability of the cytokine interleukin-6 (IL-6) to stimulate release of ROS from monocytes to be assessed in terms of oxidative damage to other cells, providing an estimation of its importance in vivo. It was found that incubation of monocytes with erythrocytes in the presence of IL-6 resulted in oxidation of the erythrocyte glutathione pool, indicating that oxidants are released in sufficient amounts to cause oxidative stress. High levels of IL-6 occurring in plasma of women with severe pre-eclampsia could therefore be responsible for depleted plasma antioxidants and haemolysis. The oxidation of erythrocyte glutathione was inhibited by the presence of the cyclooxygenase inhibitor indomethacin, suggesting that this may be of value in the treatment of oxidative pathologies.

Altered interleukin 12 and nitric oxide levels in recurrent miscarriage

The causes of recurrent miscarriage are not fully understood. Recent studies have suggested that whilst a TH 2 type immune response may be associated with a healthy pregnancy, miscarriage may be associated with a TH 1 type response. Serum levels of nitric oxide (NO) and Interleukin 12 (IL 12) were measured in; healthy non-pregnant women; healthy pregnant women; women suffering spontaneous abortion; pregnant women with a history of recurrent miscarriage; non-pregnant women with a history of recurrent miscarriage. Normal pregnancy was associated with a significant decrease in serum levels of nitrite (13.0 vs. 22.0 P < 0.0001). In women admitted with spontaneous abortion there was a significant increase in the levels of nitrite (16.0 vs. 13.0 P < 0.05), but no change in IL 12 compared to normal pregnant women. In pregnant women with a history of recurrent miscarriage levels of nitrite (16.0 vs. 13.0 P < 0.05) and IL 12 (10.0 vs. 6.0 P < 0.0006) were significantly elevated compared to normal pregnancy. When these women were sampled prior to becoming pregnant the levels of NO were found to be significantly lower than those in the non-pregnant control group (13.1 vs. 22.0 P < 0.05) although levels of IL 12 were unchanged. No correlation was found between serum nitrite and IL 12 levels. This report further supports the idea that polarisation of the immune response during pregnancy may predispose to recurrent miscarriage.

Bacteriophage infection and multiplication occur in Pseudomonas aeruginosa starved for 5 years

Bacteriophages specific for Pseudomonas aeruginosa and Escherichia coli were examined for their ability to multiply in stationary phase hosts. Four out of five bacteriophages tested, including E. coli bacteriophage T7M, were able to multiply in stationary phase hosts. The bacteriophage ACQ had a mean burst size of approximately 1000 in exponential phase P. aeruginosa hosts and 102 in starved hosts, with corresponding latent periods that increased from 65 to 210 min. The bacteriophage UT1 had a mean burst size of approximately 211 in exponential phase P. aeruginosa hosts and 11 in starved hosts, with latent periods that increased from a mean of 90 min in exponential phase hosts to 165 min in starved hosts. Bacteriophage multiplication occurred whether or not the hosts had entered stationary phase, either because the cultures had been incubated for 24 h or were starved. Significantly, bacteriophage multiplication occurred in P. aeruginosa, which had been starved for periods of 24 h, several weeks, or 5 years. Only one P. aeruginosa virus, BLB, was found to be incapable of multiplication in stationary phase hosts. These results reveal that starvation does not offer bacterial hosts refuge from bacteriophage infection and suggest that bacteriophages will be responsible for significant bacterial mortality in most natural ecosystems.

The changing pattern of eclampsia over a 60-year period

OBJECTIVE

To determine changes in the incidence and pattern of eclampsia within the same geographical area over a 60-year period.

DESIGN

A retrospective, descriptive study of 1259 consecutive women classified, at the time, as having had an eclamptic convulsion between the years 1931 and 1990.

SETTING

A large city centre teaching hospital and the surrounding catchment area.

MAIN OUTCOME MEASURES

The changes in the incidence and timing of the convulsion and the outcomes for the mother and baby.

RESULTS

Over the study period, the incidence of eclampsia fell by more than 90%, from 74.1/10,000 in the 1930s to 7.2/10,000 in the 1980s. Most of the reduction occurred over the first four decades, with little change in the last 20 years. Overall, 44% of the cases of eclampsia occurred in the antenatal period, 33% intrapartum and 23% postpartum. Since the biggest decreases were seen in the incidence of antenatal and particularly intrapartum eclampsia, there has been a relative increase in the proportion of eclampsia occurring postpartum. Maternal death from eclampsia occurred in 15.1% of cases between 1931 and 1940, 13.4% between 1941 and 1950, but fell dramatically to < or = 3.9% after 1950. There has been no maternal death since 1964. Apart from the first decade, postpartum eclampsia was associated with significantly less risk of death to the mother throughout the study period. Perinatal death rate has fallen steadily from 432.6/1000 cases of eclampsia between 1931 and 1940 over the first three decades, to 168.7/1000 between 1961 and 1970. There has been little change since, although a lower proportion of neonatal deaths occurred as stillbirths.

CONCLUSIONS

We found a significant reduction in both the incidence of eclampsia and associated morbidity in this population over the last 60 years. This has occurred in association with the introduction of the National Health Service, widespread antenatal care for all and a general improvement in health and welfare. Any further reduction in the incidence in the UK may be difficult to achieve. Since the incidence of eclampsia is now low, efforts should perhaps be directed at minimising the morbidity associated with severe pre-eclampsia rather than prevention of convulsions.

Evidence for a familial pregnancy-induced hypertension locus in the eNOS-gene region

Pregnancy-induced hypertension may be regarded as a manifestation of endothelial-cell dysfunction. The role of the eNOS gene in the development of a familial pregnancy-induced hypertension was evaluated by analysis of linkage among affected sisters and in multiplex families (n = 50). Markers from a 4-cM region encoding the eNOS gene showed distortion from the expected allele sharing among affected sisters (P = .001-.05), and the statistic obtained from the multilocus application of the affected-pedigree-member method also showed distortion (T[f(P)=sqrt(P)] = 3.53; P < .001). A LOD score of 3.36 was obtained for D7S505 when a best-fitting model derived from genetic epidemiological data was used, and LOD scores of 2.54-4.03 were obtained when various other genetic models were used. Estimates of recombination rate, rather than maximum LOD-score values, were affected by changes in the genetic parameters. The transmission-disequilibrium test, a model-free estimate of linkage, showed strongest association and linkage with a microsatellite within intron 13 of the eNOS gene (P = .005). These results support the localization of a familial pregnancy-induced hypertension-susceptibility locus in the region of chromosome 7q36 encoding the eNOS gene.

Transabdominal cervico-isthmic cerclage in the management of cervical incompetence

The use of transabdominal cervico-isthmic cerclage is described in 13 patients with a diagnosis of cervical incompetence. The patients were recruited from seven Scottish Maternity Units over a period of 10 years. The 13 patients have had a successful pregnancy in 86.6% of pregnancies with this procedure compared with a success rate of 16% in their previous pregnancies. In carefully selected cases transabdominal cervico-isthmic cerclage is a worthwhile procedure in patients with cervical incompetence when the cervix is so damaged that it would be impossible to insert a vaginal suture or when a vaginal suture has previously failed.

Tumour necrosis factor-alpha (TNF-alpha) gene polymorphism and expression in pre-eclampsia

Pre-eclampsia is an endothelial disorder and TNF-alpha has fundamental effects on endothelial cells by several means, including altering the balance between oxidant and anti-oxidant, changing the pattern of prostaglandin production and affecting expression of several cell surface components. To determine whether TNF-alpha mRNA expression is increased in pre-eclamptic patients, leucocytes from pre-eclamptic patients, normal pregnant women and normal non-pregnant women were studied for TNF-alpha expression using a quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) method. Using a model of 373A ABI Sequencer, TNF-alpha gene polymorphism was also analysed by GENESCAN and Genotyper software in order to explain the mechanism of abnormal TNF-alpha expression. Our results show that TNF-alpha mRNA expression is significantly elevated in pre-eclamptic patients compared with the other two control groups. The high expression of TNF-alpha may be associated with the TNF1 allele, whose frequency is markedly increased in pre-eclamptic patients. These observations are consistent with a major role for TNF-alpha in mediating endothelial disturbances, and suggest a key role for TNF-alpha in the development of pre-eclampsia.

Care of the patient with severe pregnancy induced hypertension

Pregnancy induced hypertension remains the largest cause of maternal death in the UK. This is often related to inadequate or incorrect care. Recent randomised studies have enabled evidenced based clinical practice to be directed to the management of this condition. This allows a logical stepwise management structure to be developed in each hospital to make sure all women at risk get the best care available. This starts with comprehensive antenatal care with close collaboration between all professionals involved, early referral to an outpatient daycare unit if hypertension develops or is suspected, early use of antihypertensive therapy to control blood pressure once the diastolic is persistently above 100 mmHg, the use of magnesium sulphate to control convulsions, delivery on the best day in the best way and careful fluid management after delivery. Postnatal care should also contain risk assessment to allow directed counseling to the women concerning subsequent pregnancies.

Management of labour in an isolated rural maternity hospital

OBJECTIVES

To evaluate the use of a maternity unit run by general practitioners and midwives, describing the outcome of labour in an unselected group of women and quantifying the contribution made by general practitioners.

DESIGN

Retrospective population based review of obstetric patients who had access to an isolated rural maternity unit.

SETTING

Rural area 120 km from a consultant maternity unit.

SUBJECTS

997 consecutive women delivered between January 1987 and May 1991.

MAIN OUTCOME MEASURES

Mode of delivery and complications by place of booking and place of delivery; need for medical intervention and transfer.

RESULTS

530 women (53%) were booked for delivery in the rural unit; this group had a caesarean section rate of 3.8% and an unplanned transfer rate of 12.8% to the consultant unit in labour. Of the 462 who delivered in the low risk unit, 25 (5%) required a forceps delivery; postnatal complications requiring emergency medical support occurred in a further 33 (7%).

CONCLUSIONS

Risk characterisation is possible, but medical support from general practitioners and obstetricians is required in almost a third of women at low risk for complications of delivery. Results of this study support the team approach to obstetric management but not the move towards isolated units without organised medical support.

Recurrent miscarriage is associated with increased numbers of CD5/20 positive lymphocytes and an increased incidence of thyroid antibodies

The aim of this study was to determine whether recurrent miscarriage (three or more miscarriages, no live children) was associated with an increased incidence of autoantibodies. Five groups were enrolled into the study; healthy non-pregnant women, healthy first-trimester pregnant women, women suffering spontaneous abortion, those undergoing termination of pregnancy and those with a previous history of miscarriage. The number of total B cells and the numbers of the antibody producing B cell subset CD5+/CD20+ were determined for each group. Samples were tested for anticardiolipin antibodies, antinuclear antibodies and thyroid microsomal and thyroglobulin antibodies. The results showed that compared to normal pregnancy or spontaneous abortion, recurrent miscarriage was associated with a significant increase in the number of CD5+/20+ positive cells (0.8 +/- 0.3 vs 0.5 +/- 0.1 vs 1.1 +/- 0.3 x 10(8)/l; p < 0.001). These women were also found to have a higher incidence of thyroid antibodies, with four out of the 11 patients being positive for thyroid microsomal antibodies. These results suggest that there may be an association between autoimmunity and recurrent miscarriage.