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de Assis V, Giugni CS, Ros ST. Evaluation of Recurrent Pregnancy Loss. Obstet Gynecol 2024; 143:645-659. [PMID: 38176012 DOI: 10.1097/aog.0000000000005498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/02/2023] [Indexed: 01/06/2024]
Abstract
Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.
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Affiliation(s)
- Viviana de Assis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
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Zhou P, Wang J, Wang J, Liu X. When autophagy meets placenta development and pregnancy complications. Front Cell Dev Biol 2024; 12:1327167. [PMID: 38371923 PMCID: PMC10869551 DOI: 10.3389/fcell.2024.1327167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Autophagy is a common biological phenomenon in eukaryotes that has evolved and reshaped to maintain cellular homeostasis. Under the pressure of starvation, hypoxia, and immune damage, autophagy provides energy and nutrients to cells, which benefits cell survival. In mammals, autophagy is an early embryonic nutrient supply system involved in early embryonic development, implantation, and pregnancy maintenance. Recent studies have found that autophagy imbalance in placental tissue plays a key role in the occurrence and development of pregnancy complications, such as gestational hypertension, gestational obesity, premature birth, miscarriage, and intrauterine growth restriction. This mini-review summarizes the molecular mechanism of autophagy regulation, the autophagy pathways, and related factors involved in placental tissue and comprehensively describes the role of autophagy in pregnancy complications.
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Affiliation(s)
- Pei Zhou
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Junqi Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jun Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
- Department of Obstetrics and Gynecology, Benxi Central Hospital of China Medical University, Benxi, Liaoning, China
| | - Xiaomei Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Gomaa IA, Sabry A, Allam ISED, Ashoush S, Reda A. Endometrial Progesterone and Estrogen Receptors in Relation to Hormonal Levels in Women with Unexplained Recurrent Miscarriage. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e676-e682. [PMID: 38029769 PMCID: PMC10686759 DOI: 10.1055/s-0043-1776030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/07/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Recurrent miscarriage has been linked to hormonal disturbance due to dysregulation of its receptors rather than to the availability of the hormone. We aimed to investigate endometrial expression of progesterone and estrogen receptors in relation to serum and endometrial hormonal levels in unexplained recurrent miscarriage. METHODS The present case control study included 20 cases with unexplained recurrent miscarriage and 20 parous women as controls. Ovulation was confirmed using an ovulation kit and 10 to 12 days after detecting the urinary luteinizing hormone surge, all women were subjected to a blood sample and to an endometrial biopsy. Progesterone and estrogen levels were measured in serum and in endometrial tissue and receptor concentrations were in the endometrial sample. RESULTS Women with recurrent miscarriage showed significantly lower concentration of receptors in both the cytoplasm and the nucleus of endometrial tissue compared with controls. The nuclear/cytoplasm ratio of progesterone receptor was significantly higher in cases compared with controls, implicating that recurrent miscarriage is probably linked to nongenomic activity of the hormone; this was also significant for estrogen receptor. Serum progesterone and estrogen hormonal levels were comparable between groups while both hormones were significantly reduced in the endometrium of recurrent miscarriage cases. Receptors significantly correlated with endometrial hormonal level but not to serum level. CONCLUSION Recurrent miscarriage might be linked to reduced endometrial progesterone and estrogen receptors and appears to be more related to nongenomic activity of progesterone. Endometrial receptors expression correlates to tissue hormonal level rather than to serum hormonal level.
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Affiliation(s)
- Ihab Adel Gomaa
- Ain Shams University Maternity Hospital, Abbaseya Square, Cairo, Egypt.
| | - Ahmed Sabry
- Ain Shams University Maternity Hospital, Abbaseya Square, Cairo, Egypt.
| | | | | | - Ahmed Reda
- Ain Shams University Maternity Hospital, Abbaseya Square, Cairo, Egypt.
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Shin G, Kim HJ, Kim SH. Internal growth of women with recurrent miscarriage: a qualitative descriptive study based on the post-traumatic growth theory. BMC Womens Health 2023; 23:386. [PMID: 37480056 PMCID: PMC10362550 DOI: 10.1186/s12905-023-02542-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/12/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Unexpected and repeated miscarriages in a woman's life cycle can be a mental and physical burden and lead to post-traumatic stress disorder. However, women may also experience inner growth with such experiences. METHODS This study was qualitative descriptive research examining the experiences of South Korean women who had recurrent miscarriages three or more times. RESULTS The average age of the participants was 34.6 years, and the average number of recurrent miscarriages was 3.87. Additionally, five themes were identified as follows: (1) Confusing as if in muddy water, (2) Self-examination of past daily life, (3) Empathy and comfort in homogeneous groups, (4) Religious beliefs that include the lost fetus, and (5) Transforming for internal growth. CONCLUSION Based on the results of this study, intervention strategies need to be implemented to support the inner growth of women who have experienced recurrent miscarriages.
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Affiliation(s)
- Gisoo Shin
- College of Nursing, Chung - Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul, 06974, Korea
| | - Hye Jin Kim
- Department of Nursing, Changshin University, 262, Paryong-Ro, MasanHoiwon-Gu, Changwon-Si, Gyeongsangnam-Do, 51352, Korea
| | - Sung Hae Kim
- Department of Nursing, College of Health, Welfare and Education, Tongmyong University, 428 Sinseon-Ro, Nam-Gu, Busan, 48520, Korea.
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Scheffer JB, Scheffer BB, Aguiar APDS, Franca JB, Lozano DM, Fanchin R. Serum progesterone level in luteal phase improves pregnancy rate in fresh cycles with blastocyst embryo transfer. JBRA Assist Reprod 2023; 27:49-54. [PMID: 36107033 PMCID: PMC10065764 DOI: 10.5935/1518-0557.20220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/20/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the association between serum level of progesterone during stimulation and in the luteal phase with pregnancy rate in a cohort of patients undergoing in vitro fertilization and embryo transfer (IVF-ET) on day 5. METHODS Retrospective Cohort Study. Patients: 62 infertile women, aged 24-42 years, undergoing ART at our center from May 2019 to May 2021. Progesterone was evaluated during ovarian stimulation on Day 2, Day 6, and Day 8 of stimulation, day of trigger (P4dhCG), and on the day of blastocyst transfer with 5 days of progesterone supplementation (P4d5+). We also calculated the difference of P4d5+ with P4dhCG. (∆P4). Then we divided the patients into two groups based on progesterone serum levels at P4d5+; <10ng/ml (Group A), ≥10ng/ml (Group B). The Student's t-test was performed for continuous variables; Mann-Whitney's Test and Spearman's Test were used where appropriate for categorical variables. p<0.05 was considered statistically significant. RESULTS There were positive correlations between βhCG positive with P4d5+ (p<0.001; Rho 0.770) and ∆P4 (p<0.001; Rho 0.703). The pregnancy rate doubled when the serum progesterone level was ≥10ng/ml on the fifth day of progesterone supplementation compared with P4<10ng/ml (44% vs. 21%, respectively). CONCLUSIONS The pregnancy rate was positively correlated with the serum P4 level on the fifth day of progesterone supplementation and with the difference between the serum progesterone level in the Dd5+ / dhCG. A higher pregnancy rate was observed when serum progesterone level on the fifth day of progesterone supplementation was ≥10ng/ml.
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Affiliation(s)
| | - Bruno Brum Scheffer
- IBRRA - Brazilian Institute of Assisted Reproduction, Belo
Horizonte, Brazil
| | | | | | - Autor
- IBRRA - Brazilian Institute of Assisted Reproduction, Belo
Horizonte, Brazil
| | - Daniel Mendez Lozano
- School of Medicine, Tecnologico de Monterrey and Center for
Reproductive Medicine CREASIS, San Pedro Monterrey, Mexico
| | - Renato Fanchin
- University Professor - Hospital Practitioner in Reproductive
Medicine, France; Hopital Foch, Suresnes, France
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Zhao QY, Li QH, Fu YY, Ren CE, Jiang AF, Meng YH. Decidual macrophages in recurrent spontaneous abortion. Front Immunol 2022; 13:994888. [PMID: 36569856 PMCID: PMC9781943 DOI: 10.3389/fimmu.2022.994888] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is defined as two or more pregnancy loss, affecting the happiness index of fertility couples. The mechanisms involved in the occurrence of RSA are not clear to date. The primary problem for the maternal immune system is how to establish and maintain the immune tolerance to the semi-allogeneic fetuses. During the pregnancy, decidual macrophages mainly play an important role in the immunologic dialogue. The purpose of this study is to explore decidual macrophages, and to understand whether there is a connection between these cells and RSA by analyzing their phenotypes and functions. Pubmed, Web of Science and Embase were searched. The eligibility criterion for this review was evaluating the literature about the pregnancy and macrophages. Any disagreement between the authors was resolved upon discussion and if required by the judgment of the corresponding author. We summarized the latest views on the phenotype, function and dysfunction of decidual macrophages to illuminate its relationship with RSA.
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Affiliation(s)
| | | | | | | | | | - Yu-Han Meng
- Center of Reproductive Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
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Kowalczyk E, Kniotek M, Korczak-Kowalska G, Borysowski J. Progesterone-induced blocking factor and interleukin 4 as novel therapeutics in the treatment of recurrent pregnancy loss. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Zhou J, Li L, Pan X, Wang J, Qi Q, Sun H, Li C, Wang L. The effect of a traditional Chinese quadri-combination therapy and its component quercetin on recurrent spontaneous abortion: A clinical trial, network pharmacology and experiments-based study. Front Pharmacol 2022; 13:965694. [PMID: 36339549 PMCID: PMC9626984 DOI: 10.3389/fphar.2022.965694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/28/2022] [Indexed: 08/02/2023] Open
Abstract
Objective: To explore the effect and mechanisms of a traditional Chinese quadri-combination therapy [Bushen, Yiqi, Lixue and Yangtai (BYLY)] in treating recurrent spontaneous abortion (RSA). Methods: A clinical trial was conducted to study the effect of BYLY on RSA. Pharmacological network analysis and UPLC-Q/TOF-mass spectrometry (MS) were applied to investigate the key active component in BYLY and potential targets. Cellular experiments based on former results were performed to examine the mechanism of BYLY in the treatment of RSA. Results: Four hundred and eighty participants enrolled in the clinical trial. The results showed that, compared with the use of BYLY or duphaston alone, a combination of duphaston and BYLY could decrease the early abortion rate in RSA (p < 0.001). Network pharmacological analysis indicated that BYLY contained 132 active components and 146 core targets, and the quercetin maybe the key effective component. In vitro experiments found that pretreatment of quercetin at the correct concentration (2 μM) prevented hypoxia-induced viability and proliferation reduction, and apoptosis and mitochondrial dysfunction. Furthermore, quercetin could modulate mitochondrial fission/fusion balance in trophoblasts, and specifically decrease the expression of Drp1 by regulating miR-34a-5p. Conclusion: BYLY could improve pregnancy outcomes of RSA, based on multi-components and multi-targets. The protective effect of quercetin on trophoblasts, through decreasing Drp1 expression via regulating miR-34a-5p, might be one possible effective mechanism.
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Affiliation(s)
- Jing Zhou
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Lisha Li
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Xinyao Pan
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Jing Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Qing Qi
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Hongmei Sun
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Chuyu Li
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
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Ono M, Toyoda N, Kagami K, Hosono T, Matsumoto T, Horike SI, Yamazaki R, Nakamura M, Mizumoto Y, Fujiwara T, Ando H, Fujiwara H, Daikoku T. Uterine Deletion of Bmal1 Impairs Placental Vascularization and Induces Intrauterine Fetal Death in Mice. Int J Mol Sci 2022; 23:ijms23147637. [PMID: 35886985 PMCID: PMC9319876 DOI: 10.3390/ijms23147637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 02/01/2023] Open
Abstract
Recently, it was demonstrated that the expression of BMAL1 was decreased in the endometrium of women suffering from recurrent spontaneous abortion. To investigate the pathological roles of uterine clock genes during pregnancy, we produced conditional deletion of uterine Bmal1 (cKO) mice and found that cKO mice could receive embryo implantation but not sustain pregnancy. Gene ontology analysis of microarray suggested that uterine NK (uNK) cell function was suppressed in cKO mice. Histological examination revealed the poor formation of maternal vascular spaces in the placenta. In contrast to WT mice, uNK cells in the spongiotrophoblast layer, where maternal uNK cells are directly in contact with fetal trophoblast, hardly expressed an immunosuppressive NK marker, CD161, in cKO mice. By progesterone supplementation, pregnancy could be sustained until the end of pregnancy in some cKO mice. Although this treatment did not improve the structural abnormalities of the placenta, it recruited CD161-positive NK cells into the spongiotrophoblast layer in cKO mice. These findings indicate that the uterine clock system may be critical for pregnancy maintenance after embryo implantation.
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Affiliation(s)
- Masanori Ono
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
- Department of Obstetrics and Gynecology, Tokyo Medical University, Shinjuku, Tokyo 160-0023, Japan
| | - Natsumi Toyoda
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
- Division of Animal Disease Model, Research Center for Experimental Modeling of Human Disease, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan
| | - Kyosuke Kagami
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
| | - Takashi Hosono
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
- Department of Cellular and Molecular Function Analysis, Graduate School of Medical Science, Kanazawa University, Kanazawa 920-8640, Japan;
| | - Takeo Matsumoto
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
| | - Shin-ichi Horike
- Division of Integrated Omics Research, Research Center for Experimental Modeling of Human Disease, Kanazawa University, Kanazawa 920-8640, Japan;
| | - Rena Yamazaki
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
| | - Mitsuhiro Nakamura
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
- Department of Obstetrics and Gynecology, Public Central Hospital of Matto Ishikawa, Hakusan 924-8588, Japan
| | - Yasunari Mizumoto
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
| | - Tomoko Fujiwara
- Department of Human Life Environments, Kyoto Notre Dame University, Kyoto 606-0847, Japan;
| | - Hitoshi Ando
- Department of Cellular and Molecular Function Analysis, Graduate School of Medical Science, Kanazawa University, Kanazawa 920-8640, Japan;
| | - Hiroshi Fujiwara
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan; (M.O.); (N.T.); (K.K.); (T.H.); (T.M.); (R.Y.); (M.N.); (Y.M.)
- Correspondence: (H.F.); (T.D.); Tel.: +81-76-265-2425 (H.F.); +81-76-265-2460 (T.D.); Fax: +81-76-234-4266 (H.F.); +81-76-234-4245 (T.D.)
| | - Takiko Daikoku
- Division of Animal Disease Model, Research Center for Experimental Modeling of Human Disease, Kanazawa University, Takaramachi 13-1, Kanazawa 920-8641, Japan
- Correspondence: (H.F.); (T.D.); Tel.: +81-76-265-2425 (H.F.); +81-76-265-2460 (T.D.); Fax: +81-76-234-4266 (H.F.); +81-76-234-4245 (T.D.)
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D’Aloja P, Da Cas R, Belleudi V, Fortinguerra F, Poggi FR, Perna S, Trotta F, Donati S. Drug Prescriptions among Italian and Immigrant Pregnant Women Resident in Italy: A Cross-Sectional Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074186. [PMID: 35409869 PMCID: PMC8998753 DOI: 10.3390/ijerph19074186] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Ensuring drug safety for pregnant women through prescription drug monitoring is essential. The aim of this study was to describe the prescription pattern of medicines among pregnant immigrant women from countries with high migratory pressure (HMPCs) compared to pregnant Italian women. The prevalence of drug prescriptions among the two study populations was analysed through record linkage procedures applied to the administrative databases of eight Italian regions, from 2016 to 2018. The overall prevalence of drug prescription was calculated considering all women who received at least one prescription during the study period. Immigrants had a lower prevalence of drug prescriptions before (51.0% vs. 58.6%) and after pregnancy (55.1% vs. 60. 3%). Conversely, during pregnancy, they obtained a slightly higher number of prescriptions (74.9% vs. 72.8%). The most prescribed class of drugs was the blood and haematopoietic organs category (category ATC B) (56.4% vs. 45.9%, immigrants compared to Italians), followed by antimicrobials (31.3% vs. 33.7%). Most prescriptions were appropriate, while folic acid administration 3 months before conception was low for both study groups (3.9% immigrants and 6.2% Italians). Progesterone seemingly was prescribed against early pregnancy loss, more frequently among Italians (16.5% vs. 8.1% immigrants). Few inappropriate medications were prescribed among antihypertensives, statins and anti-inflammatory drugs in both study groups.
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Affiliation(s)
- Paola D’Aloja
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità (National Institute of Health), 00161 Rome, Italy;
- Correspondence:
| | - Roberto Da Cas
- National Centre for Drug Research and Evaluation, Istituto Superiore di Sanità (National Institute of Health), 00161 Rome, Italy;
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, 00145 Rome, Italy; (V.B.); (F.R.P.)
| | - Filomena Fortinguerra
- HTA & Pharmaceutical Economy Division, Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
| | - Francesca Romana Poggi
- Department of Epidemiology, Lazio Regional Health Service, 00145 Rome, Italy; (V.B.); (F.R.P.)
| | - Serena Perna
- HTA & Pharmaceutical Economy Division, Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
| | - Francesco Trotta
- HTA & Pharmaceutical Economy Division, Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità (National Institute of Health), 00161 Rome, Italy;
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Progesterone: A Unique Hormone with Immunomodulatory Roles in Pregnancy. Int J Mol Sci 2022; 23:ijms23031333. [PMID: 35163255 PMCID: PMC8835837 DOI: 10.3390/ijms23031333] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022] Open
Abstract
Progesterone is well known for its numerous endocrinologic roles in pregnancy but is also endowed with fascinating immunomodulatory capabilities. It can downregulate the induction of inflammatory reactions, the activation of immune cells and the production of cytokines, which are critical mediators of immune responses. These features appear to be critical to the success of pregnancy, given the ability of maternal immune reactivity to interfere with pregnancy and to contribute to several pregnancy complications. This review summarizes the contribution of maternal immune effectors in general, and cytokines in particular, to pregnancy complications such as recurrent miscarriage, pre-eclampsia and preterm labor; it describes the promise offered by supplementation with progesterone and the oral progestogen dydrogesterone, as well as the progesterone-induced blocking factor in the prevention and/or treatment of these serious complications.
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12
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Wu H, Zhang S, Lin X, He J, Wang S, Zhou P. Pregnancy-related complications and perinatal outcomes following progesterone supplementation before 20 weeks of pregnancy in spontaneously achieved singleton pregnancies: a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:165. [PMID: 34732210 PMCID: PMC8567546 DOI: 10.1186/s12958-021-00846-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progesterone supplementation is widely performed in women with threatened miscarriage or a history of recurrent miscarriage; however, the effects of early progesterone supplementation on pregnancy-related complications and perinatal outcomes in later gestational weeks remain unknown. METHODS Ovid MEDLINE, the Cochrane Library, Embase and ClinicalTrials.gov were searched until April 3rd, 2021. Randomized controlled trials regarding spontaneously achieved singleton pregnancies who were treated with progestogen before 20 weeks of pregnancy and were compared with those women in unexposed control groups were selected for inclusion. We performed pairwise meta-analyses with the random-effects model. The risk of bias was assessed according to the Cochrane Collaboration tool. The primary outcomes included preeclampsia (PE), and gestational diabetes mellitus (GDM), with the results presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We identified nine eligible studies involving 6439 participants. The pooled OR of subsequent PE following early progestogen supplementation was 0.64 (95% CI 0.42-0.98, moderate quality of evidence). A lower OR for PE was observed in the progestogen group when the subgroup analysis was performed in the vaginal subgroup (OR 0.62, 95%CI 0.40-0.96). There was insufficient evidence of a difference in the rate of GDM between pregnant women with early progestogen supplementation and unexposed pregnant women (OR 1.02, 95% CI 0.79-1.32, low quality of evidence). The pooled OR of low birth weight (LBW) following oral dydrogesterone was 0.57 (95% CI 0.34-0.95, moderate quality of evidence). The results were affected by a single study and the total sample size of enrolled women did not reach the required information size. CONCLUSION Use of vaginal micronized progesterone (Utrogestan) in spontaneously achieved singleton pregnancies with threatened miscarriage before 20 weeks of pregnancy may reduce the risk of PE in later gestational weeks. Among spontaneously achieved singleton pregnancies with threatened miscarriage or a history of recurrent miscarriage, use of oral dydrogesterone before 20 weeks of pregnancy may result in a lower risk of LBW in later gestational weeks. However, the available data were not sufficient to reach definitive conclusions, which highlighted the need for future studies.
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Affiliation(s)
- Hanglin Wu
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, No. 369 Kun Peng Road, Hangzhou, 310008, Zhejiang, China
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Xiaona Lin
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Jing He
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, No. 369 Kun Peng Road, Hangzhou, 310008, Zhejiang, China
| | - Shasha Wang
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Ping Zhou
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China.
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13
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Li WX, Xu XH, Jin LP. Regulation of the innate immune cells during pregnancy: An immune checkpoint perspective. J Cell Mol Med 2021; 25:10362-10375. [PMID: 34708495 PMCID: PMC8581333 DOI: 10.1111/jcmm.17022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/03/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022] Open
Abstract
The foetus can be regarded as a half‐allograft implanted into the maternal body. In a successful pregnancy, the mother does not reject the foetus because of the immune tolerance mechanism at the maternal‐foetal interface. The innate immune cells are a large part of the decidual leukocytes contributing significantly to a successful pregnancy. Although the contributions have been recognized, their role in human pregnancy has not been completely elucidated. Additionally, the accumulated evidence demonstrates that the immune checkpoint molecules expressed on the immune cells are co‐inhibitory receptors regulating their activation and biological function. Therefore, it is critical to understand the immune microenvironment and explore the function of the innate immune cells during pregnancy. This review summarizes the classic immune checkpoints such as PD‐1, CTLA‐4 and some novel molecules recently identified, including TIM‐3, CD200, TIGIT and the Siglecs family on the decidual and peripheral innate immune cells during pregnancy. Furthermore, it emphasizes the role of the immune checkpoint molecules in pregnancy‐associated complications and reproductive immunotherapy.
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Affiliation(s)
- Wen-Xuan Li
- Shanghai Key Laboratory of Maternal-Fetal Medicine, Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiang-Hong Xu
- Shanghai Key Laboratory of Maternal-Fetal Medicine, Clinical and Translational Research Center, Department of Biobank, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Li-Ping Jin
- Shanghai Key Laboratory of Maternal-Fetal Medicine, Clinical and Translational Research Center, Department of Biobank, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
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14
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Lisova KM, Kalinovska IV, Pryimak SH, Tokar PY, Varlas VN. Changes in the level of fetoplacental complex hormones in pregnant women with miscarriage. J Med Life 2021; 14:487-491. [PMID: 34621371 PMCID: PMC8485377 DOI: 10.25122/jml-2021-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/05/2021] [Indexed: 11/17/2022] Open
Abstract
The purpose of the study was TO analyze the fetoplacental complex hormone levels and changes in their dynamics in pregnant women with miscarriage and the impact of these features on the subsequent course of pregnancy. Hormone levels were determined at different stages of gestation in 50 healthy women with a physiological course of pregnancy (control group) and 50 pregnant women with a history of miscarriage (main group). The women of the main group had a significantly slower rate of increase in hormones and a lag in quantitative indicators than the control group. The estradiol level indicators were 4.1 times (76.0%) and 2.89 times (65.5%) lower in women with miscarriage in the embryonic and late fetal period, respectively, compared to healthy women. Indicators of the level of placental lactogen and chorionic gonadotropin in the embryonic period in women with miscarriage were lower by 39.1% and 50.9%, respectively, compared to healthy women. In the late fetal period, the level of these hormones was lower by 72.9% and 35.4%, respectively. In the embryonic and late fetal periods, progesterone levels were lower by 67.4% and 68.4%, respectively, compared to the control group. The data obtained are evidence of a pronounced hormonal abnormality of the placenta, and hence a marker of fetoplacental dysfunction, which on the background of miscarriage develops at the early stages and continues to progress with the course of pregnancy.
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Affiliation(s)
| | | | | | - Petro Yuriyovych Tokar
- Department of Obstetrics and Gynecology, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Valentin Nicolae Varlas
- Department of Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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15
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Han Y, Liu Z, Chen T. Role of Vaginal Microbiota Dysbiosis in Gynecological Diseases and the Potential Interventions. Front Microbiol 2021; 12:643422. [PMID: 34220737 PMCID: PMC8249587 DOI: 10.3389/fmicb.2021.643422] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/19/2021] [Indexed: 12/16/2022] Open
Abstract
Vaginal microbiota dysbiosis, characterized by the loss of Lactobacillus dominance and increase of microbial diversity, is closely related to gynecological diseases; thus, intervention on microbiota composition is significant and promising in the treatment of gynecological diseases. Currently, antibiotics and/or probiotics are the mainstay of treatment, which show favorable therapeutic effects but also bring problems such as drug resistance and high recurrence. In this review, we discuss the role of vaginal microbiota dysbiosis in various gynecological infectious and non-infectious diseases, as well as the current and potential interventions.
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Affiliation(s)
- Yiwen Han
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Queen Mary School, Nanchang University, Nanchang, China
| | - Zhaoxia Liu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tingtao Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,National Engineering Research Center for Bioengineering Drugs and the Technologies, Institute of Translational Medicine, Nanchang University, Nanchang, China
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16
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Devall AJ, Papadopoulou A, Podesek M, Haas DM, Price MJ, Coomarasamy A, Gallos ID. Progestogens for preventing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013792. [PMID: 33872382 PMCID: PMC8406671 DOI: 10.1002/14651858.cd013792.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime, and 15% to 20% of pregnancies ending in a miscarriage. Progesterone has an important role in maintaining a pregnancy, and supplementation with different progestogens in early pregnancy has been attempted to rescue a pregnancy in women with early pregnancy bleeding (threatened miscarriage), and to prevent miscarriages in asymptomatic women who have a history of three or more previous miscarriages (recurrent miscarriage). OBJECTIVES To estimate the relative effectiveness and safety profiles for the different progestogen treatments for threatened and recurrent miscarriage, and provide rankings of the available treatments according to their effectiveness, safety, and side-effect profile. SEARCH METHODS We searched the following databases up to 15 December 2020: Cochrane Central Register of Controlled Trials, Ovid MEDLINE(R), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of progestogen treatment for the prevention of miscarriage. Cluster-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded quasi- and non-randomised trials. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We performed pairwise meta-analyses and indirect comparisons, where possible, to determine the relative effects of all available treatments, but due to the limited number of included studies only direct or indirect comparisons were possible. We estimated the relative effects for the primary outcome of live birth and the secondary outcomes including miscarriage (< 24 weeks of gestation), preterm birth (< 37 weeks of gestation), stillbirth, ectopic pregnancy, congenital abnormalities, and adverse drug events. Relative effects for all outcomes are reported separately by the type of miscarriage (threatened and recurrent miscarriage). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS Our meta-analysis included seven randomised trials involving 5,682 women, and all provided data for meta-analysis. All trials were conducted in hospital settings. Across seven trials (14 treatment arms), the following treatments were used: three arms (21%) used vaginal micronized progesterone; three arms (21%) used dydrogesterone; one arm (7%) used oral micronized progesterone; one arm (7%) used 17-α-hydroxyprogesterone, and six arms (43%) used placebo. Women with threatened miscarriage Based on the relative effects from the pairwise meta-analysis, vaginal micronized progesterone (two trials, 4090 women, risk ratio (RR) 1.03, 95% confidence interval (CI) 1.00 to 1.07, high-certainty evidence), and dydrogesterone (one trial, 406 women, RR 0.98, 95% CI 0.89 to 1.07, moderate-certainty evidence) probably make little or no difference to the live birth rate when compared with placebo for women with threatened miscarriage. No data are available to assess the effectiveness of 17-α-hydroxyprogesterone or oral micronized progesterone for the outcome of live birth in women with threatened miscarriage. The pre-specified subgroup analysis by number of previous miscarriages is only possible for vaginal micronized progesterone in women with threatened miscarriage. In women with no previous miscarriages and early pregnancy bleeding, there is probably little or no improvement in the live birth rate (RR 0.99, 95% CI 0.95 to 1.04, high-certainty evidence) when treated with vaginal micronized progesterone compared to placebo. However, for women with one or more previous miscarriages and early pregnancy bleeding, vaginal micronized progesterone increases the live birth rate compared to placebo (RR 1.08, 95% CI 1.02 to 1.15, high-certainty evidence). Women with recurrent miscarriage Based on the results from one trial (826 women) vaginal micronized progesterone (RR 1.04, 95% CI 0.95 to 1.15, high-certainty evidence) probably makes little or no difference to the live birth rate when compared with placebo for women with recurrent miscarriage. The evidence for dydrogesterone compared with placebo for women with recurrent miscarriage is of very low-certainty evidence, therefore the effects remain unclear. No data are available to assess the effectiveness of 17-α-hydroxyprogesterone or oral micronized progesterone for the outcome of live birth in women with recurrent miscarriage. Additional outcomes All progestogen treatments have a wide range of effects on the other pre-specified outcomes (miscarriage (< 24 weeks of gestation), preterm birth (< 37 weeks of gestation), stillbirth, ectopic pregnancy) in comparison to placebo for both threatened and recurrent miscarriage. Moderate- and low-certainty evidence with a wide range of effects suggests that there is probably no difference in congenital abnormalities and adverse drug events with vaginal micronized progesterone for threatened (congenital abnormalities RR 1.00, 95% CI 0.68 to 1.46, moderate-certainty evidence; adverse drug events RR 1.07 95% CI 0.81 to 1.39, moderate-certainty evidence) or recurrent miscarriage (congenital abnormalities 0.75, 95% CI 0.31 to 1.85, low-certainty evidence; adverse drug events RR 1.46, 95% CI 0.93 to 2.29, moderate-certainty evidence) compared with placebo. There are limited data and very low-certainty evidence on congenital abnormalities and adverse drug events for the other progestogens. AUTHORS' CONCLUSIONS The overall available evidence suggests that progestogens probably make little or no difference to live birth rate for women with threatened or recurrent miscarriage. However, vaginal micronized progesterone may increase the live birth rate for women with a history of one or more previous miscarriages and early pregnancy bleeding, with likely no difference in adverse events. There is still uncertainty over the effectiveness and safety of alternative progestogen treatments for threatened and recurrent miscarriage.
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Affiliation(s)
- Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Marcelina Podesek
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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17
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Abstract
The hormone progesterone is important for preparing the uterine lining for egg implantation and for maintaining the early stages of pregnancy. The gene encoding the progesterone receptor (PGR) carries introgressed Neandertal haplotypes with two missense substitutions and a mobile Alu element. These Neandertal gene variants have reached nearly 20% frequency in non-Africans and have been associated with preterm birth. Here, we show that one of the missense substitutions appears fixed in Neandertals, while the other substitution as well as the Alu insertion were polymorphic among Neandertals. We show that two Neandertal haplotypes carrying the PGR gene entered the modern human population and that present-day carriers of the Neandertal haplotypes express higher levels of the receptor. In a cohort of present-day Britons, these carriers have more siblings, fewer miscarriages, and less bleeding during early pregnancy suggesting that the Neandertal progesterone receptor alleles promote fertility. This may explain their high frequency in modern human populations.
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Affiliation(s)
- Hugo Zeberg
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany.,Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Janet Kelso
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
| | - Svante Pääbo
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany.,Okinawa Institute of Science and Technology, Onna-son, Japan
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18
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Devall AJ, Papadopoulou A, Haas DM, Price MJ, Coomarasamy A, Gallos ID. Progestogens for preventing miscarriage: a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Adam J Devall
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women’s Health Research; University of Birmingham; Birmingham UK
| | - Argyro Papadopoulou
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women’s Health Research; University of Birmingham; Birmingham UK
| | - David M Haas
- Department of Obstetrics and Gynecology; Indiana University School of Medicine; Indianapolis Indiana USA
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Arri Coomarasamy
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women’s Health Research; University of Birmingham; Birmingham UK
| | - Ioannis D Gallos
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women’s Health Research; University of Birmingham; Birmingham UK
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19
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Černiauskaitė M, Vaigauskaitė B, Ramašauskaitė D, Šilkūnas M. Spontaneous Heterotopic Pregnancy: Case Report and Literature Review. ACTA ACUST UNITED AC 2020; 56:medicina56080365. [PMID: 32707853 PMCID: PMC7466362 DOI: 10.3390/medicina56080365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/16/2022]
Abstract
Heterotopic pregnancy is defined as a condition when intrauterine and extrauterine pregnancy occur simultaneously. It is a life-threatening condition that requires immediate and accurate diagnostics and treatment. We present a case of a 28-year-old primigravida female who conceived spontaneously and at her seventh week of gestation and was presented to the emergency department with weakness and acute pain in lower abdomen. Laboratory tests and transvaginal ultrasonography revealed the diagnosis of heterotopic pregnancy. Urgent laparoscopic salpingotomy was chosen as a treatment option. The ectopic pregnancy was successfully removed with the preservation of the intrauterine embryo and fallopian tubes. The course of pregnancy after the surgery was without complications, and a healthy baby was delivered at the 39th week of gestation. When treated properly and on time, a heterotopic pregnancy can result in live childbirth with favorable outcomes for both the child and the mother.
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Affiliation(s)
- Miglė Černiauskaitė
- Faculty of Medicine, Vilnius University, M. K. Čiurlionio g. 21, 03101 Vilnius, Lithuania
- Correspondence: ; Tel.: +370-622-36-570
| | - Brigita Vaigauskaitė
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Clinic of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Clinics, Santariškių g. 2, 08661 Vilnius, Lithuania; (B.V.); (D.R.); (M.Š.)
| | - Diana Ramašauskaitė
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Clinic of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Clinics, Santariškių g. 2, 08661 Vilnius, Lithuania; (B.V.); (D.R.); (M.Š.)
| | - Mindaugas Šilkūnas
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Clinic of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Clinics, Santariškių g. 2, 08661 Vilnius, Lithuania; (B.V.); (D.R.); (M.Š.)
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20
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Hamulyák EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev 2020; 5:CD012852. [PMID: 32358837 PMCID: PMC7195627 DOI: 10.1002/14651858.cd012852.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aspirin and heparin are widely used as preventive strategy to reduce the high risk of recurrent pregnancy loss in women with antiphospholipid antibodies (aPL). This review supersedes a previous, out-of-date review that evaluated all potential therapies for preventing recurrent pregnancy loss in women with aPL. The current review focusses on a narrower scope because current clinical practice is restricted to using aspirin or heparins, or both for women with aPL in an attempt to reduce pregnancy complications. OBJECTIVES To assess the effects of aspirin or heparin, or both for improving pregnancy outcomes in women with persistent (on two separate occasions) aPL, either lupus anticoagulant (LAC), anticardiolipin (aCL) or aβ2-glycoprotein-I antibodies (aβ2GPI) or a combination, and recurrent pregnancy loss (two or more, which do not have to be consecutive). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 June 2019), and reference lists of retrieved studies. Where necessary, we attempted to contact trial authors. SELECTION CRITERIA Randomised, cluster-randomised and quasi-randomised controlled trials that assess the effects of aspirin, heparin (either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH]), or a combination of aspirin and heparin compared with no treatment, placebo or another, on pregnancy outcomes in women with persistent aPL and recurrent pregnancy loss were eligible. All treatment regimens were considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion criteria and risk of bias. Two review authors independently extracted data and checked them for accuracy and the certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Eleven studies (1672 women) met the inclusion criteria; nine randomised controlled trials and two quasi-RCTs. The studies were conducted in the USA, Canada, UK, China, New Zealand, Iraq and Egypt. One included trial involved 1015 women, all other included trials had considerably lower numbers of participants (i.e. 141 women or fewer). Some studies had high risk of selection and attrition bias, and many did not include sufficient information to judge the risk of reporting bias. Overall, the certainty of evidence is low to very low due to the small numbers of women in the studies and to the risk of bias. The dose and type of heparin and aspirin varied among studies. One study compared aspirin alone with placebo; no studies compared heparin alone with placebo and there were no trials that had a no treatment comparator arm during pregnancy; five studies explored the efficacy of heparin (either UFH or LMWH) combined with aspirin compared with aspirin alone; one trial compared LMWH with aspirin; two trials compared the combination of LMWH plus aspirin with the combination of UFH plus aspirin; two studies evaluated the combination of different doses of heparin combined with aspirin. All trials used aspirin at a low dose. Aspirin versus placebo We are very uncertain if aspirin has any effect on live birth compared to placebo (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71 to 1.25, 1 trial, 40 women, very low-certainty evidence). We are very uncertain if aspirin has any effect on the risk of pre-eclampsia, pregnancy loss, preterm delivery of a live infant, intrauterine growth restriction or adverse events in the child, compared to placebo. We are very uncertain if aspirin has any effect on adverse events (bleeding) in the mother compared with placebo (RR 1.29, 95% CI 0.60 to 2.77, 1 study, 40 women). The certainty of evidence for these outcomes is very low because of imprecision, due to the low numbers of women involved and the wide 95% CIs, and also because of risk of bias. Venous thromboembolism and arterial thromboembolism were not reported in the included studies. Heparin plus aspirin versus aspirin alone Heparin plus aspirin may increase the number of live births (RR 1.27, 95% CI 1.09 to 1.49, 5 studies, 1295 women, low-certainty evidence). We are uncertain if heparin plus aspirin has any effect on the risk of pre-eclampsia, preterm delivery of a live infant, or intrauterine growth restriction, compared with aspirin alone because of risk of bias and imprecision due to the low numbers of women involved and the wide 95% CIs. We are very uncertain if heparin plus aspirin has any effect on adverse events (bleeding) in the mother compared with aspirin alone (RR 1.65, 95% CI 0.19 to 14.03, 1 study, 31 women). No women in either the heparin plus aspirin group or the aspirin alone group had heparin-induced thrombocytopenia, allergic reactions, or venous or arterial thromboembolism. Similarly, no infants had congenital malformations. Heparin plus aspirin may reduce the risk of pregnancy loss (RR 0.48, 95% CI 0.32 to 0.71, 5 studies, 1295 women, low-certainty evidence). When comparing LMWH plus aspirin versus aspirin alone the pooled RR for live birth was 1.20 (95% CI 1.04 to 1.38, 3 trials, 1155 women). In the comparison of UFH plus aspirin versus aspirin alone, the RR for live birth was 1.74 (95% CI 1.28 to 2.35, 2 trials, 140 women). AUTHORS' CONCLUSIONS The combination of heparin (UFH or LMWH) plus aspirin during the course of pregnancy may increase live birth rate in women with persistent aPL when compared with aspirin treatment alone. The observed beneficial effect of heparin was driven by one large study in which LMWH plus aspirin was compared with aspirin alone. Adverse events were frequently not, or not uniformly, reported in the included studies. More research is needed in this area in order to further evaluate potential risks and benefits of this treatment strategy, especially among women with aPL and recurrent pregnancy loss, to gain consensus on the ideal prevention for recurrent pregnancy loss, based on a risk profile.
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Affiliation(s)
- Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luuk Jj Scheres
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mauritia C Marijnen
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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