Chromosomal Aneuploidy Associated With Clinical Characteristics of Pregnancy Loss

Objective

Embryonic aneuploidy is found in about half of sporadic pregnancy losses and the associations between the chromosomal aneuploidy and clinical characteristics of pregnancy loss remain unclear. The aims of this study were to evaluate the associations between chromosomal aneuploidy of products of conception (POC) and clinical features of pregnancy loss.

Methods

We conducted a retrospective cohort study including 1,102 women experienced singleton pregnancy loss and underwent chromosomal microarray analysis (CMA) detection of POC in our hospital. The results of molecular karyotypes and clinical features including maternal age, history of pregnancy loss, gestational age, vaginal bleeding and ultrasonographic findings were extracted from the medical records. χ² test was used to compare categorical data between groups.

Results

631 (57.26%) POC specimens were detected to be chromosomal aneuploidy. Aneuploid rates were significantly higher in women >35 years (P < 0.001) and pregnancy loss <11 gestational weeks (P = 0.044), but the rates of sex chromosome abnormalities and triploid were significantly higher in women ≤35 years (P < 0.001, P = 0.002) and the rates of viable autosomal trisomy and sex chromosome abnormalities were significantly high in those women with pregnancy loss ≥11 weeks (P < 0.001, P < 0.001). Aneuploid rate was overall similar between the sporadic and the recurrent pregnancy loss (RPL) (P = 0.404), but the rate of sex chromosome abnormalities was higher in women with sporadic pregnancy loss (P = 0.03). Aneuploid rates were higher in subjects with yolk sac or embryo than in those without (P < 0.001 and P = 0.001).

Conclusion

Advanced maternal age is mainly associated with autosomal trisomy, while sex chromosome abnormalities and triploid might be more likely to occur in younger women. Aneuploidy rates might be no association with previous pregnancy loss except for sex chromosome abnormalities. Pregnancy loss without yolk sac or embryo might be less related to embryonic aneuploidy, and other factors should be emphasized.

Practical Aspects of Twin Pregnancy Diagnosis in Cattle

Simple Summary

This review summarizes the clinical background, possibilities, and limitations of twin pregnancy diagnosis in cattle, with a special emphasis on pregnancy loss aspects. Due to the fact that reproductive performance is strongly affected by twin pregnancy, clinical veterinarians should become familiar with the correct diagnosis of this phenomenon. Thus, each herd must plan a herd-specific management practice to detect twin pregnancies. A highly accurate diagnostic tool is required to detect such pregnancies, already during the first month of gestation. This commentary review focuses on the diagnostic possibilities and limitations on the field.

Abstract

Twin pregnancies are an economically unwanted phenomenon in dairy cattle, not only because they increase pregnancy losses, but also because antibiotics usage and culling rate of the dam are also dramatically increased due to them, furthermore animal welfare issues are also affected through them. In cattle, under field conditions using an early pregnancy determination tool, the first accurate diagnosis from the pregnancy status is available from around day 28, although further confirmations of pregnancy are required. Twin pregnancy diagnosis is available either by rectal palpation or ultrasonography. The measurement of pregnancy specific proteins are also available to determine gestation, but there is still a long way to go to properly identify twin pregnancies. In this commentary, we compared our own results with the literature data in this field with a special emphasis on the clinical practices.

Coronavirus disease 2019 and first-trimester spontaneous abortion: a case-control study of 225 pregnant patients

Background

The disease caused by the severe acute respiratory syndrome coronavirus 2 was named coronavirus disease 2019 and classified as a global public health emergency. The evidence related to the impact of coronavirus disease 2019 on pregnancy is limited to the second and third trimester of pregnancy, whereas data on the first trimester are scant. Many viral infections can be harmful to the fetus during the first trimester of pregnancy, and whether severe acute respiratory syndrome coronavirus 2 is one of them is still unknown.

Objective

With this study, we evaluated severe acute respiratory syndrome coronavirus 2 infection as a risk factor for early pregnancy loss in the first trimester of pregnancy. Furthermore, coronavirus disease 2019 course in the first trimester was assessed.

Study Design

Between February 22 and May 21, 2020, we conducted a case-control study at S. Anna Hospital, Turin, among pregnant women in their first trimester, paired for last menstruation. The cumulative incidence of coronavirus disease 2019 was compared between women with spontaneous abortion (case group, n=100) and those with ongoing pregnancy (control group, n=125). Current or past infection was determined by the detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swab and severe acute respiratory syndrome coronavirus 2 immunoglobulin G and immunoglobulin M antibodies in a blood sample. Patient demographics, coronavirus disease 2019–related symptoms, and the main risk factors for abortion were collected.

Results

Of 225 women, 23 (10.2%) had a positive test result for coronavirus disease 2019. There was no difference in the cumulative incidence of coronavirus disease 2019 between the cases (11/100, 11%) and the controls (12/125, 9.6%) (P=.73). Logistic regression analysis confirmed that coronavirus disease 2019 was not an independent predictor of early pregnancy loss (odds ratio, 1.28; confidence interval, 0.53–3.08). Coronavirus disease 2019–related symptoms in the first trimester were fever, anosmia, ageusia, cough, arthralgia, and diarrhea; no cases of pneumonia or hospital admission owing to coronavirus disease 2019–related symptoms were recorded. No difference in the incidence of symptoms was noted between the 2 groups.

Conclusion

Severe acute respiratory syndrome coronavirus 2 infection during the first trimester of pregnancy does not seem to predispose to early pregnancy loss; its cumulative incidence did not differ between women with spontaneous abortion and women with ongoing pregnancy. Coronavirus disease 2019 appears to have a favorable maternal course at the beginning of pregnancy, consistent with what has been observed during the second and third trimesters.

Is opioid use safe in women trying to conceive?

Background

Opioids are commonly prescribed to women of reproductive age, including after delivery and miscarriage. However, to our knowledge, opioid use has not been frequently studied in relation to the common reproductive complications of impaired fecundability and pregnancy. We examined the association of opioid use during the critical window of pregnancy establishment with fecundability and pregnancy loss.

Methods

We measured opioid use by urine screening and self-report at multiple time points during preconception and early pregnancy in a prospective cohort of women attempting conception (n=1228). The main outcomes included time to hCG-detected pregnancy and incidence of live birth and pregnancy loss. We estimated fecundability odds ratios (FOR) and risk ratios (RR) with 95% confidence intervals (CI) adjusting for sociodemographic characteristics, reproductive characteristics, and use of antidepressants, tobacco, alcohol, and marijuana.

Results

Prevalence of preconception opioid use was 18% (n=226 of 1228), and in early pregnancy was 5% (n=33 of 685). Opioid use while attempting pregnancy was associated with reduced fecundability (FOR: 0.71; 95% CI: 0.50, 1.0). Risk of pregnancy loss increased as opioid exposure was detected later in gestation, from the beginning of the cycle of conception (RR: 1.5; 95% CI 0.85, 2.6), to week 4 of pregnancy (RR: 2.1; 95% CI: 1.1, 4.1), and to week 4 and 8 of pregnancy (RR: 2.5; 95% CI: 1.3, 5.0).

Conclusions

Our results are consistent with the hypothesis that opioid exposure while trying to conceive may be harmful, even among healthy, non-opioid-dependent women. Possible risks to fecundability and pregnancy viability are relevant to patients and providers when evaluating pain management approaches.ClinicalTrials.gov registration number: #NCT00467363.

Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study

Pregnancy loss, natural or induced, is linked to higher rates of mental health problems, but little is known about its effects during the postpartum period. This study identifies the percentages of women receiving at least one postpartum psychiatric treatment (PPT), defined as any psychiatric treatment (ICD-9 290-316) within six months of their first live birth, relative to their history of pregnancy loss, history of prior mental health treatments, age, and race. The population consists of young women eligible for Medicaid in states that covered all reproductive services between 1999-2012. Of 1,939,078 Medicaid beneficiaries with a first live birth, 207,654 (10.7%) experienced at least one PPT, and 216,828 (11.2%) had at least one prior pregnancy loss. A history of prior mental health treatments (MHTs) was the strongest predictor of PPT, but a history of pregnancy loss is also another important risk factor. Overall, women with a prior pregnancy loss were 35% more likely to require a PPT. When the interactions of prior mental health and prior pregnancy loss are examined in greater detail, important effects of these combinations were revealed. About 58% of those whose first MHT was after a pregnancy loss required PPT. In addition, over 99% of women with a history of MHT one year prior to their first pregnancy loss required PPT after their first live births. These findings reveal that pregnancy loss (natural or induced) is a risk factor for PPT, and that the timing of events and the time span for considering prior mental health in research on pregnancy loss can significantly change observed effects. Clinicians should screen for a convergence of a history of MHT and prior pregnancy loss when evaluating pregnant women, in order to make appropriate referrals for counseling.

Characterization of pregnancy-associated glycoproteins and progesterone as a predictor of twins and conceptus loss in high-risk-pregnancy Holstein cows

The objective of this study was to characterize plasma concentrations of pregnancy-associated glycoprotein (PAG) and progesterone (P4) as predictors of twins and pregnancy loss in Holstein cows with high-risk pregnancies. High-risk pregnancy was characterized using transrectal ultrasonography 37 d after artificial insemination (AI) based on the following criteria: small embryo size <15 mm, n = 10), slow heartbeat (<60 beats per minute, n = 11), and extra-amniotic membrane (additional amniotic membrane, n = 3). A cohort of twins (n = 41) diagnosed at d 37 post-AI was also enrolled. Each high-risk and twin pregnancy cow was paired with a cow of the same parity carrying a normal singleton at d 37 post-AI (control, n = 65). Blood samples were collected to measure PAG and P4 at d 37, 44, and 51 post-AI. Statistical analysis was performed using ANOVA, logistic regression, and receiver operator characteristic (ROC) curve with JMP software (SAS Institute Inc., Cary, NC). Pregnancy loss at d 51 post-AI was greater in high-risk pregnancies than in controls and twins (control = 1.5%; high-risk = 87.5%; twins = 12.2%). Concentration of PAG at d 37 post-AI did not differ among groups (control = 5.3 ± 0.7; high-risk = 4.8 ± 1.2; twins = 4.0 ± 0.9 ng/mL). Concentration of P4 at d 37 post-AI was greater in twins than in high-risk pregnancies and control, and lesser in high-risk pregnancies than in controls (control = 7.0 ± 0.3; high-risk = 5.9 ± 0.4; twins = 8.4 ± 0.3 ng/mL). Regression and ROC analysis for PAG at d 37 post-AI did not find a threshold to predict pregnancy loss or twins. Regression and ROC analysis for P4 at d 37 post-AI found that a threshold of 6.5 ng/mL predicted pregnancy loss with an area under the curve (AUC) of 0.64, and a threshold of 7.2 ng/mL predicted twins with AUC of 0.71. In summary, pregnancy loss and twins were predicted with only moderate accuracy by P4 concentration at d 37 post-AI, and the variability in PAG concentrations at d 37 post-AI was not sufficient to generate a threshold to predict pregnancy loss and twins in Holstein lactating cows.

Association between preconception paternal health and pregnancy loss in the USA: an analysis of US claims data

STUDY QUESTION

Is preconception paternal health associated with pregnancy loss?

SUMMARY ANSWER

Poor preconception paternal health is associated with a higher risk of pregnancy loss as confirmed in sensitivity analyses accounting for maternal age and health.

WHAT IS KNOWN ALREADY

Preconception paternal health can negatively impact perinatal outcomes.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of US insurance claims database from 2009 to 2016 covering 958 804 pregnancies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

US insurance claims database including women, men and pregnancies within the USA between 2007 and 2016. Paternal preconception health status (e.g. metabolic syndrome diagnoses (MetS), Charlson comorbidity index (CCI) and individual chronic disease diagnoses) was examined in relation to pregnancy loss (e.g. ectopic pregnancy, miscarriage and stillbirth).

MAIN RESULTS AND THE ROLE OF CHANCE

In all, 958 804 pregnancies were analyzed. The average paternal age was 35.3 years (SD 5.3) and maternal age was 33.1 years (SD 4.4). Twenty-two percent of all pregnancies ended in a loss. After adjusting for maternal factors, the risk of pregnancy loss increased with increasing paternal comorbidity. For example, compared to men with no components of MetS, the risk of pregnancy loss increased for men with one (relative risk (RR) 1.10, 95% CI 1.09-1.12), two (RR 1.15, 95% CI 1.13-1.17) or three or more (RR 1.19, 95% CI 1.14-1.24) components. Specifically, less healthy men had a higher risk of siring a pregnancy ending in spontaneous abortion, stillbirth and ectopic pregnancies. Similar patterns remained with other measures of paternal health (e.g. CCI, chronic diseases, etc.). When stratifying by maternal age as well as maternal health, a similar pattern of increasing pregnancy loss risk for men with 1, 2 or 3+ MetS was observed. A statistically significant but weak association between timing of pregnancy loss and paternal health was found.

LIMITATIONS, REASONS FOR CAUTION

Retrospective study design covering only employer insured individuals may limit generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

Optimization of a father's health may improve pregnancy outcomes.

STUDY FUNDING/COMPETING INTERESTS

National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1 TR001085). M.L.E. is an advisor for Sandstone Diagnostics, Dadi, Hannah and Underdog. No other competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Maternal health and pregnancy outcome in diagnosed and undiagnosed Marfan syndrome: A registry-based study

In Marfan syndrome (MFS), pregnancy is considered as high risk due to the deficiency of fibrillin in the connective tissue and increased risk of aortic dissection. The objective was to demonstrate the consequences on maternal health, in women with diagnosed and undiagnosed MFS at the time of pregnancy and childbirth. By using national health care registries, we identified all pregnancy related outcomes, from women with MFS (n = 183) and an age-matched background population (n = 18,300). We found 91 pregnancies during follow-up. Significantly fewer women with MFS gave birth, compared to the background population. No women with known MFS had a pregnancy related aortic dissection but complications related to the cervix were increased (HR:19.8 [95% CI:2.2-177.5]). Fifty women with MFS were undiagnosed at the time of their first pregnancy and/or childbirth. Among these, there were more birth canal related complications HR:27.2 (95% CI: 2.3-315.0), preeclampsia (HR:2.25 [95% CI: 1.11-4.60]), fetal deaths (HR:12.3 [95% CI: 1.51-99.8]), and all delivery-related dissections came from this subgroup. In conclusion, undiagnosed women with MFS experienced more pregnancy and childbirth related complications including fetal death, birth canal issues, preeclampsia, and aortic disease, which emphasizes the need for an early MFS diagnosis and special care during pregnancy and childbirth.

Mid-trimester miscarriage and subsequent pregnancy outcomes: the role of cervical insufficiency in a cohort of 175 cases

OBJECTIVE

To evaluate the causes of MTM and their impact on subsequent pregnancies.

MATERIAL AND METHODS

A retrospective single-center cohort study of all pregnancies with a second-trimester pregnancy loss between 14 weeks and 21 weeks + 6 days gestation, excluding terminations of pregnancy (TOP) and in utero fetal deaths. Predefined criteria were used to allocate cases to one of 6 primary etiologic diagnoses: cervical insufficiency, chorioamnionitis, placental anomalies, fetal anomalies, iatrogenic causes, or abdominal trauma.

RESULTS

Among 578 mid-trimester fetal losses, 175 were MTM, a prevalence of 5.7 per 1000 live births in the center. The suspected primary cause was cervical insufficiency in 76 cases (43.4%), chorioamnionitis in 59 (33.7%), placental anomalies or preterm premature rupture of membranes in 26 (14.8%), iatrogenic in 8 (4.6%), trauma in 3 (1.7%), and undetermined in 3 cases (1.7%). A subsequent pregnancy beyond 14 WG was recorded for 78 patients. Recurrent MTM occurred in 21.8% and preterm deliveries in 14.1% ; 13% of patients without evidence of cervical insufficiency in the index pregnancy required emergency cerclage.

CONCLUSION

Cervical insufficiency was the leading cause of MTM, with a high risk of recurrent MTM or preterm birth, thus prophylactic cerclage or cervical length measurements should be considered for subsequent pregnancies.

Transcriptomics-determined chemokine-cytokine pathway presents a common pathogenic mechanism in pregnancy loss and spontaneous preterm birth

PROBLEM

Various etiological factors, such as infection and inflammation, may induce the adverse outcomes of pregnancy of miscarriage, stillbirth, or preterm birth. The pathogenic mechanisms associated with these adverse pregnancies are yet unclear. We hypothesized that a common pathogenic mechanism may underlie variant adverse outcomes of pregnancy, which are induced by genetic-environmental factors. The specific objective of the current study is to uncover the common molecular mechanism(s) by identifying the specific transcripts that are present in variant subtypes of pregnancy loss and preterm birth.

METHOD OF STUDY

Transcriptomic profiling was performed with RNA expression microarray or RNA sequencing of placentas derived from pregnancy loss (which includes spontaneous miscarriage, recurrent miscarriage, and stillbirth) and spontaneous preterm birth, followed by bioinformatic analysis of multi-omic integration to identify pathogenic molecules and pathways involved in pathological pregnancies.

RESULTS

The enrichment of common differentially expressed genes between full-term birth and preterm birth and pregnancy loss of miscarriage and stillbirth revealed different pathophysiological pathway(s), including cytokine signaling dysregulated in spontaneous preterm birth, defense response, graft-versus-host disease, antigen processing and presentation, and T help cell differentiation in spontaneous miscarriage. Thirty-three genes shared between spontaneous preterm birth and spontaneous miscarriage were engaged in pathways of interferon gamma-mediated signaling and of antigen processing and presentation. For spontaneous miscarriage, immune response was enriched in the fetal tissue of chorionic villi and in the maternal facet of the placental sac. The transcript of nerve growth factor receptor was identified as the common molecule that is differentially expressed in all adverse pregnancies: spontaneous preterm birth, stillbirth, spontaneous miscarriage, and recurrent miscarriage. Superoxide dismutase 2 was up-regulated in all adverse outcomes of pregnancy except for recurrent miscarriage. Cytokine-cytokine receptor interaction was the common pathway in spontaneous preterm birth and spontaneous miscarriage. Defense response was enriched in the fetal tissue of miscarriage and in the maternal tissue in spontaneous miscarriage.

CONCLUSIONS

Our results indicated that the chemokine-cytokine pathway may play important roles in and function as a common pathogenic mechanism associated with, the different adverse outcomes of pregnancy, which demonstrated that differentially expressed transcripts could result from a common pathogenic mechanism associated with pregnancy loss and spontaneous preterm birth, although individual pregnancy outcomes may differ from each other phenotypically.

Vasomotor tone-associated factors and pregnancy outcomes of women who undergo in vitro fertilization

Vasomotor tone-associated factors play important roles in normal pregnancy, but their roles in the pregnancy outcome of women who undergo in vitro fertilization and embryo transfer (IVF-ET) remain unclear. A total of 82 infertile women who underwent successful IVF-ET were enrolled, including 18 pregnancy losses, 11 complications, and 53 normal deliveries. The serum NO and iNOS levels were significantly higher in the pregnancy loss group and significantly lower in the complication group than in the normal delivery group (p < 0.05). Significantly increased ET-1 and decreased PGI2 were found in both the pregnancy loss and complication groups compared with those in the normal delivery group (p < 0.05). NO, iNOS, and ET-1 are risk factors and PGI2 is a protective factor for pregnancy loss. ET-1 + PGI2 (AUC, 0.897; sensitivity, 90.6%; specificity, 83.3%) showed a relatively good predictive value for pregnancy loss following IVF-ET.

Effect of types of breeding on embryo survival following first AI in lactating Holstein cows

The main objective was to investigate the effects of timed-AI protocols versus AI following oestrus detection on circulating progesterone (P4) and embryo survival after first service in Holstein cows. Cycling status was determined by ultrasonography and by plasma P4 concentrations 14 and 26 days after calving, and only cows with a corpus luteum and/or P4 ≥ 1 ng/ml were used. Cows were randomly allocated to one of three types of breeding: DO (n = 80), received GnRH-7d-PGF2α-3d-GnRH and Ovsynch56 was initiated 7 days later; G7G (n = 70), received PGF2α-2d-GnRH and Ovsynch56 (GnRH-7d-PGF2α-56h-GnRH-16h-AI) was initiated 7 days later; or AI based on oestrus detection, EDAI (n = 60). Progesterone was also determined at AI and 8, 16, 18 and 20 days after AI; ISG15 and MX2 mRNA abundance were determined 16 days after AI. Mean plasma P4 at AI was greater in the EDAI group compared with DO and G7G groups, while after AI, P4 was greater in DO and G7G groups compared with EDAI group. However, the percentage of cows with a concentration of P4 < 0.8 ng/ml at AI did not differ among groups. Relative mRNA abundance of ISG15 and MX2 was greater in the DO and G7G groups compared to those in EDAI group. Pregnancy per AI 16, 32 and 60 days after AI was greater (p < .05) in cows in the DO group compared with those in EDAI group (47.5%, 38.8% and 36.3% vs. 30.0%, 21.7% and 15.0%). Pregnancy losses between 16 and 60 days after AI were greater (p < .05) in cows in the EDAI (50.0%) group compared to those subjected to DO (23.7%) or G7G (24.1%). In conclusion, the use of timed-AI synchronization protocols resulted in greater circulating P4 concentrations post-AI and greater embryo survival following first service in lactating Holstein cows.

SARS-CoV-2 in first trimester pregnancy: a cohort study

Study question

Does maternal infection with SARS-CoV-2 in first trimester pregnancy have an impact on the fetal development as measured by nuchal translucency thickness and pregnancy loss?

Summary answer

Nuchal translucency thickness at the first trimester scan was not significantly different in pregnant women with versus without SARS-CoV-2 infection in early pregnancy and there was no significant increased risk of pregnancy loss in women with SARS-CoV-2 infection in the first trimester.

What is known already

Pregnant women are more vulnerable to viral infections. Previous coronavirus epidemics have been associated with increased maternal morbidity, mortality and adverse obstetric outcomes. Currently, no evidence exists regarding possible effects of SARS-CoV-2 in first trimester pregnancies.

Study design, size, duration

Cohort study of 1,019 women with a double test taken between Feb. 17 and Apr. 23, 2020, as a part of the combined first trimester risk assessment, and 36 women with a first trimester pregnancy loss between Apr. 14 and May 21, 2020, prior to the double test. The study period was during the first SARS-CoV-2 epidemic wave in Denmark.

Participants/materials, setting, methods

Cohort 1 included pregnant women with a double test taken within the study period. The excess serum from each double test was analyzed for SARS-CoV-2 antibodies. Results were correlated to the nuchal translucency thickness and the number of pregnancy losses before or at the time of the first trimester scan. Cohort 2 included women with a pregnancy loss before the gestational age for double test sample. Serum from a blood test taken the day the pregnancy loss was identified was analyzed for SARS-CoV-2 antibodies. The study was conducted at a public university hospital serving approximately 12% of pregnant women and births in Denmark. All participants in the study provided written informed consent.

Main results and the role of chance

Eighteen (1.8%) women had SARS-CoV-2 antibodies in the serum from the double test suggestive of SARS-CoV-2 infection in early pregnancy. There was no significant difference in nuchal translucency thickness for women testing positive for previous SARS-CoV-2 infection (n = 18) versus negative (n = 994) (p = 0.62). There was no significant increased risk of pregnancy loss for women with positive antibodies (n = 1) (OR 3.4, 0.08-24.3 95% CI, p = 0.27). None of the women had been hospitalized due to SARS-CoV-2 infection. None of the women with pregnancy loss prior to the double test (Cohort 2) had SARS-CoV-2 antibodies.

Limitations, reasons for caution

These results may only apply to similar populations and to patients who do not require hospitalization due to SARS-CoV-2 infection. A limitation of the study is that only 1.8% of the study population had SARS-CoV-2 antibodies suggestive of previous infection.

Wider implication of the findings

Maternal SARS-CoV-2 infection had no effect on the nuchal translucency thickness and there was no significant increased risk of pregnancy loss for women with SARS-CoV-2 infection in first trimester pregnancy. Evidence concerning Covid-19 in pregnancy is still limited. These data indicate that infection with SARS-CoV-2 in not hospitalized women does not pose a significant threat in first trimester pregnancies. Follow up studies are needed to establish any risk to a fetus exposed to maternal SARS-CoV-2 infection.

Study funding/competing interest(s)

Prof. Henriette Svarre Nielsen (HSN) and colleagues received a grant from the Danish Government for research of Covid-19 among pregnant women. The Danish government was not involved in the study design, data collection, analysis, interpretation of data, writing of the report or decision to submit the paper for publication. AI, JOL, JBR, DMS, JEF, and ERH received funding from a Novo Nordisk Foundation (NNF) Young Investigator Grant (NNF15OC0016662) and a Danish National Science Foundation Center Grant (6110-00344B). AI received a Novo Scholarship. JOL is funded by an NNF Pregraduate Fellowship (NNF19OC0058982). DW is funded by the NNF (NNF18SA0034956, NNF14CC0001, NNF17OC0027594). AMK is funded by a grant from the Rigshospitalet’s research fund. Henriette Svarre Nielsen has received speakeŕs fees from Ferring Pharmaceuticals, Merck Denmark A/S and Ibsa Nordic (outside the submitted work). Nina la Cour Freiesleben has received a grant from Gedeon Richter (outside the submitted work). Astrid Marie Kolte has received speakeŕs from Merck (outside the submitted work). The other authors did not report any potential conflicts of interest.

Benefits and Risks of Preventing Twin Pregnancies

Clinical problems associated with twin pregnancies have been well established, and twin births are now considered undesirable or even disastrous for the dairy cattle industry and the individual cow. The high incidence of early fetal loss, abortion during the mid-lactation period, dystocia, stillbirth, and placenta retention should be considered a preventable consequence of management, as these disorders greatly compromise the welfare and productive lifespan of a cow carrying or delivering twins. The use of sexed semen generates herd replacements and additional heifers, so a proposed strategy for twin pregnancy prevention is the transfer of a single in vitro-produced female beef cow embryo to cows not suitable for producing replacements. Another proposed strategy is drainage at insemination of co-dominant follicles to prevent twin pregnancies in cows with genetic merit. As a result, embryo survival should improve, economic losses associated with twin pregnancies will be prevented, beef output from the herd will be increased, and the health and welfare of the cow will certainly benefit. In this review, the clinical prospects of preventing or avoiding twin pregnancies using both procedures are discussed.

Risk factors associated with adverse pregnancy outcomes in patients with new-onset systemic lupus erythematosus during pregnancy

OBJECTIVE

To investigate the risk factors for Adverse pregnancy outcome (APOs) in patients with new-onset SLE during pregnancy.

METHODS

Eighty-five patients with new-onset SLE during pregnancy were analyzed retrospectively. Univariate and multivariate logistic regression were used to identify risk factors for different APOs (pregnancy loss, preterm birth, fetal growth restriction, and eclampsia/preeclampsia). A two-sided p-value below 0.05 was considered significant, and two-sided 95% confidence intervals (CIs) are reported.

RESULTS

Multivariate analysis indicated that renal involvement (aOR: 7.356; 95%CI:1.516,35.692) and greater SLE disease activity index (SLEDAI) grade (aOR:5.947;95%CI: 1.586,22.294) increased the risk for composite APO, and that use of heparin therapy (aOR: 0.081; 95%CI: 0.012, 0.532) was a protective factor. Advanced gestational age at disease onset (aOR: 0.879; 95%CI: 0.819,0.943) and high serum albumin level (aOR: 0.908,95%CI: 0.831,0.992) protected against pregnancy loss. Renal involvement increased the risk for preterm birth (aOR: 2.272; 95%CI: 1.030,7.222) and fetal growth restriction (aOR: 9.070; 95%CI: 1.131,72.743). Hypertension (aOR: 19.185; 95%CI: 3.921,93.868), renal involvement (aOR: 8.380, 95%CI: 1.944,74.376) increased the risk for eclampsia/preeclampsia.

CONCLUSION

New onset SLE during pregnancy increased the risk for multiple APOs. Timely management of the risk factors identified here may help to improve pregnancy outcomes in these patients.

Evaluation of embryo aneuploidy (PGT-A) and endometrial receptivity (ERA) testing in patients with recurrent implantation failure in ICSI cycles

OBJECTIVE

The objective of a study was to assess the ability of the pre-implantation genetic testing of embryos for aneuploidy (PGT-A) and Endometrial receptivity array (ERA)-alone or in combination to improve the clinical outcomes in intracytoplasmic sperm injection (ICSI) cycles in patients with repeated implantation failure (RIF).

METHODS

This was a retrospective study of the 253 cycles with a history of the previous RIF. They were divided into four groups: Group I - frozen embryo transfers without any additional tests or procedures (pure FET), n = 72 cycles; Group II - FET with PGT-A, n = 87; Group III - FET with PGT-A and ERA, n = 72; Group IV - FET with ERA, n = 22.

RESULTS

Median age of the entire study group for the females was 35 years. Only Group II (FET + PGT-A) showed statistically significant higher chance in achieving both biochemical (p = .01, OR = 5.5) and clinical pregnancy (p =.049, OR = 2.3), as compared to the Group I (FET with no additional tests). Both Group III and Group IV failed to demonstrate better clinical outcomes as compared to the Group I.

CONCLUSIONS

Patients with RIF can benefit from testing for embryo aneuploidy using the PGT-A method, but the ability of the ERA test to improve the clinical outcome in ICSI cycles seems to be rather limited. Although the endometrium cycle is also weakened with age, the contribution of the embryo genetic quality is evidently more important for successful implantation, although in principle both factors reflect the reproductive health.

Risk Factors for Different Types of Pregnancy Losses: Analysis of 15,210 Pregnancies After Embryo Transfer

OBJECTIVE

To evaluate the risk factors for different types of pregnancy losses after embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine center.

PARTICIPANTS

A total of 15,210 pregnancies after fresh and frozen-thawed embryo transfer between January 2014 and June 2019.

MAIN OUTCOME MEASURES

The primary outcome was pregnancy loss (PL) throughout the entire pregnancy. Secondary outcomes were non-visualized PL, early miscarriage, late miscarriage, and stillbirth.

METHODS

The effect of patients' baseline characteristics and IVF/ICSI cycle-specific factors on the risk of PL after fresh and frozen-thawed ET was determined by multivariate logistic regression analysis.

RESULTS

Compared to women under 35 years old, those between 35 and 40 had an increased risk of early miscarriage [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.22-1.83], while those after 40 appeared to have an increased risk of both early miscarriage (OR 3.82, 95% CI 2.65-5.51) and late miscarriage (OR 2.79, 95% CI 1.64-4.77). Overweight patients were observed to have a higher risk of late miscarriage (OR 1.38, 95% CI 1.16-1.65), while obese patients showed a higher risk of both early miscarriage (OR 1.47, 95% CI 1.14-1.91) and late miscarriage (OR 1.80, 95% CI 1.33-2.44). Polycystic ovary syndrome (PCOS) was an independent risk factor for late miscarriage (OR 1.58, 95% CI 1.28-1.96), and the detrimental effect of PCOS was independent of obesity status. Women with uterine factors had a higher risk of early miscarriage (OR 1.77 (95% CI 1.32-2.38) than women without uterine factors. A negative correlation was observed between the thickness of the endometrium and PL (OR 0.95 95% CI 0.92-0.97). There was an increased risk of PL after frozen-thawed ET versus fresh ET (OR 1.12, 95% CI 1.01-1.24). Women who transferred ≥2 embryos showed lower risk of overall PL than women who transferred a single embryo, with adjusted ORs ranged from 0.57~0.94. However, women who transferred three embryos demonstrated a higher risk of late miscarriage than women who transferred a single embryo (OR 2.23, 95% CI 1.36-3.66).

CONCLUSIONS

Patients with uterine factors demonstrated higher risk of early miscarriage and stillbirth. Being overweight, PCOS, and transferring three embryos was associated with late miscarriage. Being aged 40 and over, obese, and using frozen embryo transfer was associated with early and late miscarriage.

Effective Communication Following Pregnancy Loss: A Study in England

Each year in the UK there are approximately 250,000 miscarriages, 3,000 stillbirths and 3,000 terminations following a diagnosis of fetal-abnormality. This paper draws from original empirical research into the experience of pregnancy loss and the accompanying decisionmaking processes. A key finding is that there is considerable variation across England in the range of options that are offered for disposal of pregnancy remains and the ways in which information around disposal are communicated. This analysis seeks to outline the key features of what constitutes effective communication in this context, where effective communication is taken to mean that patients are provided with the key information necessary, in an appropriate manner, so that they are fully able to make a decision. A primary source of evidence includes interviews with the bereaved and pregnancy-loss support workers, in order to understand how the options available, and associated necessary procedures, are communicated. In addition, patient information leaflets are also analyzed as they offer an important tool for information delivery at a difficult and emotionally charged time. Following this, an overview is provided of the information that these leaflets should contain, along with guidance on effective presentation of this information.

Risk of foetal harm with letrozole use in fertility treatment: a systematic review and meta-analysis

BACKGROUND

The aromatase inhibitor letrozole is increasingly recommended for ovulation induction, as it is more effective with fewer side-effects than other agents. But many clinicians are reluctant to use the drug for fertility treatment due to a strong-label warning against its use, which warns about congenital malformation risk to the foetus in women seeking pregnancy.

OBJECTIVE AND RATIONALE

The aim of this study was to determine the risks of congenital malformations and pregnancy loss with letrozole compared with clomiphene primarily, and with other fertility drugs and natural conception.

SEARCH METHODS

A systematic review and meta-analysis using PRISMA harms guidelines. We searched MEDLINE, EMBASE and other sources from inception until January 2020, with the MeSH words for 'letrozole' and pregnancy OR foetal/neonatal outcome. We included studies reported on congenital malformations in foetuses born to mothers conceived after fertility treatment, with letrozole versus clomiphene, placebo, gonadotrophins, metformin, natural conception or other agents, from randomised trials, comparative cohort studies and non-comparative observational cohorts. Quality of the studies was assessed using Cochrane risk of bias tool and Newcastle Ottawa Scale. The McMaster tool was used to assess the quality of reported harm for foetal congenital malformations in the studies. We compared the absolute risk of events using risk difference measures and pooled the findings using a fixed-effect model. We evaluated the statistical heterogeneity using forest plots and the I2 statistic and funnel plot to assess publication bias. We assessed the strength of evidence for congenital malformation and pregnancy loss as per the GRADE recommendations and with the Fragility index.

OUTCOMES

We included 46 studies (18 randomised trials; 21 comparative cohorts; 7 non-comparative cohorts). Overall 2.15% (101/4697; 95% CI 1.7 to 2.5) of babies conceived on letrozole for fertility treatment had congenital foetal malformations. We did not observe a significant increase in congenital malformations with letrozole versus clomiphene in the randomised trials (risk difference (RD) 0.01, 95% CI -0.02, 0.03; I2 = 0%; 14 studies) and found a significant reduction in the cohort studies (RD -0.02, 95% CI -0.04, -0.01; I2 = 0%, 11 studies). The fragility index was 44% (7/16) (either an increase in the intervention arm or a decrease in control arm was needed to alter the results). The risks of pregnancy loss were not increased with letrozole versus clomiphene in the 14 randomised trials (RD -0.01, 95% CI -0.06, 0.04; I2 = 0%), and the risks were reduced in the six cohort studies (RD -0.09, 95% CI -0.17, -0.00; I2 = 68%). The GRADE quality of evidence was low to moderate for congenital malformations and pregnancy loss. We did not find any increased congenital malformation risk with letrozole versus gonadotrophins, natural conception or natural cycle ART, but the number of studies was small.

WIDER IMPLICATIONS

There is no evidence that letrozole increases the risk of congenital foetal malformation or pregnancy loss compared with clomiphene, natural conception or other fertility agents, to warrant warning against its use. Given its therapeutic benefits and lack of evidence of harm to the foetus, clinicians should consider letrozole as first-line agent for ovulation induction.

Genetic parameters for reproductive losses estimated from in-line milk progesterone profiles in Swedish dairy cattle

This study assessed the extent of reproductive losses and associated genetic parameters in dairy cattle, using in-line milk progesterone records for 14 Swedish herds collected by DeLaval's Herd Navigator. A total of 330,071 progesterone samples were linked to 10,219 inseminations (AI) from 5,238 lactations in 1,457 Swedish Red and 1,847 Swedish Holstein cows. Pregnancy loss traits were defined as early embryonic loss (1-24 d after AI), late embryonic loss (25-41 d after AI), fetal loss (42 d after AI until calving), and total pregnancy loss (from d 1 after AI until calving). The following classical fertility traits were also analyzed: interval from calving to first service, interval from calving to last service, interval between first and last service, calving interval, and number of inseminations per service period. Least squares means with standard error (LSM ± SE), heritabilities, and genetic correlations were estimated in a mixed linear model. Fixed effects included breed, parity (1, 2, ≥3), estrus cycle number when the AI took place, and a linear regression on 305-d milk yield. Herd by year and season of AI, cow, and permanent environmental effect were considered random effects. Extensive (approximately 45%) early embryonic loss was found, but with no difference between the breeds. Swedish Red was superior to Swedish Holstein in the remaining pregnancy loss traits with, respectively: late embryonic loss of 6.1 ± 1.2% compared with 13.3 ± 1.1%, fetal loss of 7.0 ± 1.2% compared with 12.3 ± 1.2%, and total pregnancy loss of 54.4 ± 1.4% compared with 60.6 ± 1.4%. Swedish Red also had shorter calving to first service and calving to last service than Swedish Holstein. Estimated heritability was 0.03, 0.06, and 0.02 for early embryonic, late embryonic, and total pregnancy loss, respectively. Milk yield was moderately genetically correlated with both early and late embryonic loss (0.52 and 0.39, respectively). The pregnancy loss traits were also correlated with several classical fertility traits (-0.46 to 0.92). In conclusion, Swedish Red cows had lower reproductive loss during late embryonic stage, fetal stage, and in total, and better fertility than Swedish Holstein cows. The heritability estimates for pregnancy loss traits were of the same order of magnitude as previously reported for classical fertility traits. These findings could be valuable in work to determine genetic variation in reproductive loss and its potential usefulness as an alternative fertility trait to be considered in genetic or genomic evaluations.

Notch1 is crucial for decidualization and maintaining the first pregnancy in the mouse†

The endometrium undergoes a pregnancy-delivery-repair cycle multiple times during the reproductive lifespan in females. Decidualization is one of the critical events for the success of this essential process. We have previously reported that Notch1 is essential for artificial decidualization in mice. However, in a natural pregnancy, the deletion of Notch1 (PgrCre/+Notch1f/f, or Notch1d/d) only affects female fertility in the first 30 days of a 6-month fertility test, but not the later stages. In the present study, we undertook a closer evaluation at the first pregnancy of these mice to attempt to understand this puzzling phenomenon. We observed a large number of pregnancy losses in Notch1d/d mice in their first pregnancy, which led to the subfertility observed in the first 30 days of the fertility test. We then demonstrated that the initial pregnancy loss is a consequence of impaired decidualization. Furthermore, we identified a group of genes that contribute to Notch1 regulated decidualization in a natural pregnancy. Gene ontogeny analysis showed that these differentially expressed genes in the natural pregnancy are involved in cell-cell and cell-matrix interactions, different from genes that have been previously identified from the artificial decidualization model, which contribute to cell proliferation and apoptosis. In summary, we determined that Notch1 is essential for normal decidualization in the mouse uterus only in the first pregnancy but not in subsequent ones.

Determining the association of thrombophilic gene polymorphisms with recurrent pregnancy loss in Iranian women

OBJECTIVE

Thrombophilia is known to be associated with poor pregnancy outcomes. In this study, three thrombophilic gene polymorphisms, including EPCR (Ser219Gly), F11 (rs4253417) and F7 (323 Ins10) were investigated in an Iranian population of women in order to determine the correlation between thrombophilia and recurrent pregnancy loss (RPL).

METHODS

Polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) were used to evaluate the frequency of three candidate thrombophilic risk factors for recurrent pregnancy loss. The frequencies of the polymorphisms were compared between the case (144 patients with a history of at least two miscarriages) and the control (150 healthy women with no abortion) group.

RESULTS

Our results show that EPCR and FVII polymorphisms of the patient and control group have the same genotype frequency, and the difference is not statistically significant (p-value > .05). Regarding FXI polymorphism, TT genotype frequency was higher in the patient group than the control group (p-value < .05); however, CT heterozygote form was higher in the control group compared to the patient group (p-value < .05).

CONCLUSION

In FXI polymorphism, T allele is possibly an RPL risk factor and C allele has a protective role. Thus, wild type FXI could be related to RPL, but EPCR and FVII polymorphism have no such correlation.

Pregnancy Loss After Amniocentesis and Chorionic Villus Sampling: Cohort Study

INTRODUCTION

Introduction: To estimate the procedure-related risks of pregnancy loss following chorionic villus sampling (CVS) and amniocentesis (AC) compared to pregnancies without procedure.

METHODS

This cohort study enrolled all women who underwent CVS or AC at the Department of Perinatology, University Medical Centre, Ljubljana, Slovenia (from January 2013 to June 2015). For each group we obtained a maternal age and gestational age (11-14 weeks for CVS and >15 weeks for AC) for a matched control group without invasive procedures from the national database. The data was obtained from hospital records and telephone surveys concerning pregnancy outcomes. Pregnancy loss rates in intervention vs. control groups were compared by generating relative risk (RR) with a 95% confidence interval.

RESULTS

During the study period, 828 women underwent CVS and 2,164 women underwent AC. Complete outcome data was available in 2,798 cases (93.5%, 770 CVS, 2,028 AC). Pregnancy loss occurred in 8/770 (1.04%, 95% CI 0.4-2.0%) after CVS vs. 15/1130 (1.33%, 95% CI 0.8-2.2%) in matched control (RR 0.8, 95% CI 0.33-1.8, p=0.6). It occurred in 16/2028 (0.79%, 95% CI 0.5-1.3%) after AC vs. 14/395 (3.29%, 95% CI 2.1-5.8%) in matched control (RR 0.2, 95% CI 0.11-0.45, p<0.0001).

CONCLUSION

The pregnancy loss rates after CVS and AC were comparable to losses in pregnancies without these procedures. With the increasing use of non-invasive prenatal testing, information that the invasive procedures are safe when indicated is essential.

375 Economic Consequences of Pregnancy Loss in Beef Cattle

Over the last four decades, several advances in reproductive biotechnologies have helped beef producers improve genetic traits of their cattle, tighten the breeding season and shorten the calving season, leading to an increase in overall profitability of cow-calf production systems. However, even with these advancements, reproductive failure and embryo mortality are still a major cause for economic loss in beef production. Recently, we projected a loss of $6.25 per exposed cow for every 1% decrease in pregnancy rate, with an estimated gross loss of $2.8 billion annually in the United States due to pregnancy failure in beef females. It is estimated that 75 to 80% of embryonic loss occurs by d 20 of gestation; a large portion of these losses occur during the first week of gestation and likely are caused by issues relating to fertilization failure, incompetence of embryos originated from poor quality oocytes and suboptimal uterine conditions. Furthermore, within the first month of gestation, nearly half of all cows submitted to breeding will not be pregnant 30 d later, and another 5% will lose their pregnancy by d 100 of gestation. In addition, breeding related costs, including bull purchase, breeding soundness exam, estrous synchronization, semen purchase, labor associated with artificial insemination and pregnancy diagnosis, are estimate at $65 per cow exposed. Assuming a 90% pregnancy rate at the end of the breeding season, and a scenario where all 30 million beef females in the U.S. are exposed to fixed-time artificial insemination and undergo one pregnancy diagnosis, the added lost revenue of not producing a live calf to sell at weaning and the cost of breeding, would represent a loss of over $21 billion annually in the United States. Strategies that reduce pregnancy loss in beef cattle are essential to improve productivity and profitability of cow-calf production systems.

Managing Ambiguity When Caring for Women Who Experience Stillbirth

OBJECTIVE

To examine the interactions and social processes involved when nurses care for women who experience fetal demise and subsequent stillbirth.

DESIGN

Qualitative design using grounded theory.

SETTING

Single-site urban medical center in New York City.

PARTICIPANTS

Twenty registered nurses who worked in the labor and delivery department.

METHODS

I collected data via in-depth interviews and recorded, transcribed, and analyzed the data using constant comparative analysis.

RESULTS

Managing Ambiguity emerged as the overarching preliminary theory to describe how nurses cared for women who experienced stillbirth. This preliminary theory included three themes: Experiencing a Spectrum of Emotions, Managing Patient Care in an Ambiguous Context, and Managing Institutional Ambiguity. These themes provided an overview of the creative/protective and avoidant/conflicted behaviors that nurses brought to their work with women whose fetuses died in utero and were stillborn. These interactions were complicated by institutional policies and additional factors, such as workload, that often denied nurses the resources needed to engage in the patient care processes required to address the trauma experienced by women and their families.

CONCLUSION

The preliminary theory Managing Ambiguity provided a perspective on the experiences, behaviors, and social processes involved in caring for women who experience stillbirth. The absence of preparatory education, effective protocols, and institutional support contributed to the ambiguity inherent in caring for these women.