Genetic prothrombotic risk factors in women with unexplained pregnancy loss

Australasian recurrent pregnancy loss clinical management guideline 2024, part II

Part II of the Australasian guideline for the investigation and management of recurrent pregnancy loss (RPL) provides evidence-based guidance on the management of RPL provided. The implications of inherited and acquired thrombophilia with respect to RPL and suggestions for clinical management are provided. Autoimmune factors, including human leukocyte antigen, cytokines, antinuclear antibodies and coeliac antibodies, and guidance for management are discussed. Infective, inflammatory and endometrial causes of RPL are discussed in detail. Environmental and lifestyle factors, male factor and unexplained causes are outlined. Levels of evidence and grades of consensus are provided for all evidence-based statements.

Thrombophilia and Pregnancy

Leading cause of death in pregnant women still remains venous thromboembolism, with an incidence of 1.4 to 4.9 per 100,000 pregnancies. A special group of inherited and acquired coagulation disorders associated with a susceptibility to thrombosis is thrombophilia. Physiological changes during the pregnancy also contribute to the occurrence thromboembolic diseases (VTE) in pregnancy. Total rate of venous thromboembolism is 100 per 100,000 pregnancies and 200 per 100,000 births. Etiopathogenesis of obstetric complications in thrombophilia is not clearly defined, which is one of the reasons for the occasional failure of therapy. In pregnancies with hereditary thrombophilia the oxidative stress is considered to be a cause of complications, similar to preeclampsia. Based on the findings so far, additional research should clarify questions regarding the anticoagulants role in pregnancy loss prevention. In this paper, we analyze the effect of the screening on pregnancy outcomes, consider the justification for the use of anticoagulation therapy in difficult situations, discuss about previous knowledge in the field and argue the use of new specific protocols. In short, we address the justification for prescribing anticoagulants and evaluation of their effect within thrombophilia therapeutic strategies.

Hereditary thrombophilia and recurrent pregnancy loss: a systematic review and meta-analysis

STUDY QUESTION

Is there an association between hereditary thrombophilia in pregnant women and risk of recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

Pregnant women with hereditary thrombophilia have an increased risk of RPL, especially for pregnant women with the G1691A mutation of the factor V Leiden (FVL) gene, the G20210A mutation of the prothrombin gene (PGM), and deficiency of protein S (PS).

WHAT IS KNOWN ALREADY

Prior studies have suggested that pregnant women with hereditary thrombophilia have a higher risk of RPL, however, the results are inconsistent; furthermore, a complete overview is missing. This lack of information is an obstacle to the risk assessment of RPL in pregnant women with hereditary thrombophilia. A comprehensive meta-analysis on the relation between hereditary thrombophilia and the risk of RPL is needed.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis was performed using observational studies published in English before 1 April 2020 to evaluate the relation between hereditary thrombophilia and risk of RPL.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Relevant studies were identified from PubMed, Web of Science, and EMBASE searches and complemented with perusal of bibliographies of retrieved articles. The exposure of interest was hereditary thrombophilia, including FVL mutation, PGM, deficiency of antithrombin (AT), deficiency of protein C (PC), and deficiency of PS. The overall risk estimates were pooled using random effects models. Subgroup and sensitivity analyses were carried out to explore possible sources of heterogeneity and assess the robustness of the results.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 89 studies involving 30 254 individuals were included. Results showed that women with FVL mutation (odds ratio (OR): 2.44, 95% CI: 1.96-3.03), PGM (OR: 2.08, 95% CI: 1.61-2.68), or deficiency of PS (OR: 3.45, 95% CI: 1.15-10.35) had higher risks of developing RPL. Compared with the reference group, there was no observed relation between a deficiency in AT or PC and RPL (all P > 0.05). Heterogeneity in the risk estimates of RPL was partially explained by geographic region, definitions of RPL, types of RPL, and controlled confounders. Sensitivity analyses validated the robustness of the findings.

LIMITATIONS, REASONS FOR CAUTION

Only 39 of the included studies controlled for one or more confounders, and the heterogeneity across all included studies was high. Based on the data available, we cannot determine whether this association is confounded by other potential risk factors of RPL.

WIDER IMPLICATIONS OF THE FINDINGS

This systematic review and meta-analysis show a possible association between hereditary thrombophilia and an increased risk of RPL, suggesting that testing for hereditary thrombophilia should be considered in individuals with RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Hunan Provincial Key Research and Development Program (Grant number: 2018SK2062) and National Natural Science Foundation Program (Grant number: 81973137). There are no conflicts of interest.

REGISTRATION NUMBER

N/A.

Uterine Radial Artery Resistance Index Predicts Reproductive Outcome in Women with Recurrent Pregnancy Losses and Thrombophilia

Uterine radial artery resistance index (URa-RI) by Doppler ultrasound may reflect the changes in the uteroplacental circulation and be associated with adverse events in early pregnancy. Recurrent pregnancy losses (RPL) are associated with thrombophilia, and anticoagulation treatment with low molecular weight heparin improves pregnancy outcome in women with RPL and thrombophilia. A retrospective cohort study was conducted in 139 pregnant women with 3 or more RPL and thrombophilia. The relationship between pregnancy outcome and dynamic changes of URa-RI was analyzed in 116 women who delivered a liveborn infant and 23 who miscarried the index pregnancy. Patients were on preconception low molecular weight heparin, low-dose aspirin (81mg per day), and prednisone treatment. URa-RI was measured during periovulation time, at the time of positive pregnancy test, and then repeated every two weeks until 32-week gestation or the time of miscarriage. The URa-RI at 8-week gestation was significantly higher in women who miscarried the index pregnancy than those who delivered alive born infant (0.51±0.08 vs. 0.42±0.03, P<0.001). Receiver operating characteristic curve analysis demonstrated that URa-RI of 8 wk gestation effectively distinguished women who miscarried from those who had a live birth with an area under the curve of 82.6% (95% CI 69.01-97.17). After adjusting for covariates including age, BMI, and number of miscarriages, multiple logistic regression models showed that each 0.1 unit increase of URa-RI of 8 wk gestation was associated with 18.70-point increase in the risk of miscarriage (OR19.70, 95%CI 4.26-91.1, P<0.001), and women with an URa-RI≥0.45 had an OR of 49.48 (95% CI 8.01-307.95; P<0.001) for miscarriage compared to those who had URa-RI<0.45. In women with RPL and inherited thrombophilia, increased URa-RI at 8-week gestation was associated with spontaneous abortion independent of other risk factors while they were on anticoagulation treatment.

Thrombophilia and Recurrent Pregnancy Loss: Is heparin still the drug of choice?

The association between thrombophilia and recurrent pregnancy loss (RPL) has become an undisputed fact. Thorombophilia creates a hypercoaguable state which leads to arterial and/or venous thrombosis at the site of implantation or in the placental blood vessels. Anticoagulants are an effective treatment against RPL in women with acquired thrombophilia due to antiphospholipid syndrome. The results of the use of anticoagulants for treating RPL in women with inherited thrombophilia (IT) are encouraging, but recently four major multicentre studies have shown that fetal outcomes (determined by live birth rates) may not be as favourable as previously suggested. Although the reported side-effects for anticoagulants are rare and usually reversible, the current recommendation is not to use anticoagulants in women with RPL and IT, or for those with unexplained losses. This review examines the strength of the association between thrombophilia and RPL and whether the use of anticoagulants can improve fetal outcomes.

The role of thrombophilia in pregnancy

Thrombotic disease is a major cause of peripartum morbidity and mortality worldwide. Development of thrombosis in pregnancy is multifactorial due to the physiologic changes of pregnancy—which induce a relative hypercoagulable state—as well as physical changes leading to increased stasis and also the effects of both the inherited and the acquired thrombophilias. In this review, we discuss the impact of each of these factors on the development of thrombosis as well as the evidence for the impact of pregnancy-associated thrombosis on pregnancy outcome. We then discuss the use of both prophylactic and therapeutic anticoagulation during pregnancy and the puerperium. We review the indications and dosing recommendations for administration of anticoagulation in a context of discussing the evidence including the lack of evidence and formal guidelines in this area. We briefly address the role of the new oral anticoagulants in pregnancy and conclude that significant further research in women with thrombophilias and pregnancy-associated thrombosis may help clarify the management of this condition in the future.

Post-mortem examination after stillbirth: views of UK-based practitioners

OBJECTIVES

Worldwide, around four million stillbirths occur annually. The UK was recently ranked as 33rd out of 35 developed nations for stillbirth rates. The reasons for many stillbirths remain unexplained. Post-mortem examination (PME) can provide information for grieving families, and for future pregnancies. Rates of consent for PME are decreasing in the UK. The views of professionals may influence their approach to bereaved families, and, therefore, rates of consent. Arguably, obtaining qualitative insights into emotive areas such as PME from large numbers of practitioners is increasingly possible as electronic surveys become more sophisticated. Therefore we aimed to describe, using electronic media, the views of UK obstetricians, midwives and perinatal pathologists about PME for stillbirth.

STUDY DESIGN

10,000 UK midwives, 1136 UK obstetricians and all 40 UK perinatal pathologists received a link to an Internet survey via their professional organizations. A box was included for free-text responses. Iterative thematic analysis generated five themes and a 'line of argument' synthesis.

RESULTS

683 midwives, 98 obstetricians, and 11 perinatal pathologists provided open comments, generating five themes and the following line of argument: both professional views and family decision-making about postmortem after stillbirth are affected by the education and training of staff, local resources, and the quality of information available. All of these structural issues are interpreted by individual staff, women and families through personal beliefs and emotions, and professional and social discourses.

CONCLUSIONS

Internet-based surveys can generate valuable qualitative data. Effective decision-making for post-mortem after stillbirth may be improved by the introduction of user-friendly information and consent procedures, and staff training that takes account of existing innovations, and of the emotions and prior experiences of both staff and parents.

Association of the R67X and W303X non-sense polymorphisms in the protein Z-dependent protease inhibitor gene with idiopathic recurrent miscarriage

Protein Z-dependent protease inhibitor (ZPI) is a 72 kDa single-chain serpin which inhibits the activated coagulation factors X and XI. Two non-sense polymorphisms of ZPI, R67X and W303X, were recently identified, and were linked with a prothrombotic state. Here, we investigated the association of the R67X (728C>T) and W303X (1438G>A) variants in the ZPI gene with recurrent spontaneous miscarriage (RSM). This was a case-control study involving a total of 288 women with a history of two consecutive or ≥3 non-consecutive pregnancy losses between 8 and 12th week of gestation, along with 304 age-matched and ethnically matched multiparous control women, with no personal or family history of pregnancy complications. The minor allele frequency of R67X (P = 0.003) and W303X (P = 0.014) were higher in RSM cases than in control women. Both single-nucleotide polymorphisms were significantly associated with RSM under the dominant genetic association model, and were in moderate linkage disequilibrium (D' = 0.412; P < 0.001). Taking the common (728)C/(1438)G haplotype as reference, multivariate analysis confirmed the positive association of (728)T/(1438)G [P = 0.043; odds ratio (OR) = 2.25; 95% confidence interval (CI) = 1.03-4.90], and (728)T/(1438)A (P = 0.022; OR = 3.93; 95% CI = 1.23-12.59) haplotypes with increased RSM risk. These differences remained significant after controlling for some covariates. These results demonstrate that both ZPI R67X and W303X non-sense variants and specific ZPI haplotypes are significantly associated with RSM.

Can Factor V Leiden and prothrombin G20210A testing in women with recurrent pregnancy loss result in improved pregnancy outcomes?: Results from a targeted evidence-based review

Women with recurrent pregnancy loss are offered Factor V Leiden (F5) and/or prothrombin G20210A (F2) testing to identify candidates for anticoagulation to improve outcomes. A systematic literature review was performed to estimate test performance, effect sizes, and treatment effectiveness. Electronic searches were performed through April 2011, with review of references from included articles. English-language studies addressed analytic validity, clinical validity, and/or clinical utility and satisfied predefined inclusion criteria. Adequate evidence showed high analytic sensitivity and specificity for F5 and F2 testing. Evidence for clinical validity was adequate. The summary odds ratio for association of recurrent pregnancy loss with F5 in case-controlled studies was 2.02 (95% confidence interval, 1.60-2.55), with moderate heterogeneity and suggestion of publication bias. Longitudinal studies in women with recurrent pregnancy loss or unselected cohorts showed F5 carriers were more likely to have a subsequent loss than noncarriers (odds ratios: 1.93 and 2.03, respectively). Results for F2 testing were similar. For clinical utility, evidence was adequate that anticoagulation treatments were ineffective (except in antiphospholipid antibody syndrome) and had treatment-associated harms. The certainty of evidence is moderate (high, moderate, and low) that anticoagulation of women with recurrent pregnancy loss and F5/F2 variants would currently lead to net harms.

Association of inherited thrombophilia with recurrent pregnancy loss in palestinian women

Objective. This study aimed at analyzing the association between recurrent pregnancy loss (RPL) and factor V G1691A (FVL), prothrombin G20210 (FII); and MTHFR C677T (MTHFR) in Palestinian women. Method. We studied 329 Palestinian women with RPL and/or stillbirth (SB); and compared them to 402 healthy reproductive Palestinian women. Cases and controls were tested for the above mutations. Odds ratio (OR) at confidence interval (CI) of 95% was used as a measure of association between the mutations and RPL. Results. Our statistical analysis showed a slightly increased association, which was not significant between FVL and RPL (OR 1.32, 95% CI 0.90-1.94), and no association between FII (OR 0.84, 95% CI 0.38-1.92), MTHFR (OR 0.58, 95% CI 0.32-1.03), and RPL. Further analysis of RPL subgroups revealed an association between FVL and first-trimester loss (OR 1.33, 95% CI 0.892-1.989), and second-trimester loss (OR 1.13, 95% CI 0.480-2.426), both were not statistically significant. Furthermore, the only statistically significant association was between FVL and SB (OR 2.0, 95% CI 1.05-3.70). Conclusion. Our analysis had failed to find a significant association between FVL, FII, MTHFR; and RPL in either the first or second trimester. FVL was significantly associated with fetal loss if the loss was a stillbirth.

Thrombophilias and stillbirth

It is often postulated that both inherited and acquired thrombophilias increase the risk of stillbirth. In an attempt to reduce this theoretical risk, pregnant patients with prior fetal losses and thrombophilias are anticoagulated. However, there is no definitive proof that thrombophilias are causally linked to stillbirth. Prospective studies have failed to establish a definitive link between inherited thrombophilias and stillbirth. The extant literature suggests that only high concentrations of antiphospholipid antibodies are associated with stillbirth. Moreover, when pregnant women with prior fetal losses even in these cases are placed on anticoagulation, it is unclear that their recurrence risk of stillbirth decreases.

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The association between stillbirth in the first pregnancy and subsequent adverse perinatal outcomes

OBJECTIVE

We sought to examine the association between first-pregnancy stillbirth and subsequent adverse perinatal outcomes.

STUDY DESIGN

This cohort study examined the first 2 singleton deliveries at 20-44 weeks' gestation from 1991-2008 (n = 71,315) using birth certificate, hospitalization, and outpatient encounter files. Multivariable logistic regression models were used to assess the association.

RESULTS

Stillbirth was observed in 5.3 of 1000 first deliveries. There was an increased risk of ischemic placental disease (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1), fetal distress (OR, 2.8; 95% CI, 1.7-4.5), chorioamnionitis (OR, 2.3; 95% CI 1.5-4.3), extreme preterm birth (OR, 4.2; 95% CI, 1.8-9.9), and early neonatal mortality (OR, 8.3; 95% CI, 3.7-18.6) in pregnancies after stillbirth vs pregnancies after live birth. Interpregnancy intervals <2 and > or =4 years after stillbirth increased the risk of ischemic placental disease and spontaneous preterm birth. Risks varied by stillbirth subtype.

CONCLUSION

A first-pregnancy stillbirth may increase adverse perinatal outcomes in subsequent pregnancy.

Paternal thrombophilic gene mutations are not associated with recurrent miscarriage

PROBLEM

Recurrent miscarriage (RM) affects 1-3% of couples. So far, diagnostic procedures are performed only in female patients. However, the main part of the placentary perfusion is encoded by both the maternal and the paternal genome.

METHOD OF STUDY

In this case-control study, German couples with two (n = 49) or three and more RM (n = 102) and 157 German control couples were analyzed for the factor V-Leiden 169 1G > A mutation (FVL), the prothrombin (PT) 202 10G > A substitution, and the 677C > T replacement in the 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene.

RESULTS

No significant differences in the prevalence of the FVL, PT or MTHFR mutation were observed in male partners of RM patients and in control men [RM/control: FVL heterozygous 13/151 (8.6%): 14/157 (8.9%) (P = 0.9); PT heterozygous 2/151 (1.3%): 7/157 (4.5%) (P = 0.097); PT homozygous 0/151: 2/157 (1.3%); MTHFR homozygous 19/151 (12.6%): 18/157 (11.5%) (P = 0.12)]. This was also true for female RM patients. However, miscarriage during the embryonal period (5-10 weeks of gestation) was significantly associated with a maternal heterozygous FVL mutation (P = 0.014).

CONCLUSION

Recurrent miscarriage was not associated with paternal thrombophilia. Men of the control group showed an even higher incidence of the PT and MTHFR mutations. Abortions in the embryonic phase of fetal development were associated with a significantly higher incidence of maternal heterozygosity for FVL.