How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review

A Novel Splice Donor Site Mutation Leading to Inherited Type I Protein S Deficiency

Inherited Protein S (PS) deficiency is an autosomal dominant thrombotic disorder. We encountered a case of inherited type I PS deficiency following a close examination for recurrent pregnancy loss and identified the mutation responsible; a novel splice donor site mutation in intron 13 of the PROS1 gene appeared to have caused a frameshift with premature termination at amino acid +551. These results will contribute to the creation of an accurate database and define the molecular basis for PS deficiency.

Immunological Risk Factors in Recurrent Pregnancy Loss in Patients With Hereditary Thrombophilia

BACKGROUND

Recurrent pregnancy loss (RPL) is a complicated reproductive disorder with underlying genetic and immunological causes. RPL may be influenced by hereditary thrombophilia, a class of blood clotting-related genetic abnormalities, via the vascular and immune systems. This study examines the immunological characteristics that hereditary thrombophilia patients have in common with RPL.

METHODS

A prospective cohort study included 300 patients split into two groups: a control group without hereditary thrombophilia and a group with the condition. Interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ) levels were measured, along with demographic specifics, antiphospholipid antibodies, natural killer (NK) cell counts, and other cytokines. Group differences were found using statistical analysis.

RESULTS

Antiphospholipid antibodies were significantly more common in the thrombophilia group (42% testing positive, p=0.001) compared to the control group (12% testing positive), despite demographic factors being similar between groups (p=0.372 and p=0.093). When body mass index (BMI) was taken into account, the study found a statistically significant difference (p=0.046), with the thrombophilia group having a higher mean BMI (26.3 kg/m2, standard deviation (SD): 2.8) than the control group (24.7 kg/m2, SD: 3.1). IL-6 (14.8 pg/mL, SD: 3.2, p=0.029) were higher than the control group (12.4 pg/mL, SD: 2.1), and TNF-α levels were higher in the thrombophilia group (10.5 pg/mL, SD: 2.0, p=0.012) compared to the control group (8.9 pg/mL, SD: 1.5), but NK cell counts did not differ significantly (p=0.213).

CONCLUSION

This study emphasizes the role of elevated pro-inflammatory cytokines (IL-6 and TNF-α) and antiphospholipid antibodies in RPL among people with hereditary thrombophilia. In this population, early detection and immunomodulatory interventions may improve pregnancy outcomes. To fully comprehend these mechanisms and create customized treatments, collaborative research is required.

Recurrent MiscarriageGreen-top Guideline No. 17

In this guideline, recurrent miscarriage has been defined as three or more first trimester miscarriages. However, clinicians are encouraged to use their clinical discretion to recommend extensive evaluation after two first trimester miscarriages, if there is a suspicion that the miscarriages are of pathological and not of sporadic nature. Women with recurrent miscarriage should be offered testing for acquired thrombophilia, particularly for lupus anticoagulant and anticardiolipin antibodies, prior to pregnancy. [Grade C] Women with second trimester miscarriage may be offered testing for Factor V Leiden, prothrombin gene mutation and protein S deficiency, ideally within a research context. [Grade C] Inherited thrombophilias have a weak association with recurrent miscarriage. Routine testing for protein C, antithrombin deficiency and methylenetetrahydrofolate reductase mutation is not recommended. [Grade C] Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s) and in any second trimester miscarriage. [Grade D] Parental peripheral blood karyotyping should be offered for couples in whom testing of pregnancy tissue reports an unbalanced structural chromosomal abnormality [Grade D] or there is unsuccessful or no pregnancy tissue available for testing. [GPP] Women with recurrent miscarriage should be offered assessment for congenital uterine anomalies, ideally with 3D ultrasound. [Grade B] Women with recurrent miscarriage should be offered thyroid function tests and assessment for thyroid peroxidase (TPO) antibodies. [Grade C] Women with recurrent miscarriage should not be routinely offered immunological screening (such as HLA, cytokine and natural killer cell tests), infection screening or sperm DNA testing outside a research context. [Grade C] Women with recurrent miscarriage should be advised to maintain a BMI between 19 and 25 kg/m2 , smoking cessation, limit alcohol consumption and limit caffeine to less than 200 mg/day. [Grade D] For women diagnosed with antiphospholipid syndrome, aspirin and heparin should be offered from a positive test until at least 34 weeks of gestation, following discussion of potential benefits versus risks. [Grade B] Aspirin and/or heparin should not be given to women with unexplained recurrent miscarriage. [Grade B] There are currently insufficient data to support the routine use of PGT-A for couples with unexplained recurrent miscarriage, while the treatment may carry a significant cost and potential risk. [Grade C] Resection of a uterine septum should be considered for women with recurrent first or second trimester miscarriage, ideally within an appropriate audit or research context. [Grade C] Thyroxine supplementation is not routinely recommended for euthyroid women with TPO who have a history of miscarriage. [Grade A] Progestogen supplementation should be considered in women with recurrent miscarriage who present with bleeding in early pregnancy (for example 400 mg micronised vaginal progesterone twice daily at the time of bleeding until 16 weeks of gestation). [Grade B] Women with unexplained recurrent miscarriage should be offered supportive care, ideally in the setting of a dedicated recurrent miscarriage clinic. [Grade C].

Homozygous Carriers of F2 c.20210G>A Variant: A Report of Two Cases and Literature Review

Thromboembolism is known to be a multifactorial event that is impacted by various genetic and environmental factors. The genetics society's recommended name for this variant is c.*97G>A (this is the nomenclature we need to use in the patient report). However, people have been using legacy names c.20210G>A or G20210A (so these are common names). One of the most common genetic variants associated with inherited thrombophilias, F2 c.20210G>A is acknowledged to be a weak but significant risk factor for thromboembolism. However, its clinical presentation has been described as phenotypically heterogeneous. We present two rare cases with homozygous F2 c.20210G>A variant, one of which also carries a heterozygous variant in coagulation factor V gene F5, c.1601G>A (p.Arg534Gln; commonly known as factor V Leiden). We described the clinical courses of these two cases and discussed F2 c.20210G>A and factor V Leiden as genetic risk factors in thromboembolism, the role of provoking factors, such as surgery and malignancy, and the management of such patients.

The Proper Diagnosis of Thrombophilic Status in Preventing Fetal Growth Restriction

Fetal growth restriction is an important part of monitoring a pregnancy. Because guidelines or diagnostic criteria for either minor or major thrombophilia are scarce, this systematic review aims to summarize the present knowledge in the field. We performed the CRD42022376006 protocol in Prospero with a systematic literature search in PubMed and Web of Science databases and included original full-text articles (randomized control trials and clinical trials) from the last 10 years, published in English, and with the "thrombophilia AND (pregnancy OR diagnostic criteria) AND fetal growth restriction" criteria. After two researchers extracted the articles of interest, they were assessed using the Newcastle-Ottawa Scale and eight articles were included. The elements from the thrombophilia diagnostic predict IUGR, factor V Leiden mutation, MTHFR C667T mutation, protein S deficiency, antithrombin deficiency, factor VII polymorphism, and antiphospholipid antibodies, while the association of protein C, PAI-1 and certain combinations of mutations are still under debate and require the collection of more data. The present systematic review provides an extensive picture of the actual knowledge about thrombophilia diagnosis and its links with pregnancy complications, such as intrauterine growth restriction, despite its limitation in the inclusion of other actually debated disorders such as PAI-1 mutation, protein C deficiency and other thrombophilia types.

Clinical risk factors for vasculo-placental disorders: results from a prospective case-control study nested in HEMOTHEPP French cohort study

OBJECTIVE

Determine clinical risk factors for vasculo-placental disorders in singleton pregnancies.

DESIGN

Prospective case-control study nested in HEMOTHEPP French cohort.

SETTING

Women delivered between June, 2015 and January, 2019 in any maternity ward of Finistère.

POPULATION

Cases were women with vasculo-placental disorders (pre-eclampsia, intrauterine growth restriction (IUGR), placental abruption or stillbirth). Controls were women matched for age at delivery and parity.

METHODS

Clinical data were collected by obstetricians or midwives during antenatal care visits and delivery, and recorded by trained research assistants.

MAIN OUTCOME MEASURES

Occurrence of a vasculo-placental disorder.

RESULTS

505 women with vasculo-placental disorder (299 pre-eclampsia, 253 IUGR, 44 placental abruptions, 11 stillbirths) and 1515 matched controls were selected out of 20,075 participants. In multivariable analysis, four clinical parameters were associated with pre-eclampsia: obesity (Odd ratio (OR) = 3.11, 95%CI 2.11-4.58), French overseas origin (OR = 4.41, 95%CI 1.87-10.42), previous vasculo-placental disorder (OR = 5.14, 95%CI 2.72-9.70), aspirin during pregnancy (OR = 10.10, 95%CI 1.99-51.08). Three clinical parameters were associated with IUGR: auto-immune/inflammatory disorder (OR = 3.75, 95%CI 1.83-7.68), previous vasculo-placental disorder (OR = 3.63, 95%CI 2.06-6.41), smoking during pregnancy (OR = 2.66, 95%CI 1.91- 3.71). A previous venous thromboembolism (VTE) was associated with IUGR in univariable but not in multivariable analysis (OR = 3.72, 95%CI 0.82-17.00, p = 0.09).

CONCLUSIONS

Clinical risk factors differ between IUGR and pre-eclampsia, the later, but not the former, being associated with cardiovascular risk factors.

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.

The association between chronic liver diseases and preeclampsia

Background

Preeclampsia is a multisystem disorder characterized by an abnormal vascular response to placentation associated with increased systemic vascular resistance. As liver involvement is one of the main clinical features of preeclampsia, we sought to determine if there is an association between chronic liver diseases and preeclampsia.

Methods

A retrospective matched case–control analysis was conducted in a tertiary medical center. Three hundred eleven (311) pregnant women with preexisting chronic liver disease (study group), including viral and autoimmune hepatitis, non-alcoholic fatty liver, Wilson disease, and cirrhosis, were match for age, parity, and number of fetuses to 933 healthy pregnant women (control group). The primary outcome measure was the incidence of preeclampsia in each group. Secondary outcome measures were obstetrical and neonatal complications. Confounders found to be significant on univariate analysis were evaluated using logistic regression models, and odds ratios (OR) and confidence intervals (CI) were calculated.

Results

Preeclampsia was diagnosed in 28 women (9.0%) in the study group and 33 women (3.54%) in the control group (p < 0.001).

On multivariate analysis adjusted for maternal age, parity, previous preeclampsia, chronic hypertension, gestational diabetes mellitus, pregestational diabetes mellitus, antiphospholipid syndrome, and mode of conception, chronic liver disease was found to be an independent risk factor for preeclampsia (aOR 2.631, 95% CI 1.518–4.561). Although there was no difference in the gestational week at delivery between the groups (38.6 ± 2.13 vs. 38.8 ± 2.17 for study and control group, respectively, p = 0.410), the study group had a lower mean neonatal birthweight (3088 ± 551 vs. 3182 ± 566 g, p = 0.011). There were no between-group differences in the other parameters evaluated.

Conclusion

In our study, preexisting chronic liver disease was associated with a 2.6-fold increased risk of preeclampsia.

Delivery timing in dichorionic diamniotic twin pregnancies complicated by preeclampsia: a decision analysis

OBJECTIVE

To determine the optimal timing of delivery in Dichorionic-diamniotic (DCDA) pregnancies complicated by preeclampsia without severe features.

METHODS

A decision-analytic model was created to compare outcomes of expectant management vs. delivery from 34 to 37w0d. Outcomes included quality-adjusted life years (QALYs), development of severe preeclampsia, maternal mortality, maternal stroke, small for gestational age (SGA) due to fetal growth restriction (FGR) detected antenatally, stillbirth, cerebral palsy (CP), and neonatal mortality. Probabilities, utilities, and life expectancies were derived from the literature. Univariate analysis was used to evaluate the impact of delivery at various gestational ages. Maternal and neonatal outcomes were calculated for a theoretical cohort of 10,000 DCDA pregnancies with preeclampsia.

RESULTS

The optimal gestational age for delivery was 36w0d when the total QALYs (868,112) were highest. Delivery at 34w0d resulted in the fewest cases of severe preeclampsia, maternal mortality, and maternal stroke (0, 4, and 15 cases per 10,000, respectively). The incidence of each of these adverse outcomes increased with gestational age, with the greatest number of adverse outcomes at 37w0d (2452 cases of severe preeclampsia, eight maternal deaths, and 31 cases of maternal stroke per 10,000). Delivery at 34w0d resulted in the fewest cases of severe preeclampsia (0), maternal stroke (15), maternal mortality (4), stillbirth (0), and SGA (1183). However, this strategy was also associated with most cases of neonatal CP (91) and neonatal mortality (87).

CONCLUSION

DCDA twin pregnancies complicated by preeclampsia without severe features appear to have the best outcomes when delivered at 36w0d. Specifically, when compared to delivery at 37w0d, this strategy reduced maternal and neonatal morbidity and mortality.

Factor V Leiden G1691A and Prothrombin Gene G20210A Mutations on Pregnancy Outcome

Factor V Leiden (FVL) G1619A mutation and prothrombin gene (PTG) G20210A are the most common inherited thrombophilias. They have been associated with various obstetric complications such as venous thromboembolism, recurrent pregnancy loss, preeclampsia, abruptio placentae, and small for gestational age fetus. The prevalence of these two mutations is 3-15% in Caucasians and is assumed to be far less common in other ethnic populations. However, there have been several controversies regarding advising routine screening of these thrombophilias because of a widely variable strength of association between different ethnic groups, as well as contradictory conclusions by different studies in regards to the association. In this study, the literature was analyzed thoroughly for the effect of FVL G1619A and PTG G20210A mutations on various obstetric outcomes. A review of multiple case-control and prospective studies suggests that despite the availability of robust data on this subject the results remain inconclusive and insubstantial. Further superior quality research, preferably prospective studies, is warranted to conclusively establish this relationship and to enable practitioners to follow a definitive protocol in the screening of various populations for these mutations to achieve an improved pregnancy outcome.

Inherited thrombophilia is significantly associated with severe preeclampsia

Methods to prevent the development of pathologies due to placental dysfunctions, such as gestational hypertension and preeclampsia, are the main approaches for obtaining the best maternal and fetal antepartum and postpartum prognosis. During 5 years of study (January, 2015 to December, 2019), the cases of pregnancy and puerperium complicated with pathology due to placental dysfunction were analyzed. The main objective was to determine the magnitude of the impact of thrombophilia on the development of an entity of gestational hypertension disorder. We compared the impact of thrombophilia and its associated complications in patients with gestational hypertension with moderate and severe preeclampsia. Thus, we found obesity, thrombophilia, and underlying cardiac pathology to be significant risk factors for severe preeclampsia. Regarding the comparative analysis of the risk factors and complications associated with patients with mild preeclampsia compared with those with severe preeclampsia, the presence in severe preeclampsia of thrombophilia, endocrine, liver, and cardiac pathology was higher and, a higher rate of complications was observed; complications included fetal death, intrauterine growth restriction (IUGR), prematurity, fetal arrhythmia with acute fetal distress, HELLP syndrome, and placental abruption. Thrombophilia has a significant effect on the development of severe preeclampsia, and oligohydramnios as specific complication of mild preeclampsia. Factors indicating an increased risk of progression from mild preeclampsia to severe preeclampsia are in addition to inherited thrombophilia the underlying pathologies, namely cardiac, hepatic, and endocrine factors.

Why we succeed and fail in detecting fetal growth restriction: A population-based study

INTRODUCTION

The objective of this study was to explore the association between detection of fetal growth restriction and maternal-, healthcare provider- and organizational factors.

MATERIAL AND METHODS

A historical, observational, multicentre study. All women who gave birth to a child with a birthweight <2.3rd centile from 1 September 2012 to 31 August 2015 in Zealand, Denmark, were included. The population was identified through the Danish Fetal Medicine Database. Medical charts were reviewed to obtain data regarding maternal characteristics and information on the healthcare professionals. Date of authorization for the midwives and obstetricians involved was extracted from the Danish Health Authorization Registry. Multivariable Cox regression models were used to identify predictors of antenatal detection of fetal growth restriction, and analyses were adjusted for hospital, body mass index, parity, the presence of at least one risk factor and experience of the first midwife, number of midwife visits, number of visits to a doctor, the experience of the consultant midwife or the educational level of the doctor, the number of scans and gaps in continuity of midwife-care. Antenatal detection was defined as an ultrasound estimated fetal weight <2.3rd centile (corresponding to -2 standard deviations) prior to delivery.

RESULTS

Among 78 544 pregnancies, 3069 (3.9%) had a fetal growth restriction. Detection occurred in 31% of fetal growth-restricted pregnancies. Clinical experience (defined as years since graduation) of the first consultation midwife was positively associated with detection, with a hazard ratio [HR] of 1.15, 95% confidence interval [CI] 1.03-1.28), for every 10 years of additional experience. The hazard of detection increased with the number of midwife consultations (HR 1.15, 95% CI 1.05-1.26) and with multiparity (HR 1.28, 95% CI 1.03-1.58). After adjusting for all covariates, an unexplained difference between hospitals (P = .01) remained.

CONCLUSIONS

The low-risk nullipara may constitute an overlooked group of women at increased risk of antenatal non-detection of fetal growth restriction. Being screened by experienced midwives during early pregnancy and having access to multiple midwife consultations may improve future diagnosis.

Association of MTHFR 677C>T polymorphism with IUGR and placental abruption risk: A systematic review and meta-analysis

OBJECTIVE

The effects of the MTHFR 677C > T polymorphism on the intrauterine growth restriction (IUGR) and placental abruption risk have been evaluated in some studies. However, those studies results were conflicting and ambiguous. Therefore, we carried out the current meta-analysis to evaluate the association of MTHFR 677C > T polymorphism with risk of IUGR and placental abruption from all eligible studies.

METHODS

An electronic search of the PubMed, Embase, Scopus and CNKI databases was performed up to February 25, 2020.

RESULTS

A total of 25 case-control studies including eight studies with 687 cases and 2336 controls for IUGR and 17 studies with 1574 cases and 5758 controls for placental abruption were selected. The analysis results indicated that MTHFR 677C > T polymorphism was associated with an increased risk of IUGR and placental abruption in global population. When stratified by ethnicity a significant association between the MTHFR 677C > T polymorphism and IUGR risk was found in Caucasians and Africans. However, there was no a significant association between the MTHFR 677C > T polymorphism and placental abruption risk by ethnicity.

CONCLUSIONS

Our pooled data indicated that the MTHFR 677C > T polymorphism might play a role in development of IUGR and placental abruption.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

The Correlation Between Abnormal Uterine Artery Flow in the First Trimester and Genetic Thrombophilic Alteration: A Prospective Case-Controlled Pilot Study

INTRODUCTION

Evaluation of the first trimester uterine artery flow can predict the development of obstetrical complications. A genotype, making women prone to microthrombi. constitutes the main known susceptibility factor for anomalous development of placenta. Our aim was to study whether polymorphisms of 10 genes leading to blood clotting abnormalities are related to abnormal uterine artery blood flow in the first trimester, and may predict placenta-related diseases.

MATERIAL AND METHODS

In primary analyses we included 19 singleton pregnancies with abnormal blood flow in the uterine arteries during the first trimester of gestation, and 24 matched control with normal flow patterns. All patients were genotyped for sequence variations in F5, F2, F11, MTHFR, SERPINE-1, CYP4V2, SELE, GP6, angiotensinogen (AGT) and fibrinogen gamma (FGG) genes and followed up until delivery.

RESULTS

There were no differences between groups regarding selected sequence variations in any of these genes. The co-occurrence of several polymorphisms in the same patient was also not related to the blood flow patterns in the uterine arteries.

CONCLUSIONS

Although we found certain trends of genetic polymorphisms being related to preeclampsia and fetal growth, we failed to find an association between clotting gene polymorphisms, single or in combination, with the abnormal uterine flow in the first trimester.

Evaluation of the plasma protein S dynamics during pregnancy using a total protein S assay: Protein S-specific activity decreased from the second trimester

AIM

The relationship between congenital protein S (PS) deficiency and complications during pregnancy remains unclear, partly due to the difficulty of precisely evaluating the PS level with conventional assays and the physiological decrease of PS during pregnancy. A new PS assay was developed to measure the total PS antigen and activity quantitatively and calculate PS-specific activity. This study aimed to evaluate the plasma PS dynamics during pregnancy using the new PS assay and establish the reference interval for pregnant women.

METHODS

A total of 253 pregnant women without a personal or family history of thromboembolism were recruited. Blood samples were obtained in the first, second and third trimesters and at one month post-partum. The total PS antigen, activity, and PS-specific activity were studied. Results were analyzed by the repeated measures single-factor anovas followed by a post-hoc test using Excel Statistics.

RESULTS

The mean ± standard deviation (IU/mL) of the total PS antigen levels in the first, second and third trimesters and 1 month post-partum were 0.67 ± 0.12, 0.67 ± 0.09, 0.68 ± 0.11 and 0.92 ± 0.13, respectively. The total PS activity (IU/mL) in the first, second and third trimesters and 1 month post-partum were 0.69 ± 0.14, 0.59 ± 0.10, 0.58 ± 0.12 and 0.87 ± 0.15, respectively. The PS-specific activity was within the normal range of nonpregnant women in the first trimester (1.02 ± 0.10) but decreased in the second and third trimesters (0.88 ± 0.09 and 0.85 ± 0.09, respectively) before increasing in the post-partum period (0.94 ± 0.08).

CONCLUSION

The total PS antigen and activity decrease throughout pregnancy, while the PS-specific activity decreases in the second and third trimesters.

ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.

Aspirin, low molecular weight heparin, or both in preventing pregnancy complications in women with recurrent pregnancy loss and factor V Leiden mutation

Objective: The aim of this study was to compare the effects of low molecular weight heparin (LMWH), LMWH plus low dose aspirin, or low dose aspirin only on pregnancy outcomes in recurrent pregnancy loss (RPL) patients with factor V Leiden mutation (FVLM).Materials and methods: A total of 2764 RPL patients were evaluated in for the etiology of RPL. Mutations in factor V Leiden homozygous and heterozygous were determined. Subsequently, 196 of these patients were diagnosed with FVLM and included in the study; of these 174 completed the study. At the sixth week of gestation of subsequent pregnancy participants were randomly distributed into three groups. Group A (n = 61) was composed of patients with an oral dose of 100 mg aspirin daily, Group B (n = 59) consisted of patients using 40 mg enoxaparin and 100 mg orally aspirin daily, and Group C (n = 54) included patients using 40 mg enoxaparin daily during pregnancy.Results: Among the 174 patients who completed the study, the live birth and miscarriage rates were similar for the three groups (p = .843 and p = .694, respectively). There was no significant difference among the groups in rates of eclampsia, placental abruption, intrauterine fetal growth restriction and gestational diabetes mellitus. The number of preeclamptic patients was significantly higher in Group A than Groups B and C. The levels of preterm birth was significantly higher in Group A than Groups B and C.Conclusion: Using low dose aspirin, LMWH plus aspirin, or LMWH alone yielded comparable live birth rates in RPL patients with FVLM. However, LMWH decreased the risk of preeclampsia in this group of patients. LMWH might therefore have a preventive role regarding preeclampsia.

ACOG Practice Bulletin No. 197: Inherited Thrombophilias in Pregnancy

Inherited thrombophilias are associated with an increased risk of venous thromboembolism and have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The purpose of this document is to review common thrombophilias and their association with maternal venous thromboembolism risk and adverse pregnancy outcomes, indications for screening to detect these conditions, and management options in pregnancy. This Practice Bulletin has been revised to provide additional information on recommendations for candidates for thrombophilia evaluation, updated consensus guidelines regarding the need for prophylaxis in women with an inherited thrombophilia during pregnancy and the postpartum period, and discussion of new published consensus guidelines from the Society for Obstetric Anesthesia and Perinatology addressing thromboprophylaxis and neuraxial anesthetic considerations in the obstetric population.

Risk factors and role of low molecular weight heparin in obstetric complications among women with inherited thrombophilia - a cohort study

Introduction

Although there is a vast literature regarding the association between inherited thrombophilia, obstetric complications and the effect of low molecular weight heparin (LMWH), these are controversial and we have not found publications related to additional risk factors other than thrombophilia.

Our objectives were to assess the prevalence of miscarriage, placenta-mediated pregnancy complications and fetal loss in pregnant women with IT, establishing associated risk factors and the effect of LMWH.

Materials and methods

A retrospective cohort of pregnant women with IT was formed. Risk factors considered were: high-risk IT, age ≥35 years, body mass index ≥25 and ≥30, assisted reproductive technology, antiphospholipid antibodies, autoimmune disease, first-degree family history of obstetric complications and personal history of venous or arterial thromboembolic disease, the outcomes being M, FL and PMPC.

Results and conclusions

Data from 250 pregnancies in 88 women were obtained.

There were 112 (45%) Ms, 13 (5.2%) FLs and 25 (10%) PMPCs.

High-risk IT was associated with FL (OR = 4.96; 95% CI, 1.42–17.3). Antiphospholipid antibodies and family history of obstetric complications were associated with PMPC (OR = 7.12; 95% CI, 1.89–26.74, OR = 3.88; 95% CI, 1.18–12.78, respectively). The LMWH presented a benefit in the combined outcome (any obstetric complication, OR = 0.25; 95% CI, 0.12–0.54) and M (OR = 0.41; 95% CI, 0.20–0.82).

We conclude that obstetric complications are common in women with IT. Antiphospholipid antibodies, family history of obstetric complications and high-risk IT might be additional risk factors. The LMWH has an apparent protective effect against obstetric complications, which is consistent with some previous studies.

Stillbirth and factor V Leiden - A regional based prospective evaluation

BACKGROUND

Approximately 10% of Swedes are carriers of coagulation factor V Leiden (FVL). It has been suggested that carriers are at an increased risk of stillbirth. We aimed to assess the risk of stillbirth in carriers of FVL as compared to non-carriers.

METHODS

A consecutive registration of all stillbirths from 2001 to 2015 in the whole Stockholm region has been performed. A FVL blood sample, an autopsy and histopathological examination of the placenta was scheduled to be offered all women with stillbirth. Main outcome was the difference in carriership of FVL between cases with live- vs. stillbirth. The primary cause of death was determined according to the Stockholm hierarchical classification of stillbirth.

RESULTS

The incidence of stillbirth was 3.6‰. Out of the 1392 cases of stillbirth occurring during the study period, FVL status was determined in 963 women. Of these 74 (7.7%) were carriers of FVL as compared to 8.1% in the control group (p = 0.6). A primary cause of death due to infection was twice as common among non-carriers compared to carriers of FVL (odds ratio [OR] = 2.3, 95% CI 1.08-4.8). In the whole study group, the prevalence of SGA was 14-fold increased among stillbirths as compared to live births (OR = 13.9, 95% CI 12.4-15.6).

CONCLUSION

Maternal FVL carriership was not related to an increased risk of stillbirth. However, a diagnosis of primary cause of death due to infection was less likely among FVL carriers.

Genetic risk assessment of thrombophilia in patients with adverse obstetric outcomes

OBJECTIVES

To investigate the incidence of inherited thrombophilias in patients with adverse obstetric outcomes and to compare detection rates of thrombophilias between standard blood tests and a novel genetic test.

METHODS

This is a case-control prospective study performed in Hospital Sant Joan de Déu in Barcelona, Spain. Cases had a history of intrauterine growth restriction requiring delivery before 34 weeks gestation, placental abruption before 34 weeks gestation, or severe preeclampsia. Controls had at least two normal, spontaneously conceived pregnancies at term, without complications or no underlying medical disease. At least 3 months after delivery, all case and control women underwent blood collection for standard blood tests for thrombophilias and saliva collection for the genetic test, which enables the diagnosis of 12 hereditary thrombophilias by analyzing genetic variants affecting different points of the blood coagulation cascade.

RESULTS

The study included 33 cases and 41 controls. There were no statistically significant differences between cases and controls in the standard blood tests for thrombophilias in plasma or the TiC test for genetic variables. One clinical-genetic model was generated using variables with the lowest P values: ABO, body mass index, C_rs5985, C_rs6025, and protein S. This model exhibited good prediction capacity, with an area under the curve of almost 0.7 (P <0.05), sensitivity of almost 67%, and specificity of 70%.

CONCLUSION

Although some association may exist between hypercoagulability and pregnancy outcomes, no significant direct correlation was observed between adverse obstetric outcomes and inherited thrombophilias when analyzed using either standard blood tests or the genetic test. Future studies with a larger sample size are required to create a clinical-genetic model that better discriminates women with a history of adverse pregnancy outcomes and an increased risk of poor outcomes in subsequent pregnancies.

Comparison of different types of twin pregnancies in terms of obstetric and perinatal outcomes: association of vanished twins with methylenetetrahydrofolate reductase (MTHFR) polymorphism(s)

PURPOSE

Vanished twin (VT) has been associated with poor perinatal outcomes. Our research aimed to investigate the outcomes of pregnancies with vanished twin and its possible association with methylenetetrahydrofolate reductase (MTHFR) polymorphisms.

METHODS

This study consisted of 30 of 38 VT pregnancies (group 1, VT group), 109 singletons (group 2), 70 spontaneous twins (group 3), and 101 in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) twins (group 4).

RESULTS

Most patients in group 1 (28/30) were tested for MTHFR genes (C677T or A1298C polymorphisms). Eight of the 38 pregnancies with VT (21.1%) resulted in miscarriage. The prevalence of "2 or more pregnancy losses" in the "obstetric history" in group 1 was higher (23.3%) than those in the other groups (p = 0.007, χ² = 17.8). The allelic frequencies of MTHFR 677 and MTHFR 1298 in group 1 were 0.268 and 0.429, respectively (higher than those in healthy population). The median birthweights in groups 1, 2, 3, and 4 were 2940, 3200, 2300, and 2095 g, respectively. The prevalence of respiratory distress syndrome was significantly higher in the IVF/ICSI twin pregnancy group (p < 0.001, χ² = 21.2). Early pregnancy loss and the presence of "2 or more miscarriages" in the obstetric history of pregnancies with VT were more frequent.

CONCLUSION

The coincidence of VT and MTHFR polymorphisms might play an incidental or factual role in this connection.

Association of hereditary antithrombin deficiency with intrauterine growth restriction

: Antithrombin is a major suppressor of thrombin, factor Xa and blood coagulation. Inherited antithrombin deficiency is rare and is considered among the common causes of inherited thrombophilia. The relationship between antithrombin and IUGR, is questionable. The aim of this study was to trace the relationship between antithrombin deficiency and the intrauterine weight reduction and neonatal morbidity. The study was conducted on 55 full-term neonates (including 25 baby boys and 30 baby girls), all were admitted to Neonatal Intensive Care Unit in Cairo University Hospitals with IUGR; and another 110 healthy full-term neonates as control group. ATIII activities were assessed in citrated of patient and control samples automatically on coagulometer (Stago, France). There was a highly significant relationship regarding ATIII deficiency in IUGR group in relation to control group (P value <0.001). In conclusion, we have identified antithrombin deficiency in Egyptian infants as an additional cause for low-birth weight and intrauterine growth retardation.

The association between IUGR and maternal inherited thrombophilias: A case-control study

One of the risk factors for vascular obstetric complications, such as intrauterine growth restriction (IUGR), is inherited thrombophilias. Nevertheless, routine screening for thrombophilias is not endorsed in pregnant women due to their low prevalence and conflicting results of published studies regarding the usefulness of screening in these patients. The cause of IUGR remains unknown in almost 1 quarter of cases. There are no published studies evaluating the association of inherited thrombophilias and IUGR in patients with IUGR of unknown origin. Understanding and preventing IUGR is an important public health concern, as IUGR has been associated with fetal mortality and neonatal morbidity, as well as adverse long-standing consequences. This study aimed to evaluate the prevalence of inherited thrombophilias in IUGR of unknown cause and to test the association between the inherited thrombophilias and IUGR of unknown cause.This study included 33 cases of IUGR of unknown cause tested for inherited thrombophilias and 66 controls individually matched for age, ethnicity, and smoking status.Patients with plasminogen activator inhibitor 1 (PAI-1) and methylenetetrahydrofolate reductase (MTHFR) had significantly higher odds for IUGR of unknown cause (P < .001 and P = .002, respectively) with OR 13.546 (CI 95% 3.79-48.37) and 8.139 (CI 95% 2.20-30.10), respectively. A positive association between other inherited thrombophilias (homozygous 20210 prothrombin gene mutation and homozygous factor V Leiden) and IUGR of unknown cause was also found, P = .096, OR 6.106 (CI 95% 0.72-51.30), although it was not statistically significant (P = .096, OR = 6.106, CI 95% 0.72-51.30).Our results indicate that PAI-1 and MTHFR thrombophilias represent risk factors for IUGR of otherwise unidentified cause.

Methylenetetrahydrofolate Reductase Polymorphisms and Pregnancy Outcome

Introduction Aim of the study was to evaluate the effect of methylenetetrahydrofolate reductase (MTHFR) polymorphisms on pregnancy outcome.

Materials and Methods A total of 617 pregnancies of women who were investigated for MTHFR C677T and A1298C polymorphisms prior to pregnancy were included in the study. Cases were classified into “homozygous polymorphisms” (Group I), “heterozygous polymorphisms” (Group II), and patients without polymorphisms who functioned as controls (Group III). Patients with polymorphisms were assigned to a specific protocol at least 3 months before becoming pregnant. Administration of low molecular weight heparin (LMWH) was started very early during pregnancy. The Beksac Obstetrics Index (BOI) was used to estimate the obstetric risk levels for the different groups.

Results We found that the early pregnancy loss (EPL) rate increased as MTHFR polymorphism complexity increased and that the early EPL rate was significantly higher in patients with MTHFR C677T polymorphism compared to patients with MTHFR A1298C polymorphism (p = 0.039). There were significant differences between the previous pregnancies of the patients in the 3 study groups in terms of perinatal complications and EPLs (p = 0.003 and p = 0.019). The BOI decreased as the severity of polymorphisms increased. An association between MTHFR polymorphisms and congenital malformations and chromosomal abnormalities was observed. We could not demonstrate any statistically significant difference between study groups when the 3 groups were compared with regard to the pregnancy outcomes under specific management protocols.

Conclusion MTHFR polymorphisms are potential risk factors for adverse pregnancy outcomes.

Adverse pregnancy outcomes and inherited thrombophilia

AIM

(1) To evaluate the prevalence of inherited thrombophilia in pregnant women with adverse pregnancy outcomes: intrauterine growth retardation (IUGR), preeclampsia (PE) and placental abruption. (2) To assess the impact of inherited thrombophilia on the nature of obstetric complications. (3) To assess levels of protein S, protein C, antithrombin III and homocysteine in pregnant women with adverse pregnancy outcomes.

SUBJECTS AND METHODS

The study comprised 162 pregnant women. The patients were divided into three test groups and one control group. In all 162 patients the following tests were completed: activated protein C resistance (APC-R), the level of free protein S, activity of protein C, antithrombin III and the level of homocysteine. The data were statistically analyzed via χ2 of independence or homogeneity test.

RESULTS

In 32 of 162 patients participating in clinical research thrombophilia was diagnosed (10 patients with APC-R, 21 patients with protein S deficiency, one patient with hyperhomocysteinemia): seven patients belonged to the control group and 25 patients had diagnosed adverse pregnancy outcomes (P=0.04). In 32 patients with diagnosed thrombophilia, level of protein S was decreased (P=0.04). Protein S deficiency was diagnosed, when level of protein S was lower than 30% in the second trimester and lower than 24% in the third trimester. The incidence of activated protein C resistance caused by the mutation of factor V Leiden was in six patients (5.9%) with adverse pregnancy outcomes, and in four patients (6.6%) from the control group. Results were not statistically significant. No protein C deficiency was diagnosed (diagnosis: level<60%), but in 50% of patients with thrombophilia level of protein C was over the norm (P=0.02). The level of antithrombin III was often decreased in patients with preeclampsia - (32.4%), then in the other patients - (17.2%) (P=0.04), but no patient was diagnosed with antithrombin III deficiency (diagnosis: level<60%).

CONCLUSIONS

Tests for thrombophilia should be carried out in women with adverse pregnancy outcomes in their history, who are planning pregnancy, to start anticoagulant prophylaxis. Our study supports the thesis that tests for thrombophilia should be carried out in women with a history of adverse pregnancy outcomes and who are planning a pregnancy to start anticoagulant prophylaxis.

Hereditary Thrombophilia and Recurrent Pregnancy Loss

The challenging nature of recurrent pregnancy loss (RPL) is multifactorial, but largely begins with determining who meets diagnostic criteria for RPL as definitions vary and frequently change. Many patients seek obstetrical intervention after losses, even if they do not meet the criteria for RPL, and even those strictly meeting criteria often present a conundrum as to the etiology of their condition. The contribution of hereditary thrombophilia to RPL, the impact of each disorder on the clotting cascade, available evidence regarding pregnancy outcomes, and current recommendations for evaluation and treatment is presented.

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology

The current proposal for cerebral venous thrombosis guideline followed the Grading of Recommendations, Assessment, Development, and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews of all available evidence and writing recommendations and deciding on their strength on an explicit and transparent manner, based on the quality of available scientific evidence. The guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic resonance or computed tomography angiography for confirming the diagnosis of cerebral venous thrombosis and not screening patients with cerebral venous thrombosis routinely for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral venous thrombosis and decompressive surgery to prevent death due to brain herniation. We suggest to use preferentially low-molecular weight heparin in the acute phase and not using direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations due to very poor quality of evidence concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that in women who suffered a previous cerebral venous thrombosis, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular weight heparin should be considered throughout pregnancy and puerperium. Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of cerebral venous thrombosis.

Fetal and umbilical Doppler ultrasound in high-risk pregnancies

BACKGROUND

Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible that false positive Doppler ultrasound findings could lead to adverse outcomes from unnecessary interventions, including preterm delivery.

OBJECTIVES

The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes.

SEARCH METHODS

We updated the search of Cochrane Pregnancy and Childbirth's Trials Register on 31 March 2017 and checked reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Cluster-randomised trials were eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Nineteen trials involving 10,667 women were included. Risk of bias in trials was difficult to assess accurately due to incomplete reporting. None of the evidence relating to our main outcomes was graded as high quality. The quality of evidence was downgraded due to missing information on trial methods, imprecision in risk estimates and heterogeneity. Eighteen of these studies compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). One more recent trial compared Doppler examination of other fetal blood vessels (ductus venosus) with computerised CTG.The use of Doppler ultrasound of the umbilical artery in high-risk pregnancy was associated with fewer perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352, evidence graded moderate). The results for stillbirths were consistent with the overall rate of perinatal deaths, although there was no clear difference between groups for this outcome (RR 0.65, 95% CI 0.41 to 1.04; 15 studies, 9560 babies, evidence graded low). Where Doppler ultrasound was used, there were fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects, evidence graded moderate) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women, evidence graded moderate). There was no comparative long-term follow-up of babies exposed to Doppler ultrasound in pregnancy in women at increased risk of complications.No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies, evidence graded low). Data for serious neonatal morbidity were not pooled due to high heterogeneity between the three studies that reported it (1098 babies) (evidence graded very low).The use of Doppler to evaluate early and late changes in ductus venosus in early fetal growth restriction was not associated with significant differences in any perinatal death after randomisation. However, there was an improvement in long-term neurological outcome in the cohort of babies in whom the trigger for delivery was either late changes in ductus venosus or abnormalities seen on computerised CTG.

AUTHORS' CONCLUSIONS

Current evidence suggests that the use of Doppler ultrasound on the umbilical artery in high-risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions. The results should be interpreted with caution, as the evidence is not of high quality. Serial monitoring of Doppler changes in ductus venosus may be beneficial, but more studies of high quality with follow-up including neurological development are needed for evidence to be conclusive.

Early onset fetal growth restriction

Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.

Associations between pre-eclampsia and protein C and protein S levels among pregnant Nigerian women

OBJECTIVE

To evaluate levels of protein C and free protein S among women with pre-eclampsia, and determine whether there is a relationship between deficiencies and pre-eclampsia.

METHODS

A cross-sectional study was conducted at a hospital in Nigeria from July 2013 to March 2014 among 90 pregnant women with pre-eclampsia (blood pressure ≥140/90 mm Hg, proteinuria ≥300 mg in 24 hours) and 90 normotensive pregnant women (control group). Plasma levels of protein C and free protein S were analyzed by enzyme-linked immunosorbent assay, and protein C activity by a chromogenic method.

RESULTS

Mean protein C antigen and activity levels did not differ between groups (P=0.639 and P=0.444, respectively). The incidence of protein C antigen and activity deficiency also did not differ (P=0.288 and P>0.99, respectively). The mean free protein S antigen level was higher among women with pre-eclampsia (54.48%±19.58%) than in the control group (47.23%±10.27%; P=0.004). No woman in the control group had protein S deficiency, as compared with 2 (2%) of the women with pre-eclampsia (P=0.497). No association was found between deficiencies of these proteins and pre-eclampsia.

CONCLUSION

Deficiencies of protein C and free protein S are unlikely to be etiopathogenetic for pre-eclampsia; therefore, therapeutic intervention should focus on other potential pathogenetic pathways.

The Prevalence of Thrombophilia in Women With Recurrent Fetal Loss and Outcome of Anticoagulation Therapy for the Prevention of Miscarriages

OBJECTIVE

To estimate the prevalence of thrombophilia in women with recurrent miscarriages and to assess the effect of antithrombotic therapy.

DESIGN

A retrospective cohort study between the years 2004 and 2010.

SETTING

A hypercoagulation community clinic in northern Israel.

PATIENTS

Four hundred ninety pregnant women referred for thrombophilia screening.

MAIN OUTCOME MEASURES

Screening results for thrombophilia and antithrombotic treatment with enoxaparin, aspirin, or both and pregnancy outcomes.

RESULTS

The most common thrombophilia in our study group was factor V Leiden mutation with a prevalence of 20.9% followed by protein S deficiency with a prevalence of 19%. Live birth rate was higher in the group of women who received enoxaparin regardless of whether a specific thrombophilia could be found. This finding was more pronounced in women who had ≥4 miscarriages.

CONCLUSION

The prevalence of thrombophilia was higher in our study group than in the general population. Furthermore, treatment with enoxaparin might improve the rate of live births in women with or without evidence of thrombophilia, especially in women with ≥4 miscarriages.

Low-molecular-weight-heparin can benefit women with recurrent pregnancy loss and sole protein S deficiency: a historical control cohort study from Taiwan

BACKGROUND

Heritable thrombophilias are assumed important etiologies for recurrent pregnancy loss. Unlike in the Caucasian populations, protein S and protein C deficiencies, instead of Factor V Lieden and Prothrombin mutations, are relatively common in the Han Chinese population. In this study we aimed to investigate the therapeutic effect of low molecular weight heparin upon women with recurrent pregnancy loss and documented protein S deficiency.

METHODS

During 2011-2016, 68 women with recurrent pregnancy loss (RPL) and protein S deficiency (both the free antigen and function of protein S were reduced) were initially enrolled. All the women must have experienced at least three recurrent miscarriages. After excluding those carrying balanced translocation, medical condition such as diabetes mellitus, chronic hypertension, and autoimmune disorders (including systemic lupus erythematosus and anti-phospholipid syndrome), coexisting thrombophilias other than persistent protein S deficiency (including transient low protein S level, protein C deficiency, and antithrombin III), only 51 women with RPL and sole protein S deficiency were enrolled. Initially they were prescribed low dose Aspirin (ASA: 100 mg/day) and unfortunately there were still 39 women ended up again with early pregnancy loss (12 livebirths were achieved though). Low-molecular-weight-heparin (LMWH) was given for the 39 women in a dose of 1 mg/Kg every 12 h from the day when the next clinical pregnancy was confirmed to the timing at least 24 h before delivery. The perinatal outcomes were assessed.

RESULTS

Of 50 treatment subjects performed for the 39 women (i.e. 11 women enrolled twice for two pregnancies), 46 singletons and one twin achieved livebirths. The successful live-birth rate in the whole series was 94 % (47/50). Nineteen livebirths delivered vaginally whereas 28 delivered by cesarean section. The cesarean delivery rate is thus 59.57 %. Emergent deliveries occurred in 3 but no postpartum hemorrhage had been noted.

CONCLUSIONS

Our pilot study in Taiwan, an East Asian population, indicated anti-coagulation therapy is of benefit to women with recurrent pregnancy loss who had documented sole protein S deficiency.

TRIAL REGISTRATION

ISRCTN64574169. Retrospectively registered 29 Jun 2016.

Birthweight in pregnant women with protein S deficiency treated with low-molecular-weight heparin: a retrospective cohort study

OBJECTIVE

To determine the risk of small-for-gestational-age (SGA) and intrauterine growth retardation (IUGR) in pregnant women with protein S (PS) deficiency who received low-molecular-weight heparin (LMWH).

METHODS

Retrospective cohort study of pregnant women seen from January 2002 to December 2011. The study cohort comprised a total of 328 patients with PS deficiency, who received prophylactic enoxaparin during pregnancy. The control cohort included 11 884 pregnant women without significant past medical history. The risk of SGA and IUGR was calculated as odds ratio. Multivariate regression analysis over the entire reference population was performed determining the risk of both SGA and IUGR by adjusting for maternal age, first delivery, maternal underweight status, pre-eclampsia, other treated thrombophilias or history of recurrent abortion.

RESULTS

The SGA rates in the PS deficiency and control cohorts were 10.7% and 8.5%, respectively (p > 0.05). There was no increased risk of SGA (unadjusted OR = 1.28, 95% confidence interval [CI] 0.9-1.83; adjusted OR = 1.35, 95% CI 0.91-2.01). The IUGR rate was 2.7% in pregnant women with PS deficiency versus 4.1% in the control group (p > 0.05). Also, we did not find a significant risk of IUGR (OR = 0.66; 95% CI 0.34-1.28; adjusted OR = 0.843; 95% CI 0.42-1.70).

CONCLUSIONS

In women with PS deficiency treated with LMWH, the risk of SGA and IUGR is similar to the one found in healthy pregnant women.

The Impact of Inherited Thrombophilia Types and Low Molecular Weight Heparin Treatment on Pregnancy Complications in Women with Previous Adverse Outcome

PURPOSE

To assess the distribution of births and spontaneous abortions, first-trimester abortion (FTA) and mid-trimester abortion (MTA), in untreated (n=128) and low molecular weight heparin (LMWH) treated pregnancies (n=50) of the same women with inherited thrombophilias and adverse pregnancy outcome (APO) in previous pregnancies. We particularly investigated the impact of LMWH on reducing the pregnancy complications in two thrombophilia types, "Conventional" and "Novel".

MATERIALS AND METHODS

50 women with inherited thrombophilia (26 Conventional and 24 Novel) and APO in previous pregnancies were included in the study. Conventional group included factor V Leiden (FVL), prothrombin G20210A (PT) mutations and antithrombin (AT), protein S (PS), and protein C (PC) deficiency, while the Novel group included methylentetrahydrofolate-reductase (MTHFR), plasminogen activator inhibitor-1 (PAI-1), and angiotensin converting enzyme (ACE) polymorphism. APO was defined as one of the following: preterm birth (PTB), fetal growth restriction (FGR), preeclampsia (PE), intrauterine fetal death (IUFD), placental abruption (PA) and deep venous thrombosis (DVT).

RESULTS

There was no difference in distribution of births and spontaneous abortions between Conventional and Novel thrombophilia in untreated pregnancies (χ²=2.7; p=0.100) and LMWH treated pregnancies (χ²=0.442; p=0.506). In untreaed pregnancies thrombophilia type did not have any impact on the frequency of FTA and MTA (χ²=0.14; p=0.711). In birth-ended pregnancies LMWH treatement reduced the incidence of IUFD (p=0.011) in Conventional and FGR, IUFD, and PTB in Novel thrombophilia group.

CONCLUSION

The equal impact of two thrombophilia types on the pregnancy outcomes and a more favorable effect of LMWH therapy on pregnancy complications in Novel thrombophilia group point the need for Novel thrombophilias screening and the future studies on this issue should be recommended.

Safety of Pregnancy After Cerebral Venous Thrombosis

Background and Purpose—

Pregnancy and puerperium are associated with an increased risk of venous thrombotic events (VTEs), including cerebral venous thrombosis (CVT). We aimed to systematically review, in pregnant woman with previous CVT, (1) the risk of recurrence of CVT or other VTE; (2) the result of pregnancy; and (3) the association of antithrombotic prophylaxis with these outcomes.

Methods—

We searched MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov (from inception to July 2015), and reference lists of included studies and review articles. We considered observational studies reporting original data on the frequency of CVT or other VTE associated with pregnancy or puerperium in women with history of CVT.

Results—

Thirteen studies were included. A simple pooled analysis of individual patient data and meta-analysis of proportions using a random effect model were performed. (1) 1 CVT recurrences/217 pregnancies (9 per 1000; 95% confidence interval, 3–33) and 5 noncerebral VTE/186 pregnancies (27 per 1000; 95% confidence interval, 12–61). (2) Pregnancy outcome: 33 spontaneous abortions/186 pregnancies (17.7%; 95% confidence interval, 13–24). (3) Data on the risk of CVT/extracerebral VTE according to antithrombotic prophylaxis was limited. Miscarriage did not differ significantly in women undergoing antithrombotic therapy or not (11.3% versus 18.8%; P =0.34).

Conclusions—

In women with previous CVT, the absolute risk of pregnancy-related venous thrombosis is low but the relative risk of noncerebral VTE is 16-fold higher and the recurrence of CVT is 80-fold higher than the baseline risk described in general population studies. The rate of miscarriage is not significantly different from that estimated for the general population.

Dysfunction in the coagulation system and schizophrenia

Although different hypotheses have been formulated to explain schizophrenia pathogenesis, the links between them are weak. The observation that five psychotic patients on chronic warfarin therapy for deep-vein thrombosis showed long-term remission of psychotic symptoms made us suspect that abnormalities in the coagulation pathway, specifically low tissue plasminogen activator (tPA) activity, could be one of the missing links. Our hypothesis is supported by a high prevalence of conditions affecting tPA activity in drug-naive schizophrenia, such as antiphospholipid antibodies, elevated cytokine levels, hyperinsulinemia and hyperhomocysteinemia. We recently screened a group of schizophrenia patients and controls for conditions affecting tPA activity. Free-protein S deficiency was highly prevalent among patients, but not found in controls. Free-protein S and functional protein C are natural anticoagulants that form complexes that inhibit tPA inhibitors. All participants had normal protein C levels, suggesting that protein S could have a role in schizophrenia, independent of protein C. Chronic patients and those studied during acute episodes had between three and six conditions affecting tPA and/or protein S activity, while patients in remission had up to two, which led us to postulate that multiple conditions affecting tPA and/or protein S activity could contribute to the full expression of schizophrenia phenotype. This paper describes the physiological roles of tPA and protein S, reviewing how their activity influences pathogenesis and comorbidity of schizophrenia. Next, it analyzes how activity of tPA and protein S is influenced by biochemical abnormalities found in schizophrenia. Last, it suggests future directions for research, such as studies on animal models and on therapeutic approaches for schizophrenia aiming at increasing tPA and protein S activity.

Effects of anticoagulant therapy on pregnancy outcomes in patients with thrombophilia and previous poor obstetric history

This study investigates the effects of anticoagulant therapy on pregnancy outcomes in 204 patients with thrombophilia and previous poor obstetric outcomes. Patients with poor obstetric history (pre-eclampsia, intrauterine growth retardation, fetal death, placental abruption, recurrent pregnancy loss) and having hereditary thrombophilia were included in this study. Poor obstetric outcomes were observed more frequently in patients who had not taken anticogulant therapy compared with treated group. Live birth rate, gestational age at birth and Apgar scores were significantly higher in the treated group when compared with the untreated group. There were no significant differences in terms of birthweight, mode of delivery and admission rates to the neonatal intensive care unit (NICU). Low-molecular-weight heparin (LMWH) plus acetylsalicylic acid (ASA) had higher gestational age at birth, Apgar scores, live birth rate and a lower abortion rates when compared with controls; in contrast, no significant difference was observed in terms of birthweight, mode of delivery, obstetric complications and admission rates to NICU. There were no significant differences between control group and both LMWH only and ASA only groups in terms of gestational age at birth, Apgar scores, birthweight, mode of delivery, obstetric complications and admission rates to NICU. Only LMWH group had higher live birth rate as compared with control group. The use of only ASA did not seem to affect the perinatal complication rates and outcomes. In conclusion, anticoagulant therapy with both LMWH and ASA seems to provide better obstetric outcomes in pregnant women with thrombophilia and previous poor obstetric outcomes.

Cerebral ultrasound abnormalities in offsprings of women with C677T homozygous mutation in the MTHFR gene: a prospective study

BACKGROUND

Perinatal stroke is a common cause of neurologic disability. Being clinically under-recognized, its true incidence is not known. Maternal thrombophilia is likely to be a predisposing factor. To date, a general consensus for evaluation of babies born to mothers with genetic thrombotic predisposition is missing. This study was undertaken to assess the frequency of cerebral abnormalities in the offspring of women with homozygous C677T mutation in the MTHFR gene, and to seek for association with additional maternal or pregnancy risk factors.

METHODS

Mother-infant pairs were consecutively recruited from October 2006 through February 2013. Neonates underwent a thorough physical examination at birth, and a cerebral ultrasound examination (cUS) was performed within 24 hours of their life. In neonates with major cerebral lesions, a thrombophilia panel test was obtained. Follow-up cUS was performed in babies with major or minor cerebral abnormalities.

RESULTS

Ninety-one neonates (47 males) were enrolled. By cUS, abnormalities were detected in 18 (19.8%) neonates. Twelve neonates were diagnosed with a minor lesion; a major ischemic/hemorrhagic lesion was found in 6 neonates. There were a neat male preponderance and significant associations with a history of suspected miscarriage, maternal coagulation factors gene mutations, and reduced protein S or protein C activity.

CONCLUSIONS

Our data confirmed a high incidence of cerebral abnormalities in neonates born to women with C677T homozygous mutation in the MTHFR gene. cUS at birth proved to be an effective screening tool or a diagnostic test, that should be routinely performed in babies born to mothers with known thrombotic predisposition.

Low levels of plasma protein S, protein C and coagulation factor XII during early pregnancy and adverse pregnancy outcome

It was the study objective to evaluate whether low levels of plasma protein S (PS) activity, free PS, protein C (PC) activity and coagulation factor XII (FXII) during early pregnancy are related to adverse pregnancy outcomes. Peripheral blood samples were obtained at 8-14 gestational weeks (GW) from a consecutive series of 1,220 women. The levels of plasma PS activity, free PS, PC activity, and FXII were measured. Cut-off values were defined as < 1st, < 5th, and < 10th percentiles of values obtained from 933 women whose pregnancies ended in normal deliveries without complications. PS activity of < 10th percentile yielded risks of pregnancy-induced hypertension (PIH) and severe PIH, while free PS level of < 5th percentile yielded a risk of pre-eclampsia. FXII level of < 1st percentile yielded a risk of premature delivery (PD) at < 34 GW. None was associated with PD at < 37 GW, fetal growth restriction or fetal loss. A multivariate analysis demonstrated that PS activity of < 10th percentile (odds ratio 5.9, 95 % confidence interval 1.7-18.1) and body mass index (BMI) ≥ 25 kg/m² (4.3, 1.1-13.3) were independent risk factors for severe PIH. Similarly, free PS level of < 5th percentile (4.4, 1.0-14.3) and BMI ≥ 25 kg/m² (4.0, 1.3-10.9) were independent risk factors for pre-eclampsia. In conclusion, women with low levels of plasma PS activity and free PS during early pregnancy might have increased risks of PIH, severe PIH or pre-eclampsia. Women with low FXII level might have an increased risk of PD at < 34 GW.