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Scarrone M, Salmeri N, Buzzaccarini G, Canti V, Pasi F, Papaleo E, Rovere-Querini P, Candiani M, Alteri A, Busnelli A, Vanni VS. Low-molecular-weight heparin in the prevention of unexplained recurrent miscarriage: a systematic review and meta-analysis. Sci Rep 2024; 14:14168. [PMID: 38898143 PMCID: PMC11187099 DOI: 10.1038/s41598-024-62949-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
The etiology of recurrent pregnancy loss (RPL) is complex and multifactorial and in half of patients it remains unexplained (U-RPL). Recently, low-molecular-weight heparin (LMWH) has gained increasing relevance for its therapeutic potential. On this regard, the aim of this systematic review and meta-analysis is to analyze the efficacy of low molecular weight heparin (LMWH) from the beginning of pregnancy in terms of live birth rates (LBR) in U-RPL. Registered randomized controlled trials (RCTs) were included. We stratified findings based on relevant clinical factors including number of previous miscarriages, treatment type and control type. Intervention or exposure was defined as the administration of LMWH alone or in combination with low-dose aspirin (LDA). A total of 6 studies involving 1016 patients were included. The meta-analysis results showed that LMWH used in the treatment of U-RPL was not associated with an increase in LBR with a pooled OR of 1.01, a medium heterogeneity (26.42%) and no publication bias. Results of other sub-analyses according to country, treatment type, and control type showed no significant effect of LMWH on LBR in all subgroups, with a high heterogeneity. The results highlight a non-significant effect of LMWH in U-RPL on LBR based on moderate quality evidence.Registration number: PROSPERO: ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022326433 ).
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Affiliation(s)
| | - Noemi Salmeri
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Buzzaccarini
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Canti
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Federica Pasi
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Papaleo
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Rovere-Querini
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Massimo Candiani
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Alteri
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Andrea Busnelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Via Rita Levi Montalcini, 4, 20090, Rozzano, Milano, Italy
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Via Rita Levi Montalcini, 4, 20090, Rozzano, Milano, Italy
| | - Valeria Stella Vanni
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Turesheva A, Aimagambetova G, Ukybassova T, Marat A, Kanabekova P, Kaldygulova L, Amanzholkyzy A, Ryzhkova S, Nogay A, Khamidullina Z, Ilmaliyeva A, Almawi WY, Atageldiyeva K. Recurrent Pregnancy Loss Etiology, Risk Factors, Diagnosis, and Management. Fresh Look into a Full Box. J Clin Med 2023; 12:4074. [PMID: 37373766 DOI: 10.3390/jcm12124074] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Recurrent pregnancy loss is a complex health challenge with no universally accepted definition. Inconsistency in definitions involves not only the number of spontaneous abortions (two or three) that are accepted for recurrent pregnancy loss but the types of pregnancy and gestational age at miscarriage. Due to the heterogeneity of definitions and criteria applied by international guidelines for recurrent pregnancy loss, the true incidence of recurrent miscarriage, which is reported to range from 1% to 5%, is difficult to estimate. Moreover, the exact etiology of recurrent pregnancy loss remains questionable; thus, it is considered a polyetiological and multifactorial condition with many modifiable and non-modifiable factors involved. Even after thoroughly evaluating recurrent pregnancy loss etiology and risk factors, up to 75% of cases remain unexplained. This review aimed to summarize and critically analyze accumulated knowledge on the etiology, risk factors, relevant diagnostic options, and management approach to recurrent pregnancy loss. The relevance of various factors and their proposed roles in recurrent pregnancy loss pathogenesis remains a matter of discussion. The diagnostic approach and the management largely depend on the etiology and risk factors taken into consideration by a healthcare professional as a cause of recurrent miscarriage for a particular woman or couple. Underestimation of social and health consequences of recurrent pregnancy loss leads to compromised reproductive health and psychological well-being of women after miscarriage. Studies on etiology and risk factors for recurrent pregnancy loss, especially idiopathic, should be continued. The existing international guidelines require updates to assist clinical practice.
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Affiliation(s)
- Akbayan Turesheva
- Department of Normal Physiology, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | | | - Talshyn Ukybassova
- Clinical Academic Department of Women's Health, CF "University Medical Center", Astana 010000, Kazakhstan
| | - Aizada Marat
- Department of Obstetrics and Gynecology #1, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Perizat Kanabekova
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
| | - Lyazzat Kaldygulova
- Department of Obstetrics and Gynecology #2, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Ainur Amanzholkyzy
- Department of Normal Physiology, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Svetlana Ryzhkova
- Department of Obstetrics and Gynecology #2, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Anastassiya Nogay
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
| | - Zaituna Khamidullina
- Department of Obstetrics and Gynecology #1, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Aktoty Ilmaliyeva
- Department of Medicine #3, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Wassim Y Almawi
- Faculte' des Sciences de Tunis, Universite' de Tunis El Manar, Tunis 5000, Tunisia
| | - Kuralay Atageldiyeva
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
- Clinical Academic Department of Internal Medicine, CF "University Medical Center", Astana 010000, Kazakhstan
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Treating unexplained recurrent pregnancy loss based on lessons learned from obstetric antiphospholipid syndrome and inherited thrombophilia: A propensity-score adjusted retrospective study. J Reprod Immunol 2022; 154:103760. [PMID: 36395545 DOI: 10.1016/j.jri.2022.103760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 09/14/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022]
Abstract
The efficacy of low molecular weight heparin (LMWH) is well-established in patients with obstetric antiphospholipid syndrome (O-APS). Their role in women with unexplained recurrent pregnancy loss (U-RPL) and late obstetrical complications (intrauterine growth restriction, IUGR and preeclampsia) is controversial. Here we compared rates of miscarriage and late obstetrical complications in RPL patients diagnosed with O-APS (n = 57) or hereditary thrombophilia (n = 25) (both assuming LMWH from the beginning of pregnancy) and in patients with a history of U-RPL (n = 118), assuming or not LMWH, followed at the 'Pregnancy at risk' and 'Recurrent pregnancy loss' outpatient clinics at the San Raffaele Hospital from April 2010 to April 2020. Patients with systemic autoimmune diseases other than primary O-APS were excluded. We tested for bivariate or multivariate associations among adverse pregnancy outcomes, the presence of thrombophilia and LMWH use by using chi-square test, Anova, propensity score adjusted univariate logistic regression and multivariate analysis as appropriate. U-RPL patients assuming LMWH from the beginning of pregnancy (group A) had a significantly lower rate of miscarriage compared to U-RPL patients who were not treated with LMWH (group B) (13 % vs. 41 % respectively, p 0.001) and similar pregnancy rates compared to both O-APS patients with a history of RPL taking LMWH (group C, 18 %) and RPL patients with thrombophilia and treated with LMWH (group D, 16 %). Our data highlight a protective effect of LMWH on miscarriage in patients with a history of U-RPL. In these patients, LMWH seems as effective as in O-APS and hereditary thrombophilia in reducing RPL.
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Efficacy of Low Molecular Weight Heparin in Preventing Perinatal Venous Thrombosis: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1248577. [PMID: 35928971 PMCID: PMC9345706 DOI: 10.1155/2022/1248577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/05/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022]
Abstract
Background There have been controversies about the preventive effect of low molecular weight heparin (LMWH) on venous thrombosis (VT) in the perinatal period. This study is aimed at exploring the effectiveness of LMWH in preventing perinatal VT through meta-analysis. Methods Databases such as CNKI, China Biology Medicine disc (CBMdisc), Wanfang, PubMed, MEDLINE, Embase, and Central were searched. Inclusion criteria were as follows: (1) subjects: women at high risk of perinatal VT; (2) experimental group and control group; (3) intervention measures: the experimental group was given LMWH, while the control group was given placebo or standard heparin or physical therapy; (4) outcomes: perinatal VT events or bleeding events; and (5) randomized controlled trials (RCTs). Jadad scale was used to evaluate the literature quality. The Mantel-Haenszel method was used to calculate the odds ratio (OR) and 95% confidence interval (CI). The chi-square test was used to analyze the heterogeneity of the included literature. Subgroup analysis was used to explore the source of heterogeneity. Publication bias was evaluated via funnel plot and Egger test. Results The incidence of perinatal VT in the LMWH group was lower than that in the control group (OR = 0.16, 95% CI (0.08, 0.32), P < 0.00001). There was no heterogeneity among literatures (P = 0.77, I2 = 0%) and no publication bias. The incidence of postpartum VT in the LMWH group was lower than that in the control group (OR = 0.14, 95% CI (0.07, 0.30), P < 0.00001). There was no heterogeneity among literatures (P = 0.69, I2 = 0%) and no publication bias. The incidence of perinatal bleeding in the LMWH group was higher than in the control group (OR = 1.72, 95% CI (1.06, 2.77), P = 0.03). There was no heterogeneity among literatures (P = 0.25, I2 = 26%) and no publication bias. Conclusion LMWH can reduce the incidence of perinatal VT in high-risk women but increase the risk of bleeding. The use of LMWH to prevent perinatal VT should be closely monitored.
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Chen Y, Wang T, Liu X, Ye C, Xing D, Wu R, Li F, Chen L. Low molecular weight heparin and pregnancy outcomes in women with inherited thrombophilia: A systematic review and meta-analysis. J Obstet Gynaecol Res 2022; 48:2134-2150. [PMID: 35661489 DOI: 10.1111/jog.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/11/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
AIM To determine whether the use of low molecular weight heparin (LMWH) improves the pregnancy outcomes in women with inherited thrombophilia by conducting a meta-analysis of randomized controlled trials and observational studies. METHODS A systematic literature search of several databases was conducted through September 19, 2020 to identify relevant studies. The outcomes of interest included live birth and adverse pregnancy outcomes (APOs). The overall risk estimates were pooled using random-effects meta-analysis. RESULTS Ten randomized controlled trials and 12 cohort studies were included. In the meta-analyses of randomized controlled trials, the effectiveness of LMWH-treatment was found to be statistically significant in decreasing the risk of APOs (risk ratio [RR] = 0.76; 95% confidence interval [CI]: 0.61-0.95; p = 0.020), rather than in increasing the rate of live birth (RR = 1.12; 95% CI: 0.93-1.34; p = 0.230). In the meta-analyses of cohort studies, results showed that the use of LMWH was associated with a significantly higher proportion of live birth (RR = 1.86; 95% CI: 1.09-3.19; p = 0.020) as well as a significantly lower ratio of APOs (RR = 0.46; 95% CI: 0.31-0.69; p < 0.001) in women with inherited thrombophilia. CONCLUSIONS The use of LMWH may have a potentially beneficial effect on reducing the risk of APOs and even increasing the live birth rate in women with inherited thrombophilia. Further well-designed clinical trials with large samples are needed to address the role of LMWH in improving pregnancy outcomes among pregnant women with inherited thrombophilia.
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Affiliation(s)
- Yan Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China.,NHC Key Laboratory for Birth Defect for Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Hunan, China
| | - Xiaoling Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Changxiang Ye
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Dexiu Xing
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Rong Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Fang Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China.,Hunan Provincial Key Laboratory of clinical epidemiology, Changsha, Hunan, China
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Cruz-Lemini M, Vázquez JC, Ullmo J, Llurba E. Low-molecular-weight heparin for prevention of preeclampsia and other placenta-mediated complications: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 226:S1126-S1144.e17. [PMID: 34301348 DOI: 10.1016/j.ajog.2020.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Evidence on the impact of low-molecular-weight heparin, alone or in combination with low-dose aspirin, for the prevention for preeclampsia in high-risk patients is conflicting. OBJECTIVE We conducted a meta-analysis of studies published to assess the effectiveness of low-molecular-weight heparin for the prevention of preeclampsia and other placenta-related complications in high-risk women. DATA SOURCES A systematic search was performed to identify relevant studies, using the databases PubMed and Cochrane Central Register of Controlled Trials, without publication time restrictions. STUDY ELIGIBILITY CRITERIA Randomized controlled trials comparing treatment with low-molecular-weight heparin or unfractionated heparin (with or without low-dose aspirin), in high-risk women, defined as either history of preeclampsia, intrauterine growth restriction, fetal demise, or miscarriage or being at high risk after first-trimester screening of preeclampsia. STUDY APPRAISAL AND SYNTHESIS METHODS The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was the development of preeclampsia. We performed prespecified subgroup analyses according to combination with low-dose aspirin, low-molecular-weight heparin type, gestational age when treatment was started, and study population (patients with thrombophilia, at high risk of preeclampsia or miscarriage). Secondary outcomes included small for gestational age, perinatal death, miscarriage, and placental abruption. Pooled odds ratios with 95% confidence intervals were calculated using a random-effects model. Quality of evidence was assessed using the grading of recommendations assessment, development, and evaluation methodology. RESULTS A total of 15 studies (2795 participants) were included. In high-risk women, treatment with low-molecular-weight heparin was associated with a reduction in the development of preeclampsia (odds ratio, 0.62; 95% confidence interval, 0.43-0.90; P=.010); small for gestational age (odds ratio, 0.61; 95% confidence interval, 0.44-0.85; P=.003), and perinatal death (odds ratio, 0.49; 95% confidence interval, 0.25-0.94; P=.030). This reduction was stronger if low-molecular-weight heparin was started before 16 weeks' gestation (13 studies, 2474 participants) for preeclampsia (odds ratio, 0.55; 95% confidence interval, 0.39-0.76; P=.0004). When only studies including low-dose aspirin as an intervention were analyzed (6 randomized controlled trials, 920 participants), a significant reduction was observed in those with combined treatment (low-molecular-weight heparin plus low-dose aspirin) compared with low-dose aspirin alone (odds ratio, 0.62; 95% confidence interval, 0.41-0.95; P=.030). Overall, adverse events were neither serious nor significantly different. Quality of evidence ranged from very low to moderate, mostly because of the lack of blinding, imprecision, and inconsistency. CONCLUSION Low-molecular-weight heparin use was associated with a significant reduction in the risk of preeclampsia and other placenta-mediated complications in high-risk women and when treatment was started before 16 weeks' gestation. Combined treatment with low-dose aspirin was associated with a significant reduction in the risk of preeclampsia compared with low-dose aspirin alone. However, there exists important clinical and statistical heterogeneity, and therefore, these results merit confirmation in large well-designed clinical trials.
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Yan X, Wang D, Yan P, Li H. Low molecular weight heparin or LMWH plus aspirin in the treatment of unexplained recurrent miscarriage with negative antiphospholipid antibodies: A meta-analysis of randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2021; 268:22-30. [PMID: 34794071 DOI: 10.1016/j.ejogrb.2021.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Unexplained recurrent miscarriage (uRM) has caused serious distress to women of childbearing age, and effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of low molecular weight heparin (LMWH) and LMWH combined with aspirin for uRM. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported the LMWH or LMWH combined with aspirin for women with uRM and negative antiphospholipid antibodies (aPL). The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data, and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS A total of 7 studies involving 1849 patients were included. The meta-analysis results showed that compared with the control group, both LMWH and LMWH + aspirin interventions showed no substantial influence on miscarriage rate (LMWH: RR = 0.69, 95%CI: 0.34-1.39, P = 0.293, LMWH + aspirin: RR = 0.62, 95%CI: 0.30-1.27, P = 0.19) and the occurrence of pre-eclampsia (LMWH: RR = 1.1, 95%CI: 0.53-2.31, P = 0.792; LMWH + aspirin: RR = 1.49, 95%CI: 0.25-8.79, P = 0.662). LMWH therapy had no influence on the live births (RR = 0.99, 95%CI: 0.92-1.06, P = 0.72). Subgroup analysis showed that enoxaparin is not effective in women with uRM and negative aPL (miscarriage rate: RR = 0.82, 95%CI: 0.31-2.19, P = 0.695; pre-eclampsia: RR = 1.03, 95%CI: 0.46-2.33, P = 0.936). CONCLUSIONS LMWH and LMWH combined with aspirin therapy cannot improve the pregnancy outcome of women with uRM and negative aPL. However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
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Affiliation(s)
- Xiaoli Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan Wang
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ping Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongyu Li
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Wang G, Zhang R, Li C, Chen A. Evaluation of the effect of low molecular weight heparin in unexplained recurrent pregnancy loss: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2021; 35:7601-7608. [PMID: 34311655 DOI: 10.1080/14767058.2021.1957819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The effectiveness of low molecular weight heparin (LMWH) in preventing miscarriage of unexplained recurrent pregnancy loss remains controversial. In order to explore the effect of LMWH therapy in unexplained recurrent pregnancy loss, we conducted this meta-analysis. METHODS We searched four databases PubMed, Cochrane Library, EMBASE, and Clinical Trials.gov (up to February 2020) for the randomized control trials (RCTs) evaluating the effectiveness of LMWH on the treatment of recurrent miscarriage. We used Stata software to perform a meta-analysis. Moreover, we performed analyses of sensitivity and predefined subgroups based on the definition of recurrent miscarriage (e.g. 2 or more miscarriages or 3 or more miscarriages) to search the source of heterogeneity. RESULTS 5 studies met the selection criteria, involving 1452 participants. LMWH reduce the risk of miscarriage of women suffering ≥3 miscarriages (RR = 0.46; 95% CI = 0.35-0.61, p = .00), but the risk of miscarriage of women suffering ≥2 miscarriages was not decreased by LMWH (RR = 0.70; 95% CI = 0.57-0.86, p = .26). No substantial influence was found on Live birth rate (RR = 1.19; 95% CI = 0.99-1.43), Preterm birth (RR = 0.95; 95% CI = 0.65-1.38), Preeclampsia (RR = 0.89, 95% CI = 0.45-1.76), Small for gestational age (RR = 0.89; 95% CI = 0.64-1.51). CONCLUSION LMWH treatment may decrease the miscarriage rate in women suffering a history of 3 or more miscarriages, but not reduce the incidence of miscarriage in women suffering a history of 2 or more miscarriages. We need more RCTs to provide robust and reliable results.
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Affiliation(s)
- Guangning Wang
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ran Zhang
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan Li
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aiping Chen
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
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Low Molecular Weight Heparins (LMWH) and Implications along Pregnancy: a Focus on the Placenta. Reprod Sci 2021; 29:1414-1423. [PMID: 34231172 DOI: 10.1007/s43032-021-00678-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Low molecular weight heparins (LMWH) have been largely studied for their use during pregnancy. The biology and the pharmacology of these molecules are well known and may be summarized in three main mechanisms of action: anti-coagulant, anti-inflammatory, and immunomodulant. The clinical implications of these drugs during pregnancy are mainly related to their action on the placenta, because of the presence of specific molecular and cellular targets, particularly at the trophoblast-endometrial interface. As well as for the prevention and treatment of thromboembolism, LMWH have been largely investigated for the improvement of embryo implantation and for the prevention of placenta-related complications such as preeclampsia, fetal growth restriction, and intrauterine fetal death. However, data on this topic are still unclear. The present review discusses the biological features, the mechanisms of action, and the possible contribution of LMWH to the success of placentation along pregnancy, pointing out the need for future basic science and clinical researches in this important field with the final aim to improve clinical practice in high-risk pregnancies.
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Mol BW. Letter to the Editor Regarding Safety and Efficacy of Enoxaparin in Pregnancy: A Systematic Review and Meta-analysis. Are All the Underlying Data True? Adv Ther 2021; 38:2757-2758. [PMID: 33745110 DOI: 10.1007/s12325-021-01673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/14/2021] [Indexed: 10/21/2022]
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Middleton P, Shepherd E, Gomersall JC. Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period. Cochrane Database Syst Rev 2021; 3:CD001689. [PMID: 33779986 PMCID: PMC8092635 DOI: 10.1002/14651858.cd001689.pub4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE), although rare, is a major cause of maternal mortality and morbidity. Some women are at increased risk of VTE during pregnancy and the early postnatal period (e.g. caesarean section, family history of VTE, or thrombophilia), and so prophylaxis may be considered. As some methods of prophylaxis carry risks of adverse effects, and risk of VTE is often low, benefits of thromboprophylaxis may be outweighed by harms. OBJECTIVES To assess the effects of thromboprophylaxis during pregnancy and the early postnatal period on the risk of venous thromboembolic disease and adverse effects in women at increased risk of VTE. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 October 2019). In addition, we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for unpublished, planned and ongoing trial reports (18 October 2019). SELECTION CRITERIA Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, or two (or more) methods of thromboprophylaxis. DATA COLLECTION AND ANALYSIS At least two review authors assessed trial eligibility, extracted data, assessed risk of bias, and judged certainty of evidence for selected critical outcomes (using GRADE). We conducted fixed-effect meta-analysis and reported data (all dichotomous) as summary risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS Twenty-nine trials (involving 3839 women), overall at moderate to high risk of bias were included. Trials were conducted across the antenatal, peripartum and postnatal periods, with most in high-income countries. Interventions included types and regimens of heparin (low molecular weight heparin (LMWH) and unfractionated heparin (UFH)), hydroxyethyl starch (HES), and compression stockings or devices. Data were limited due to a small number of trials in comparisons and/or few or no events reported. All critical outcomes (assessed for comparisons of heparin versus no treatment/placebo, and LMWH versus UFH) were considered to have very low-certainty evidence, downgraded mainly for study limitations and imprecise effect estimates. Maternal death was not reported in most studies. Antenatal (± postnatal) prophylaxis For the primary outcomes symptomatic thromboembolic events pulmonary embolism (PE) and/or deep vein thrombosis (DVT), and the critical outcome of adverse effects sufficient to stop treatment, the evidence was very uncertain. Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 0.39; 95% CI 0.08 to 1.98; 4 trials, 476 women; very low-certainty evidence); - LMWH versus UFH (RR 0.47; 95% CI 0.09 to 2.49; 4 trials, 404 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.02 to 7.14; 3 trials, 187 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Symptomatic DVT: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.04 to 3.10; 4 trials, 227 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Adverse effects sufficient to stop treatment: - heparin versus no treatment/placebo (RR 0.49; 95% CI 0.05 to 5.31; 1 trial, 139 women; very low-certainty evidence); - LMWH versus UFH (RR 0.07; 95% CI 0.01 to 0.54; 2 trials, 226 women; very low-certainty evidence). Peripartum/postnatal prophylaxis Vaginal or caesarean birth When UFH and no treatment were compared, the effects on symptomatic thromboembolic events (RR 0.16; 95% CI 0.02 to 1.36; 1 trial, 210 women; very low-certainty evidence), symptomatic PE (RR 0.16; 95% CI 0.01 to 3.34; 1 trial, 210 women; very low-certainty evidence), and symptomatic DVT (RR 0.27; 95% CI 0.03 to 2.55; 1 trial, 210 women; very low-certainty evidence) were very uncertain. Maternal death and adverse effects sufficient to stop treatment were not reported. Caesarean birth Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.39 to 4.27; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 1.10; 95% CI 0.25 to 4.87; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 217 women); Symptomatic DVT: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.24 to 6.94; 5 trials, 1140 women; very low-certainty evidence); LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Maternal death: - heparin versus placebo (no events, 1 trial, 300 women); Adverse effects sufficient to stop treatment: - heparin versus placebo (no events; 1 trial, 140 women). Postnatal prophylaxis No events were reported for LMWH versus no treatment/placebo for: symptomatic thromboembolic events, symptomatic PE and symptomatic DVT (all 2 trials, 58 women), or maternal death (1 trial, 24 women). Adverse effects sufficient to stop treatment were not reported. We were unable to conduct subgroup analyses due to lack of data. Sensitivity analysis including the nine studies at low risk of bias did not impact overall findings. AUTHORS' CONCLUSIONS The evidence is very uncertain about benefits and harms of VTE thromboprophylaxis in women during pregnancy and the early postnatal period at increased risk of VTE. Further high-quality very large-scale randomised trials are needed to determine effects of currently used treatments in women with different VTE risk factors. As sufficiently large definitive trials are unlikely to be funded, secondary data analyses based on high-quality registry data are important.
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Affiliation(s)
- Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Emily Shepherd
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Judith C Gomersall
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
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Bettiol A, Avagliano L, Lombardi N, Crescioli G, Emmi G, Urban ML, Virgili G, Ravaldi C, Vannacci A. Pharmacological Interventions for the Prevention of Fetal Growth Restriction: A Systematic Review and Network Meta-Analysis. Clin Pharmacol Ther 2021; 110:189-199. [PMID: 33423282 DOI: 10.1002/cpt.2164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/08/2022]
Abstract
The prevention of fetal growth restriction (FGR) is challenging in clinical practice. To date, no meta-analysis summarized evidence on the relative benefits and harms of pharmacological interventions for FGR prevention. We performed a systematic review and network meta-analysis (NetMA), searching PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception until November 2019. We included clinical trials and observational studies on singleton gestating women evaluating antiplatelet, anticoagulant, or other treatments, compared between each other or with controls (placebo or no treatment), and considering the pregnancy outcome FGR (primary outcome of the NetMA). Secondary efficacy outcomes included preterm birth, placental abruption, and fetal or neonatal death. Safety outcomes included bleeding and thrombocytopenia. Network meta-analyses using a frequentist framework were conducted to derive odds ratios (ORs) and 95% confidence intervals (CIs). Of 18,780 citations, we included 30 studies on 4,326 patients. Low molecular weight heparin (LMWH), alone or associated with low-dose aspirin (LDA), appeared more efficacious than controls in preventing FGR (OR 2.00, 95% CI 1.27-3.16 and OR 2.67, 95% CI 1.21-5.89 for controls vs. LMWH and LDA + LMWH, respectively). No difference between active treatments emerged in terms of FGR prevention, but estimates for treatments other than LMWH +/- LDA were imprecise. Only the confidence in the evidence regarding LMWH vs. controls was judged as moderate, according to the Confidence in Network Meta-Analysis framework. No treatment was associated with an increased risk of bleeding, although estimates were precise enough only for LMWH. These results should inform clinicians on the benefits of active pharmacological prophylaxis for FGR prevention.
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Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Laura Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milan, Milan, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Claudia Ravaldi
- PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
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Dias ATB, Modesto TB, Oliveira SAD. Effectiveness of the use of Low Molecular Heparin in patients with repetition abortion history: Systematic review and meta-analysis. JBRA Assist Reprod 2021; 25:10-27. [PMID: 32598832 PMCID: PMC7863102 DOI: 10.5935/1518-0557.20200042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of using low molecular weight heparin (LMWH) in women with a history of recurrent abortion without an identified cause. Methods: To develop a systematic review to select the studies. Total found 437 papers. Seven studies were completed or requested. The following variables were analyzed: clinical pregnancy, implantation rate, live births, abortion, premature birth, pregnancy, continuous pregnancy, beyond the 20th gestational week, congenital abnormality, hemorrhage, preeclampsia, placental premature detachment. Results: The LMWH group had a higher incidence of continuous pregnancy after the 20th week of gestation and there was no significant difference between the LMWH group and the expectant management group in the analysis of other variables. Conclusions: There was no data showing risk and/or less use of LMWH compared to expectant management; on the contrary, LMWH use increased the incidence of evolutionary pregnancy after the 20th gestational week. LMWH has some influence on prophylactic treatment of repeat abortion for unknown cause.
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Affiliation(s)
| | - Tauane Bahia Modesto
- State University of Bahia (UNEB) - Life Sciences Department. Salvador - Bahia - Brazil
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14
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The role of low molecular weight heparin on recurrent pregnancy loss: A systematic review and meta-analysis. Taiwan J Obstet Gynecol 2021; 60:1-8. [PMID: 33494980 DOI: 10.1016/j.tjog.2020.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
To assess the roles of the low molecular weight heparin (LMWH) on recurrent pregnancy loss (RPL). The relevant studies of all randomized controlled trials (RCTs) were retrieved, and the systematic evaluation was conducted. PubMed, Embase, and Cochrane library databases were searched by using keywords, including low-molecular-weight heparin or LMWH, and recurrent miscarriage or recurrent pregnancy loss in pregnant women from their earliest data to February 2020. Two investigators independently evaluated eligibility. Risk ratios (RRs) and their corresponding 95% confidence interval (CI) were determined. To pool the results, this meta-analysis was performed using random-effect model due to the high heterogeneity among these eight studies. A total of eight RCTs involving 1854 participants were included in the meta-analysis involving 963 patients with RPL who were prescribed LMWH (enoxaparin, tinzaparin, or dalteparin) alone and 891 patients who were treated with no LMWH interventions (placebo, folic acid or non-treatment) were compared. Pooled data from the remaining eight RCTs showed the differences between intervention groups and control groups. Compared with control groups, LMWH had significantly improved live births (RR,1.19; 95%CI, 1.03 to 1.38; P = 0.02), and reduced miscarriage rates (RR, 0.62; 95%CI, 0.43 to 0.91; P = 0.01). The study suggested that LMWH could improve the live births and reduce the miscarriage rates of RPL. Therefore, LMWH might be a good treatment choice for women with unexplained PRL.
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Hold your needles in women with recurrent pregnancy losses with or without hereditary thrombophilia: Meta-analysis and review of the literature. J Gynecol Obstet Hum Reprod 2020; 50:101935. [PMID: 33035720 DOI: 10.1016/j.jogoh.2020.101935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The use of antithrombotic prophylaxis in women with recurrent pregnancy losses (RPL) remains controversial. METHODS We performed meta-analysis of randomized controlled trials (RCTs) comparing low molecular weight heparin (LMWH) versus No LMWH in women with or without hereditary thrombophilia and RPL. Twelve RCTs met our inclusion criteria and 2298 women were included in this meta-analysis. Our primary end point was live birth and odds ratio (OR) for live birth are reported. RESULTS In women with thrombophilia the benefit of LMWH on live birth is not significant but heterogeneity of the studies is significant (OR, 2.09; 95 % CI, 0.58-7.57; p = 0.26; I2 = 86 %, p = 0.0001). Considering women without thrombophilia there is no benefit of LMWH in OR of live birth and data from studies have low heterogeneity (OR, 1.25; 95 % CI, 0.88-1.78; p = 0 0.21; I2 = 44 %, p = 0.07). CONCLUSIONS Hold your needles in women with RPL. Probably in some hereditary thrombophilic defects LMWH has a positive effect on OR for live birth.
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Yang S, Ni R, Lu Y, Wang S, Xie F, Zhang C, Lu L. A three-arm, multicenter, open-label randomized controlled trial of hydroxychloroquine and low-dose prednisone to treat recurrent pregnancy loss in women with undifferentiated connective tissue diseases: protocol for the Immunosuppressant regimens for LIving FEtuses (ILIFE) trial. Trials 2020; 21:771. [PMID: 32907619 PMCID: PMC7488113 DOI: 10.1186/s13063-020-04716-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/29/2020] [Indexed: 11/22/2022] Open
Abstract
Background Undifferentiated connective tissue disease (UCTD) is known to induce adverse pregnancy outcomes and even recurrent spontaneous abortion (RSA) by placental vascular damage and inflammation activation. Anticoagulation can prevent pregnancy morbidities. However, it is unknown whether the addition of immune suppressants to anticoagulation can prevent spontaneous pregnancy loss in UCTD patients. The purpose of this study is to evaluate the efficacy of hydroxychloroquine (HCQ) and low-dose prednisone on recurrent pregnancy loss for women with UCTD. Methods The Immunosuppressant for Living Fetuses (ILIFE) Trial is a three-arm, multicenter, open-label randomized controlled trial with the primary objective of comparing hydroxychloroquine combined with low-dose prednisone and anticoagulation with anticoagulation alone in treating UCTD women with recurrent spontaneous abortion. The third arm of using hydroxychloroquine combined with anticoagulant for secondary comparison. A total of 426 eligible patients will be randomly assigned to each of the three arms with a 1:1:1 allocation ratio. The primary outcome is the rate of live births. Secondary outcomes include adverse pregnancy outcomes and progression of UCTD. Discussion This is the first multi-center, open-label, randomized controlled trial which evaluates the efficacy of immunosuppressant regimens on pregnancy outcomes and UCTD progression. It will provide evidence on whether the immunosuppressant ameliorates the pregnancy prognosis in UCTD patients with RSA and the progression into defined connective tissue disease. Trial registration ClinicalTrials.gov NCT03671174. Registered on 14 September 2018.
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Affiliation(s)
- Shaoying Yang
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, 200001, China
| | - Ruoning Ni
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD, USA
| | - Yikang Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, 200001, China
| | - Suli Wang
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, 200001, China
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chunyan Zhang
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, 200001, China.
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, 200001, China.
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Thrombophilia associated gene polymorphisms: Does use of medication, including anti-coagulants, minerals or folic acid, prevent the miscarriages? J Reprod Immunol 2020; 141:103172. [PMID: 32634649 DOI: 10.1016/j.jri.2020.103172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/15/2020] [Accepted: 06/20/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recurrent pregnancy loss (RPL) has been associated with thrombophilia. The use of prophylactic treatments against thrombophilia becomes necessary in order to increase the live birth rates in women with RPL. The aim of this study was to genotype thrombophilia associated polymorphisms and investigates the benefit of prophylactic treatment on the clinical pregnancy outcomes of women with specific genotypes of these polymorphisms. MATERIALS AND METHODS A total of 62 women were included in this study. The polymorphisms associated with thrombophilia, including methyltetrahydrofolate reductase (MTHFR) 1298 and 677, Factor V Leiden (FVL) 1691, plasminogen activator inhibitor-1 (PA1-1) G/G and Factor II prothrombin 20,210, were genotyped using the real time PCR. The effect of prophylactic treatment using anti-coagulants of 0.4 mL dose of enoxaparin (3000-6000IU) and 75 mg dose of aspirin, 81 mg dose of aspirin, mineral of 15 mg dose of zinco c or10 mg dose of folic acid, was correlated with the genotypes of polymorphisms. RESULTS AND CONCLUSION The clinical pregnancy outcomes were significantly improved in patients with MTHFR 677CC genotype when treated with zinco c. Furthermore, treatment with 75 mg of aspirin resulted in higher negative pregnancy rates in patients with MTHFR A1298C genotypes. Therefore, the results of this study should be used to re-evaluate the clinical applications in women with miscarriages.
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18
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Li J, Gao YH, Xu L, Li ZY. Meta-analysis of heparin combined with aspirin versus aspirin alone for unexplained recurrent spontaneous abortion. Int J Gynaecol Obstet 2020; 151:23-32. [PMID: 32535924 DOI: 10.1002/ijgo.13266] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/23/2020] [Accepted: 06/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Unexplained recurrent spontaneous abortion (URSA) frustrates women of childbearing age profoundly, and effective therapies are particularly important. OBJECTIVE To compare the efficacy of heparin combined with aspirin and aspirin alone for URSA. SEARCH STRATEGY Electronic databases (PubMed, Medline, Web of Science, Clinical key and Cochrane Library) were searched for relevant studies from database inception to August 2019. SELECTION CRITERIA Studies of women of childbearing age with at least two consecutive abortions were included. DATA COLLECTION AND ANALYSIS Relevant items were extracted, tabulated, and subjected to STATA for data analysis. Study women were divided into group A (taking heparin plus aspirin) and group B (taking aspirin alone). The primary outcome was the rate of live birth. MAIN RESULTS Women from eight randomized controlled trials were included: 493 in group A and 501 in group B. The number of live births was significantly higher in group A (P=0.003). The result remained the same in subgroup analysis by presence of antiphospholipid antibodies. Among women who had a live birth, gestational age at delivery tended to be older in group B (P=0.054). No differences in birthweight or intrauterine growth restriction were observed. Adverse effects were sporadically reported. CONCLUSION Among women with URSA, heparin combined with aspirin increased the live birth rate as compared with aspirin alone. There was a beneficial tendency of taking aspirin-only to prolong gestation week.
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Affiliation(s)
- Jie Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Yue-Hua Gao
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Lin Xu
- Department of Gynecology and Obstetrics, Anyi People's hospital, Nanchang, PR China
| | - Zeng-Yan Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
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Bordewijk EM, Wang R, Askie LM, Gurrin LC, Thornton JG, van Wely M, Li W, Mol BW. Data integrity of 35 randomised controlled trials in women’ health. Eur J Obstet Gynecol Reprod Biol 2020; 249:72-83. [DOI: 10.1016/j.ejogrb.2020.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 03/27/2020] [Accepted: 04/02/2020] [Indexed: 11/28/2022]
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Ali S, Majid S, Niamat Ali M, Taing S. Evaluation of T cell cytokines and their role in recurrent miscarriage. Int Immunopharmacol 2020; 82:106347. [PMID: 32143004 DOI: 10.1016/j.intimp.2020.106347] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/08/2020] [Accepted: 02/23/2020] [Indexed: 01/03/2023]
Abstract
Recurrent miscarriage (RM) is defined as two or more consecutive pregnancy losses that affect approximately 5% of conceived women worldwide. RM is a multi-factorial reproductive problem and has been associated with parental chromosomal abnormalities, embryonic chromosomal rearrangements, uterine anomalies, autoimmune disorders, endocrine dysfunction, thrombophilia, life style factors, and maternal infections. However, the exact cause is still undecided in remaining 50% of cases. Immunological rejection of the embryo due to exacerbated maternal immune reaction against paternal embryonic antigens has been set forth as one of the significant reason for RM. The accurate means that shield the embryo during normal pregnancy from the attack of maternal immune network and dismissal are inadequately implicit. However, it is suggested that the genetically irreconcilable embryo escapes maternal immune rejection due to communication among many vital cytokines exuded at maternal-embryonic interface both by maternal and embryonic cells. Previous investigations suggested the Th1/Th2 dominance in altered immunity of RM patients, according to which the allogenic embryo flees maternal T cell reaction by inclining the Th0 differentiation toward Th2 pathway resulting into diminished pro-inflammatory Th1 immunity. However, recently pro-inflammatory Th17 cells and immunoregulatory Treg cells have been discovered as essential immune players in RM besides Th1/Th2 components. Cytokines are believed to develop a complicated regulatory network so as to establish a state of homeostasis between the semi-allogenic embryo and the maternal immune system. However, an adverse imbalance among cytokines at maternal-embryonic interface perhaps due to their gene polymorphisms may render immunoregulatory means not enough to re-establish homeostasis and thus may collapse pregnancy.
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Affiliation(s)
- Shafat Ali
- Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, 190006 Srinagar, J&K, India
| | - Sabhiya Majid
- Department of Biochemistry, Government Medical College, Srinagar, J&K, India
| | - Md Niamat Ali
- Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, 190006 Srinagar, J&K, India.
| | - Shahnaz Taing
- Department of Obstetrics and Gynaecology, Government Medical College Associated Lalla Ded Hospital, Srinagar, J&K, India
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Jacobson B, Rambiritch V, Paek D, Sayre T, Naidoo P, Shan J, Leisegang R. Safety and Efficacy of Enoxaparin in Pregnancy: A Systematic Review and Meta-Analysis. Adv Ther 2020; 37:27-40. [PMID: 31673991 PMCID: PMC6979442 DOI: 10.1007/s12325-019-01124-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/19/2022]
Abstract
Introduction International guidelines support the use of low molecular weight heparins for the treatment of thromboembolism and thromboprophylaxis during pregnancy. However, evidence of the benefit and harm associated with specific low molecular weight heparins such as enoxaparin is dated. No current systematic review and meta-analysis describing the safety and efficacy of enoxaparin for thromboembolism and thromboprophylaxis during pregnancy exists. Methods PubMed, Embase, and Cochrane databases were searched on August 17, 2018 for clinical trials or observational studies in pregnant women receiving enoxaparin; patients with a prosthetic heart valve were excluded. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random effects model, and heterogeneity was measured using the I2 statistic. Results Of the 485 records identified in the search, 24 studies published clinical trials, and observational studies were found dating back to 2000. Only one observational cohort and one randomized control trial focused on the use of enoxaparin for thromboprophylaxis and therefore efficacy was not assessed; the other studies included women with recurrent pregnancy loss (15 studies), history of placental vascular complications (five studies), and recurrent in vitro fertilization failure (two studies) and were therefore analyzed in terms of safety only. Bleeding events were non-significantly more often reported for enoxaparin compared to untreated controls (RR 1.35 [0.88–2.07]) but less often reported for enoxaparin versus aspirin (RR 0.93 [0.62–1.39]); thromboembolic events, thrombocytopenia, and teratogenicity were rarely reported events; in patients with a history of recurrent pregnancy loss, encouragingly the rates of pregnancy loss were significantly lower for enoxaparin compared to untreated controls (RR 0.58 [0.34–0.96]) and enoxaparin + aspirin versus aspirin alone (RR 0.42 [0.32–0.56]) as well as observably lower for enoxaparin versus aspirin alone (RR 0.39 [0.15–1.01]), though significant heterogeneity was observed (I2 > 60). Conclusion Literature on the efficacy and safety of enoxaparin for thromboembolism and thromboprophylaxis remains scanty, and therefore efficacy was not assessed; in terms of safety, when including other indications for enoxaparin in pregnancy, we found that enoxaparin was associated with significantly lower complications than aspirin. Given differences in study design and study heterogeneity, pregnancy loss results should be interpreted with caution. Moreover, reports of thromboembolic events, thrombocytopenia, and congenital malformations were rare. Funding Sanofi. Electronic supplementary material The online version of this article (10.1007/s12325-019-01124-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Barry Jacobson
- Department of Haematology and Molecular Medicine, University of Witwatersrand, 1 Jan Smuts Ave, Johannesburg, South Africa
| | - Virendra Rambiritch
- Department of Pharmacology, University of KwaZulu-Natal, University Rd, Westville, South Africa
| | - Dara Paek
- Doctor Evidence, 301 Arizona Ave, Santa Monica, CA, USA
| | - Tobias Sayre
- Doctor Evidence, 301 Arizona Ave, Santa Monica, CA, USA
| | - Poobalan Naidoo
- Sanofi Affiliate, Medical, 2 Bond St, Grand Central, Midrand, South Africa
- Department of Health Informatics, School of Health Professions, Rutgers, State University of New Jersey, 57 US Highway 1, New Brunswick, NJ, USA
| | - Jenny Shan
- Sanofi Global, Medical, 54-56 Rue la Boétie, Paris, France
| | - Rory Leisegang
- Department of Pharmaceutical Biosciences, Uppsala University, 752 36, Uppsala, Sweden.
- FAMCRU, The Department of Paediatrics & Child Health, Stellenbosch University, Tygerberg, Cape Town, South Africa.
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du Fossé N, van der Hoorn ML, Eikmans M, Heidt S, le Cessie S, Mulders A, van Lith J, Lashley E. Evaluating the role of paternal factors in aetiology and prognosis of recurrent pregnancy loss: study protocol for a hospital-based multicentre case-control study and cohort study (REMI III project). BMJ Open 2019; 9:e033095. [PMID: 31727666 PMCID: PMC6887057 DOI: 10.1136/bmjopen-2019-033095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Recurrent pregnancy loss (RPL) is defined as the spontaneous demise of two or more pregnancies before the fetus reaches viability. Despite investigation of multiple known maternal risk factors, in more than 50% of couples, this condition remains unexplained. Studies focusing on paternal factors in RPL are scarce, and therefore, paternal evaluation in RPL is currently very limited. However, regarding single miscarriage, there are multiple publications suggesting a contributive role of paternal factors. In this project, we aim to identify paternal factors associated with RPL and to improve couple-specific prediction of future pregnancy outcomes by developing a prediction model containing both maternal and paternal factors. METHODS AND ANALYSIS In a case-control design, the relation between unexplained RPL and paternal age, lifestyle factors, sperm DNA damage and immunomodulatory factors in peripheral blood and semen will be studied. Prospectively, 135 couples with naturally conceived unexplained RPL (cases) and 135 fertile couples without a history of pregnancy loss (controls) will be included, with collection of paternal blood and semen samples and documentation of clinical and lifestyle characteristics. In addition, 600 couples from both groups will be included retrospectively. To adjust for confounders, multivariate logistic regression will be used. The predictive value of paternal and maternal factors will be studied in the total RPL cohort consisting of approximately 735 couples. The primary outcome of the cohort study is live birth within 5 years after initial visit of the clinic. Secondary outcomes are ongoing pregnancy, time interval until next pregnancy and pregnancy complications. ETHICS AND DISSEMINATION This project is approved by the Medical Research Ethics Committee of the Leiden University Medical Center. No risks or burden are expected from the study. The findings of this study will be disseminated via peer-reviewed publications and presentations at international conferences. TRIAL REGISTRATION NUMBER NL7762.
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Affiliation(s)
- Nadia du Fossé
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michael Eikmans
- Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia le Cessie
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemarie Mulders
- Gynaecology and Obstetrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan van Lith
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eileen Lashley
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Karadağ C, Akar B, Gönenç G, Aslancan R, Yılmaz N, Çalışkan E. Aspirin, low molecular weight heparin, or both in preventing pregnancy complications in women with recurrent pregnancy loss and factor V Leiden mutation. J Matern Fetal Neonatal Med 2019; 33:1934-1939. [PMID: 31550962 DOI: 10.1080/14767058.2019.1671348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Cihan Karadağ
- Department of Obstetrics and Gynecology, Okan University School of Medicine, İstanbul, Turkey
| | - Bertan Akar
- Department of Obstetrics and Gynecology, İstinye University School of Medicine, İstanbul, Turkey
| | - Gökçenur Gönenç
- Department of Obstetrics and Gynecology, Okan University School of Medicine, İstanbul, Turkey
| | - Reyhan Aslancan
- Department of Obstetrics and Gynecology, Bahçeşehir University School of Medicine, İstanbul, Turkey
| | - Nagihan Yılmaz
- Department of Obstetrics and Gynecology, İstanbul Aydın University School of Medicine, İstanbul, Turkey
| | - Eray Çalışkan
- Department of Obstetrics and Gynecology, Okan University School of Medicine, İstanbul, Turkey
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Lin T, Chen Y, Cheng X, Li N, Sheng X. Enoxaparin (or plus aspirin) for the prevention of recurrent miscarriage: A meta-analysis of randomized controlled studies. Eur J Obstet Gynecol Reprod Biol 2019; 234:53-57. [DOI: 10.1016/j.ejogrb.2018.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/28/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
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Lowry DE, Corsi DJ, White RR, Guo M, Lanes A, Smith G, Rodger M, Wen SW, Walker M, Gaudet L. Association between prophylactic low-molecular-weight heparin use in pregnancy and macrosomia: analysis of the Ottawa and Kingston birth cohort. J Thromb Haemost 2019; 17:345-349. [PMID: 30552749 DOI: 10.1111/jth.14358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022]
Abstract
Essentials Low-molecular-weight heparin (LMWH) is used to prevent venous thromboembolism (VTE) in pregnancy. We evaluated the association between LMWH and large for gestational age (LGA) infants. We found no significant associations between LMWH use and LGA. LMWH does not appear to increase the risk for the delivery of an LGA infant. SUMMARY: Background Low-molecular-weight heparin (LMWH), an anticoagulant, is the recommended drug for thromboprophylaxis and treatment of venous thromboembolism (VTE) in pregnancy. During pregnancy, LMWH is routinely prescribed to mothers with an increased risk of VTE or with a history of thrombosis. Although clinical reports of larger offspring born to women administered LMWH have been noted, no studies to date have evaluated or associated the use of LMWH and large for gestational age (LGA) infants. Objectives To determine whether there is an association between LMWH usage in mothers and the prevalence of LGA. Patients/Methods We performed an analysis of the Ottawa and Kingston (OaK) Birth Cohort and report characteristics of LMWH and association LGA (> 10%ile). We used coarsened exact matching (CEM) methods to account for bias and confounding. Results A total of 7519 women from the OaK Birth Cohort were included; 59 were administered LMWH during pregnancy (0.78%). Mothers prescribed LMWH had significantly greater BMI (P = 0.0001), age (P = 0.0001) and parity (P = 0.02). Gestational length was shorter among women administered LMWH compared to those without treatment (37.7 ± 2.0 vs. 39.2 ± 2.0, P < 0.0001), an iatrogenic finding. The odds ratio of an LGA delivery among women administered LMWH was 1.02 (95% confidence interval [CI], 0.48-2.16; P = 0.96) in unadjusted analyses and was 1.15 (95% CI, 0.49-2.71) in the matched sample adjusted for maternal age, BMI and gestational age. Conclusions These results, although exploratory, provide indirect evidence of no increased risk of LGA infants among women prescribed LMWH.
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Affiliation(s)
- D E Lowry
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - D J Corsi
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - R R White
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - M Guo
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - A Lanes
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - G Smith
- Department of Obstetrics and Gynecology, Queen's Perinatal Research Unit, Kingston General Hospital, Queens University, Kingston, Ontario, Canada
| | - M Rodger
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - S W Wen
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - M Walker
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - L Gaudet
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
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Wojcieszek AM, Shepherd E, Middleton P, Lassi ZS, Wilson T, Murphy MM, Heazell AEP, Ellwood DA, Silver RM, Flenady V. Care prior to and during subsequent pregnancies following stillbirth for improving outcomes. Cochrane Database Syst Rev 2018; 12:CD012203. [PMID: 30556599 PMCID: PMC6516997 DOI: 10.1002/14651858.cd012203.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Stillbirth affects at least 2.6 million families worldwide every year and has enduring consequences for parents and health services. Parents entering a subsequent pregnancy following stillbirth face a risk of stillbirth recurrence, alongside increased risks of other adverse pregnancy outcomes and psychosocial challenges. These parents may benefit from a range of interventions to optimise their short- and longer-term medical health and psychosocial well-being. OBJECTIVES To assess the effects of different interventions or models of care prior to and during subsequent pregnancies following stillbirth on maternal, fetal, neonatal and family health outcomes, and health service utilisation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 June 2018), along with ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 June 2018). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs). Trials using a cluster-randomised design were eligible for inclusion, but we found no such reports. We included trials published as abstract only, provided sufficient information was available to allow assessment of trial eligibility and risk of bias. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and undertook data extraction and 'Risk of bias' assessments. We extracted data from published reports, or sourced data directly from trialists. We checked the data for accuracy and resolved discrepancies by discussion or correspondence with trialists, or both. We conducted an assessment of the quality of the evidence using the GRADE approach. MAIN RESULTS We included nine RCTs and one qRCT, and judged them to be at low to moderate risk of bias. Trials were carried out between the years 1964 and 2015 and took place predominantly in high-income countries in Europe. All trials assessed medical interventions; no trials assessed psychosocial interventions or incorporated psychosocial aspects of care. Trials evaluated the use of antiplatelet agents (low-dose aspirin (LDA) or low-molecular-weight heparin (LMWH), or both), third-party leukocyte immunisation, intravenous immunoglobulin, and progestogen. Trial participants were women who were either pregnant or attempting to conceive following a pregnancy loss, fetal death, or adverse outcome in a previous pregnancy.We extracted data for 222 women who had experienced a previous stillbirth of 20 weeks' gestation or more from the broader trial data sets, and included them in this review. Our GRADE assessments of the quality of evidence ranged from very low to low, due largely to serious imprecision in effect estimates as a result of small sample sizes, low numbers of events, and wide confidence intervals (CIs) crossing the line of no effect. Most of the analyses in this review were not sufficiently powered to detect differences in the outcomes assessed. The results presented are therefore largely uncertain.Main comparisonsLMWH versus no treatment/standard care (three RCTs, 123 women, depending on the outcome)It was uncertain whether LMWH reduced the risk of stillbirth (risk ratio (RR) 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), adverse perinatal outcome (RR 0.81, 95% CI 0.20 to 3.32; 2 trials; 77 participants; low-quality evidence), adverse maternal psychological effects (RR 1.00, 95% CI 0.07 to 14.90; 1 trial; 40 participants; very low-quality evidence), perinatal mortality (RR 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), or any preterm birth (< 37 weeks) (RR 1.01, 0.58 to 1.74; 3 trials; 114 participants; low-quality evidence). No neonatal deaths were reported in the trials assessed and no data were available for maternal-infant attachment. There was no clear evidence of a difference between the groups among the remaining secondary outcomes.LDA versus placebo (one RCT, 24 women)It was uncertain whether LDA reduced the risk of stillbirth (RR 0.85, 95% CI 0.06 to 12.01), neonatal death (RR 0.29, 95% CI 0.01 to 6.38), adverse perinatal outcome (RR 0.28, 95% CI 0.03 to 2.34), perinatal mortality, or any preterm birth (< 37 weeks) (both of the latter RR 0.42, 95% CI 0.04 to 4.06; all very low-quality evidence). No data were available for adverse maternal psychological effects or maternal-infant attachment. LDA appeared to be associated with an increase in birthweight (mean difference (MD) 790.00 g, 95% CI 295.03 to 1284.97 g) when compared to placebo, but this result was very unstable due to the extremely small sample size. Whether LDA has any effect on the remaining secondary outcomes was also uncertain.Other comparisonsLDA appeared to be associated with an increase in birthweight when compared to LDA + LMWH (MD -650.00 g, 95% CI -1210.33 to -89.67 g; 1 trial; 29 infants), as did third-party leukocyte immunisation when compared to placebo (MD 1195.00 g, 95% CI 273.35 to 2116.65 g; 1 trial, 4 infants), but these results were again very unstable due to extremely small sample sizes. The effects of the interventions on the remaining outcomes were also uncertain. AUTHORS' CONCLUSIONS There is insufficient evidence in this review to inform clinical practice about the effectiveness of interventions to improve care prior to and during subsequent pregnancies following a stillbirth. There is a clear and urgent need for well-designed trials addressing this research question. The evaluation of medical interventions such as LDA, in the specific context of stillbirth prevention (and recurrent stillbirth prevention), is warranted. However, appropriate methodologies to evaluate such therapies need to be determined, particularly where clinical equipoise may be lacking. Careful trial design and multicentre collaboration is necessary to carry out trials that would be sufficiently large to detect differences in statistically rare outcomes such as stillbirth and neonatal death. The evaluation of psychosocial interventions addressing maternal-fetal attachment and parental anxiety and depression is also an urgent priority. In a randomised-trial context, such trials may allocate parents to different forms of support, to determine which have the greatest benefit with the least financial cost. Importantly, consistency in nomenclature and in data collection across all future trials (randomised and non-randomised) may be facilitated by a core outcomes data set for stillbirth research. All future trials should assess short- and longer-term psychosocial outcomes for parents and families, alongside economic costs of interventions.
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Affiliation(s)
- Aleena M Wojcieszek
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
| | - Emily Shepherd
- The University of AdelaideRobinson Research Institute, Discipline of Obstetrics and Gynaecology, Adelaide Medical SchoolAdelaideSouth AustraliaAustralia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSAAustralia
| | - Zohra S Lassi
- The University of AdelaideThe Robinson Research InstituteAdelaideSouth AustraliaAustralia5005
| | - Trish Wilson
- Trish Wilson Counselling61A Brecon CrescentBuderimQLDAustralia4556
| | - Margaret M Murphy
- University College CorkSchool of Nursing and MidwiferyBrookfield Health Sciences ComplexCollege RoadCorkIrelandT12 AK54
| | - Alexander EP Heazell
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - David A Ellwood
- Griffith UniversitySchool of MedicineGold Coast CampusLevel 8, G40Gold CoastQueensland,Australia4216
| | - Robert M Silver
- University of UtahDivision of Maternal‐Fetal Medicine, Health Services Center30 North 1900 East SOM 2B200Salt Lake CityUtahUSA84132
| | - Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
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Blomqvist L, Hellgren M, Strandell A. Acetylsalicylic acid does not prevent first-trimester unexplained recurrent pregnancy loss: A randomized controlled trial. Acta Obstet Gynecol Scand 2018; 97:1365-1372. [PMID: 29972884 DOI: 10.1111/aogs.13420] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Recurrent pregnancy loss occurs in about 1% of fertile couples. Without proper evidence for an effect, different treatments have been used when no etiological factor has been detected. The present trial is the first randomized trial to compare 75 mg acetylsalicylic acid with placebo for women with recurrent pregnancy loss. MATERIAL AND METHODS This randomized, double-blind, placebo-controlled trial was conducted at a single center between 2008 and 2015. Recurrent pregnancy loss was defined as at least 3 consecutive first-trimester miscarriages within the couple. Women < 40 years old with a body mass index < 35 kg/m2 were eligible if the workup was negative. Randomization was through a third party, who manufactured and delivered the study drugs, and occurred when fetal heartbeat was detected, to either 75 mg acetylsalicylic acid or placebo; 200 women in each group. Group allocation was concealed until all the study participants had a pregnancy outcome registered. All women attended the same control program. Primary outcome was live birth. Statistical analyses were according to intention-to-treat. RESULTS All 400 women completed the follow up. Live birth rate was 83.0% (n = 166) and 85.5% (n = 171) for the acetylsalicylic acid and placebo groups, respectively (P = 0.58). The difference was -2.5% (95% CI -10.1% to 5.1%). The risk ratio was 0.97 (95% CI 0.89-1.06). CONCLUSIONS Treatment with acetylsalicylic acid did not prevent recurrent miscarriage in women with at least three consecutive miscarriages in the first trimester, of unknown reasons and in the same relationship. The fertility prognosis is very good, the live birth rate being > 80% with or without acetylsalicylic acid.
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Affiliation(s)
- Lennart Blomqvist
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, Borås, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Shlomo M, Gorodischer R, Daniel S, Wiznitzer A, Matok I, Fishman B, Koren G, Levy A. The Fetal Safety of Enoxaparin Use During Pregnancy: A Population-Based Retrospective Cohort Study. Drug Saf 2018; 40:1147-1155. [PMID: 28733971 DOI: 10.1007/s40264-017-0573-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Enoxaparin is widely used during pregnancy as pregnancy is a hypercoagulable state; however, its fetal safety has scarcely been investigated. OBJECTIVE Our study aimed to examine fetal safety following enoxaparin exposure during pregnancy. METHODS A population-based, retrospective cohort study was performed by linking computerized databases, including the drug dispensing registries of Clalit Health Services in Israel and maternal and infant hospital records, between 1998 and 2009. Multivariate logistic regression models were used to examine associations between first- and third-trimester exposure to enoxaparin, major malformations, and other adverse birth outcomes, adjusted for confounders. RESULTS From a total of 109,473 singleton pregnancies, 418 and 572 were exposed to enoxaparin during the first and third trimesters, respectively. Exposure to enoxaparin during the first trimester of pregnancy was not associated with an increased risk of major congenital malformations [adjusted odds ratio (aOR) 1.1, 95% confidence interval (CI) 0.8-1.6], while exposure during the third trimester was not associated with an increased risk of low birth weight (aOR 1.1, 95% CI 0.8-1.4), low Apgar score (aOR 0.9, 95% CI 0.4-1.8), or risk of perinatal mortality (aOR 0.6, 95% CI 0.1-2.9). CONCLUSION Exposure to enoxaparin during pregnancy was not associated with an increased risk of major malformations in general or according to organ systems. Nonetheless, risk for specific malformations cannot be ruled out.
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Affiliation(s)
- Meital Shlomo
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Rafael Gorodischer
- Department of Pediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel.,Clalit Health Services (Southern District), Beer-Sheva, Israel.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Sharon Daniel
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel.,Department of Pediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Arnon Wiznitzer
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Soroka Medical Center, Beer-Sheva, Israel.,Clalit Health Services (Southern District), Beer-Sheva, Israel
| | - Ilan Matok
- The Motherisk Program, Division of Clinical Pharmacology-Toxicology, Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Boris Fishman
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Gideon Koren
- The Motherisk Program, Division of Clinical Pharmacology-Toxicology, Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada.,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel
| | - Amalia Levy
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel. .,BeMORE Collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure Collaboration), Beer-Sheva, Israel.
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Lv S, Yu J, Xu X. A comparison of effectiveness among frequent treatments of recurrent spontaneous abortion: A Bayesian network meta-analysis. Am J Reprod Immunol 2018; 80:e12856. [PMID: 29709100 DOI: 10.1111/aji.12856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/21/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE A comprehensive network meta-analysis was designed to clarify contradictions and offer valuable clinical guidance in the treatment of recurrent spontaneous abortion (RSA). METHOD The included clinical trials were selected from the relevant medical journal databases and screened. Treatments were ranked by the surface under the cumulative ranking curve. Heat plots were constructed to analyze the inconsistency between direct data and network results, and adjusted funnel plots were constructed to assess publication bias. RESULTS Forty-nine randomized controlled trials involving a total of 8496 RSA patients were selected. With placebo as control, corticosteroid plus low dose aspirin (LDA) plus unfractionated heparin (UFH), granulocyte colony-stimulating factor (G-CSF) alone, and LDA plus low molecular weight heparin (LMWH) all demonstrated effectiveness in increasing successful live birth rates and reducing the incidences of miscarriage. However, no treatment was demonstrably superior to placebo in terms of pregnancy success. For all 3 endpoints (live birth, abortion and success pregnancy), the adjusted funnel plots were symmetric to zero and indicated no publication bias. In terms of live birth and abortion rates, no treatment outperformed placebo in patients with antiphospholipid syndrome. CONCLUSION In consideration of live birth and abortion rates, corticosteroid plus LDA plus UFH appeared to be the optimum treatment strategy; G-CSF was second, followed by LDA with LMWH, LDA plus LMWH plus intravenous immunoglobulin, corticosteroid with LDA and others. Subgroup analysis demonstrated no benefit of antithrombotic therapy in patients with antiphospholipid syndrome.
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Affiliation(s)
- Sha Lv
- Department of Gynaecology and Obstetrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jing Yu
- Department of Medical Imaging, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xiaoxiao Xu
- Department of Gynaecology and Obstetrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Rasmark Roepke E, Hellgren M, Hjertberg R, Blomqvist L, Matthiesen L, Henic E, Lalitkumar S, Strandell A. Treatment efficacy for idiopathic recurrent pregnancy loss - a systematic review and meta-analyses. Acta Obstet Gynecol Scand 2018; 97:921-941. [PMID: 29603135 DOI: 10.1111/aogs.13352] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/21/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Medical treatment of women with idiopathic recurrent pregnancy loss is controversial. The objective was to assess the effects of different treatments on live birth rates and complications in women with unexplained recurrent pregnancy loss. MATERIAL AND METHODS We searched MEDLINE, Embase and the Cochrane Library, and identified 1415 publications. This systematic review included 21 randomized controlled trials regarding acetylsalicylic acid, low-molecular-weight heparin, progesterone, intravenous immunoglobulin or leukocyte immune therapy in women with three or more consecutive miscarriages of unknown cause. The study quality was assessed and data was extracted independently by at least two authors. RESULTS No significant difference in live birth rate was found when acetylsalicylic acid was compared with low-molecular-weight heparin or with placebo. Meta-analyses of low-molecular-weight heparin vs. control found no significant differences in live birth rate [risk ratio (RR) 1.47, 95% CI 0.83-2.61]. Treatment with progesterone starting in the luteal phase seemed effective in increasing live birth rate (RR 1.18, 95% CI 1.09-1.27) but not when started after conception. Intravenous immunoglobulin showed no effect on live birth rate compared with placebo (RR 1.07, 95% CI 0.91-1.26). Paternal immunization compared with autologous immunization showed a significant difference in outcome (RR 1.8, 95% CI 1.34-2.41), although the studies were small and at high risk of bias. CONCLUSION The literature does not allow advice on any specific treatment for idiopathic recurrent pregnancy loss, with the exception of progesterone starting from ovulation. We suggest that any treatment for recurrent pregnancy loss should be used within the context of a randomized controlled trial.
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Affiliation(s)
- Emma Rasmark Roepke
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Lennart Blomqvist
- Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Leif Matthiesen
- Department of Obstetrics and Gynecology, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Emir Henic
- Reproductive Medicine Center, Skåne University Hospital, Malmö, Sweden
| | - Sujata Lalitkumar
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Shaaban OM, Abbas AM, Zahran KM, Fathalla MM, Anan MA, Salman SA. Low-Molecular-Weight Heparin for the Treatment of Unexplained Recurrent Miscarriage With Negative Antiphospholipid Antibodies: A Randomized Controlled Trial. Clin Appl Thromb Hemost 2017; 23:567-572. [PMID: 27572887 DOI: 10.1177/1076029616665167] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Recurrent miscarriage (RM) is one of the most common clinical problems in reproduction with no definite cause in about 50% of the cases. The study aims to evaluate the effect of low-molecular-weight heparin (LMWH) in the treatment of women with RM negatively tested for antiphospholipid antibodies (APAs). METHODS An open-labeled registered randomized controlled study (NCT 01608347) included women who attended the outpatient clinic in Assiut Women Health Hospital and Nag-Hamady Central Hospital, Egypt, with 3 or more unexplained RM. Eligible participants were randomly assigned into 2 groups. The study group included 150 patients receiving LMWH (Tinzaparin sodium 4500 IU) subcutaneous daily injection with 500 µg folic acid once daily orally started once positive pregnancy test till the 20th week of gestation. The control group included 150 patients receiving the same dose of folic acid alone. The primary outcome of the study was the rate of continuation of a viable pregnancy after 20 weeks of gestation. RESULTS There was no significant difference between both groups as regards age, parity, or number of previous miscarriages. There was a significant increase in women who continued their pregnancy beyond 20 weeks in the study group compared to the control group (73.3% vs 48%, respectively; P = .002). The take-home baby rate was also significantly higher in the LMWH group compared to the control group ( P = .001). CONCLUSION Early start of LMWH decreases the incidence of miscarriage in the first 20 weeks of pregnancy in women with unexplained RM negative for APAs.
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Affiliation(s)
- Omar M Shaaban
- 1 Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- 1 Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Kamal M Zahran
- 1 Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed M Fathalla
- 1 Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed A Anan
- 2 Department of Obstetrics and Gynecology, Nag-Hamady Hospital, Qena, Egypt
| | - Safwat A Salman
- 1 Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Connell MT, Sjaarda LA, Radin RG, Kuhr D, Mumford SL, Plowden TC, Silver RM, Schisterman EF. The Effects of Aspirin in Gestation and Reproduction (EAGeR) Trial: A Story of Discovery. Semin Reprod Med 2017; 35:344-352. [PMID: 29036741 PMCID: PMC6234510 DOI: 10.1055/s-0037-1606384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Human reproduction is an inefficient process. There are several drivers of complications along the path to and during pregnancy, one of which is inflammation. Treatments to mitigate the deleterious effects of aberrant inflammation with something inexpensive and widely available like aspirin could have dramatic global impact. The Effects of Aspirin in Gestation and Reproduction (EAGeR) trial enrolled women aged 18 to 40 years with one to two prior pregnancy losses and no diagnosis of infertility. Patients were randomized to either low-dose aspirin or placebo. Here, we review the collective findings of the EAGeR trial to date and discuss several important lessons learned from the unique data resulting from this groundbreaking trial. Findings reported from this trial provide significant advances in the understanding of aspirin’s potential mechanisms in modulating reproductive processes and the role of inflammation in these processes. This review describes the collective findings of the EAGeR trial in the context of the existing literature regarding aspirin and inflammation in reproduction to inform relevant next steps in fertility and obstetric research, as well as potential implications for clinical care.
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Affiliation(s)
- Matthew T. Connell
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
- Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A. Sjaarda
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Rose G. Radin
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Daniel Kuhr
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Sunni L. Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Torie C. Plowden
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
- Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, Utah
| | - Enrique F. Schisterman
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
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Merviel P, Cabry R, Lourdel E, Lanta S, Amant C, Copin H, Benkhalifa M. Comparison of two preventive treatments for patients with recurrent miscarriages carrying a C677T methylenetetrahydrofolate reductase mutation: 5-year experience. J Int Med Res 2017; 45:1720-1730. [PMID: 28703660 PMCID: PMC5805189 DOI: 10.1177/0300060516675111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the effect of anticoagulant treatment on pregnancy outcomes in
patients with previous recurrent miscarriages (RM) who carry a
methylenetetrahydrofolate reductase (MTHFR) gene
mutation. Methods In this longitudinal retrospective study, patients with RM were treated
during pregnancy with either: (i) 100 mg/day aspirin and 5 mg/day folic acid
(group 1); or the same protocol plus 0.4 mg/day enoxaparin (group 2). An
age-matched group of triparous women without RM or thrombophilia was used as
the control group (group 3). Results This study enrolled 246 women with RM (123 per treatment group) and
age-matched controls (n = 117). The delivery rate was
significantly lower in group 1 than group 2 (46.3% versus 79.7%,
respectively). The miscarriage rate was significantly lower in group 2
compared with group 1 (20.3% versus 51.2%, respectively). In the control
group 3, the delivery rate was 86.3% and the miscarriage rate was 12.8%. Conclusion Treatment with low-dose aspirin, enoxaparin and folic acid was the most
effective therapy in women with RM who carried a C677T
MTHFR mutation.
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Affiliation(s)
- Philippe Merviel
- 1 Department of Obstetrics, Gynaecology and Reproductive Medicine, Bretagne Occidentale University, Brest University Medical Centre, Brest, France
| | - Rosalie Cabry
- 2 Department of Obstetrics, Gynaecology and Reproductive Medicine, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
| | - Emmanuelle Lourdel
- 2 Department of Obstetrics, Gynaecology and Reproductive Medicine, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
| | - Segolene Lanta
- 2 Department of Obstetrics, Gynaecology and Reproductive Medicine, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
| | - Carole Amant
- 3 Molecular Genetics Laboratory, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
| | - Henri Copin
- 4 Department of Reproductive Medicine and Cytogenetics, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
| | - Moncef Benkhalifa
- 4 Department of Reproductive Medicine and Cytogenetics, Picardie University Jules Verne, Amiens University Medical Centre, Amiens, France
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Mastrolia SA, Novack L, Thachil J, Rabinovich A, Pikovsky O, Klaitman V, Loverro G, Erez O. LMWH in the prevention of preeclampsia and fetal growth restriction in women without thrombophilia. A systematic review and meta-analysis. Thromb Haemost 2016; 116:868-878. [PMID: 27440387 DOI: 10.1160/th16-02-0169] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/17/2016] [Indexed: 12/18/2022]
Abstract
Placental mediated pregnancy complications such as preeclampsia and fetal growth restriction (FGR) are common, serious, and associated with increased morbidity and mortality. We conducted a systematic review and meta-analysis to determine the effect of treatment with low-molecular-weight heparins (LMWHs) for secondary prevention of these complications in non thrombophilic women. We searched the electronic databases PubMed, Scopus, and Cochrane Library for randomised controlled trials addressing this question. Five studies including 403 patients met the inclusion criteria, 68 developed preeclampsia and 118 FGR. The studies were very heterogeneous in terms of inclusion criteria, LMWH preparation, and dosage. Meta-analyses were performed using random-effect models. The overall use of LMWHs was associated with a risk reduction for preeclampsia (Relative risk (RR) 0.366; 95 % confidence interval (CI), 0.219-0.614) and FGR (RR 0.409; 95 % CI, 0.195-0.932) vs. no treatment. From the data available for analysis it appears that the use of Dalteparin is associated with a risk reduction for preeclampsia (p=0.002) and FGR (p<0.001); while Enoxaparin is associated with risk reduction for preeclampsia (p=0.013) but not for FGR (p=0.3). In spite of the small number of studies addressing the research question, and the high variability among them, our meta-analysis found a modest beneficial effect of LMWH for secondary prevention of preeclampsia and FGR. Further studies are needed to address these questions before a definite conclusion can be reached.
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Affiliation(s)
| | | | | | | | | | | | | | - Offer Erez
- Prof. Offer Erez, MD, Acting Director Maternity Department D and Obstetrical Day care Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, P. O.Box 151, 84101, Beer Sheva, Israel, Tel.: +972 8 6400061, E-mail
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Rogenhofer N, Markoff A, Wagner A, Klein HG, Petroff D, Schleussner E, Thaler CJ. Lessons From the EThIGII Trial. Clin Appl Thromb Hemost 2016; 23:27-33. [DOI: 10.1177/1076029616658117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study presents sample size considerations derived from the Efficacy of Thromboprophylaxis as an Intervention during Gravidity (EThIGII) trial (ClinicalTrials.gov: NCT00400387) to address the question of low-molecular-weight heparin (LMWH) treatment in women with recurrent pregnancy loss (RPL) depending on the M2/ANXA5 haplotype. To evaluate the possible influence of such treatment on miscarriage rates of trial participants, a post hoc analysis of ANXA5 promoter genotypes in the light of M2/ANXA5 ( RPRGL3) distribution was performed using logistic models. DNA for genotyping was available from 129 LMWH and 95 control patients, 44 (19.6%) of whom were M2/ANXA5 carriers. Miscarriages occurred in 1 (4.0%) of 25 M2/ANXA5 carriers from the LMWH group compared to 4 (21.1%) of 19 in the control group, resulting in an odds ratio (95% confidence interval) for miscarriage of 0.16 (0.016-1.5) for women treated with LMWH. In noncarriers, miscarriage rates were 6 (5.8%) of 104 versus 7 (9.2%) of 76 for the LMWH and the control groups, respectively, corresponding to an odds ratio for miscarriage of 0.60 (0.19-1.9). The apparent beneficial effects of miscarriage rate reduction in M2/ANXA5 carriers with RPL concur with biological considerations about improvement in reduced ANXA5 function through LMWH treatment in an adequate murine model. The data obtained were instrumental to design proper assessment of the existence and magnitude of this effect.
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Affiliation(s)
- Nina Rogenhofer
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Gynecology and Obstetrics, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Arseni Markoff
- Insititute of Human Genetics, UKM and WWU Muenster, Muenster, Germany
| | - Annett Wagner
- Center for Human Genetics and Laboratory Diagnostics, Dr Klein, Dr Rost and Colleagues, Martinsried, Germany
| | - Hanns-Georg Klein
- Center for Human Genetics and Laboratory Diagnostics, Dr Klein, Dr Rost and Colleagues, Martinsried, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany
| | | | - Christian J. Thaler
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Gynecology and Obstetrics, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
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Serum hCG-β levels of postovulatory day 12 and 14 with the sequential application of hCG-β fold change significantly increased predictability of pregnancy outcome after IVF-ET cycle. J Assist Reprod Genet 2016; 33:1185-94. [PMID: 27262839 DOI: 10.1007/s10815-016-0744-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To investigate hCG-β level on postovulatory day (POD) 12 and its fold increase as predictors for pregnancy outcome after in vitro fertilization (IVF) cycles. METHODS A retrospective cohort study was performed in total 1408 fresh and 598 frozen cycles between November 2008 and October 2011, which resulted in biochemical pregnancy, early pregnancy loss, or live birth of singleton pregnancy. The serum hCG-β levels of POD 12 and 14 were compared among biochemical pregnancy, early pregnancy loss, and live birth groups. The cutoff values of POD 12 and 14 hCG-β levels and the degree of hCG-β increase from POD 12 to 14 were determined for each pregnancy outcome. RESULTS POD 12 and 14 hCG-β levels stratified based on pregnancy outcomes were significantly different among the biochemical pregnancy, early pregnancy loss, and live birth in both fresh and frozen cycles. Serum hCG-β levels of POD 12 and 14 and the fold increase of hCG-β levels from POD 12 to 14 significantly predict pregnancy outcomes after fresh and frozen cycles. Among these, the cutoff value of POD 14 hCG-β had the highest sensitivity and positive predictive value (PPV). In fresh cycles, the cutoff values of POD 12 and 14 serum hCG-β levels for clinical pregnancies were 30.2 mIU/mL (sensitivity 81.3 %, specificity 79.6 %, and PPV 92.3 %) and 70.5 mIU/mL (sensitivity 88.4 %, specificity 85.2 %, and PPV 94.7 %). In pregnancies with POD 12 serum hCG-β levels ≥30.2 mIU/mL, the cutoff level of increase of hCG-β for clinical pregnancy was 2.56 (sensitivity 73.6 %, specificity 72.4 %, and PPV 97.8 %). Sequential application of cutoff values such as POD 12 hCG-β and fold increase of hCG-β improved predictability of pregnancy outcome as compared with that of POD 12 hCG-β alone. The cutoff values of POD 12 and 14 serum hCG-β levels for live birth were 40.5 mIU/mL (sensitivity 75.2 %, specificity 72.6 %, PPV 78.9 %) and 104.5 mIU/mL (sensitivity 80.3 %, specificity 74.1 %, PPV 80.8 %). In the frozen cycles, the cutoff values of POD 12 and 14 serum hCG-β level for clinical pregnancy were 31.5 IU/L (sensitivity 80.4 %, specificity 71.1 % and PPV 90 %) and 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %). In pregnancies with POD 12 serum hCG-β level ≥31.5 mIU/mL, the cutoff value for fold increase of hCG-β was 2.38 for clinical pregnancy (sensitivity 81.6 %, specificity 71.4 % and PPV 87.9 %). The cutoff values of POD 12 and 14 for live birth were 43.5 mIU/mL (sensitivity 72.6 %, specificity 71.7 %, PPV 77.2 %) and 101.6 mIU/mL (sensitivity 79.6 %, specificity 71.1 %, PPV 78.4 %). Sequential application of cutoff values for POD 12 hCG-β level and fold increase of hCG-β significantly increased PPV for live birth but not clinical pregnancy in frozen cycles. CONCLUSIONS Early prediction of pregnancy outcome by using POD 12 and 14 cutoff levels and sequential application of cutoff value of fold increase could provide appropriate reference to health care providers to initiate earlier management of high-risk pregnancies and precise follow-up of abnormal pregnancies.
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Toth B, Würfel W, Bohlmann MK, Gillessen-Kaesbach G, Nawroth F, Rogenhofer N, Tempfer C, Wischmann T, von Wolff M. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG (S1-Level, AWMF Registry No. 015/050, December 2013). Geburtshilfe Frauenheilkd 2015; 75:1117-1129. [PMID: 26997666 DOI: 10.1055/s-0035-1558299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Purpose: Official guideline coordinated and published by the German Society of Gynecology and Obstetrics (DGGG). Aim of the guideline was to standardize the diagnosis and treatment of patients with recurrent miscarriage (RM). Recommendations were proposed, based on the current national and international literature and the experience of the involved physicians. Consistent definitions, objective assessments and standardized therapy were applied. Methods: Members of the different involved societies developed a consensus in an informal process based on the current literature. The consensus was subsequently approved by the heads of the scientific societies. Recommendations: Recommendations for the diagnosis and treatment of patients with RM were compiled which took the importance of established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders into consideration.
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Affiliation(s)
- B Toth
- Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Universitätsfrauenklinik Heidelberg, Heidelberg
| | - W Würfel
- Kinderwunsch Centrum München-Pasing, München
| | - M K Bohlmann
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Mannheim, Mannheim
| | | | - F Nawroth
- Facharzt-Zentrum für Kinderwunsch, Pränatale Medizin, Endokrinologie und Osteologie, Hamburg
| | - N Rogenhofer
- Hormon und Kinderwunschzentrum der Ludwig-Maximilians-Universität München, München
| | - C Tempfer
- Universitätsfrauenklinik der Ruhr-Universität Bochum, Marienhospital Herne, Herne
| | - T Wischmann
- Institut für Medizinische Psychologie im Zentrum für Psychosoziale Medizin des Universitätsklinikums Heidelberg, Heidelberg
| | - M von Wolff
- Inselspital, Universitätsfrauenklinik, Abteilung Gynäkologische Endokrinologie und Reproduktionsmedizin, Bern, Switzerland
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Zhang T, Ye X, Zhu T, Xiao X, Liu Y, Wei X, Liu Y, Wu C, Guan R, Li X, Guo X, Hu H, He J. Antithrombotic Treatment for Recurrent Miscarriage: Bayesian Network Meta-Analysis and Systematic Review. Medicine (Baltimore) 2015; 94:e1732. [PMID: 26559249 PMCID: PMC4912243 DOI: 10.1097/md.0000000000001732] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/21/2015] [Accepted: 09/09/2015] [Indexed: 11/26/2022] Open
Abstract
Combined use of heparin and aspirin is frequently prescribed for treatment of recurrent miscarriage (RM) in patients with antiphospholipid syndrome (APS), or in those without apparent cause of RM other than thrombophilia; however, this strategy is largely based on expert opinion and has not been well studied. The option for the use of different antithrombotic therapies to improve live birth remains unclear. In this network meta-analysis, we incorporated direct and indirect evidence to evaluate effects of different antithrombotic treatments on prevention of pregnancy losses.We searched PubMed and Embase for randomized clinical trials comparing effects of at least 2 antithrombotic treatments on live birth in RM patients published from 1965 through the early of May 2015. Potential risk bias of eligible trials was evaluated according to the Cochrane Collaboration guidelines. Bayesian network meta-analysis was used to estimate relative effects on live birth.A total of 19 trials involving 2391 RM patients with or without thrombophilia and 543 with APS were included. No beneficial effect of antithrombotic treatment was observed either in RM patients with or without thrombophilia or in patients with APS; however, for patients with or without thrombophilia, low molecular weight heparin therapy had the greatest probability (61.48%) of being the best option in terms of live birth; for patients with APS, unfractionated heparin plus aspirin was the superior treatment for RM with the highest possibility (75.15%) of being top 2 places for reducing pregnancy losses. Aspirin was inferior in both groups.Our results do not support the use of combined low molecular weight heparin and aspirin for RM treatment, and suggested aspirin may have negative effects for lowering the risk of pregnancy loss.
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Affiliation(s)
- Tianyi Zhang
- From the Department of Health Statistics, Second Military Medical University (TYZ, XFY, TTZ, XX CW, XJG, JH); School of Medicine, Shanghai Jiao Tong University (YZL, XW); Department of Obstetrics and Gynecology (RG); Department of Radiology (XL); Department of Hematology, Changhai Hospital, Second Military Medical University, Shanghai, China (HLH) College of Art & Science, University of San Francisco (YL)
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Schleussner E, Kamin G, Seliger G, Rogenhofer N, Ebner S, Toth B, Schenk M, Henes M, Bohlmann MK, Fischer T, Brosteanu O, Bauersachs R, Petroff D. Low-molecular-weight heparin for women with unexplained recurrent pregnancy loss: a multicenter trial with a minimization randomization scheme. Ann Intern Med 2015; 162:601-9. [PMID: 25938990 DOI: 10.7326/m14-2062] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A daily injection of low-molecular-weight heparin (LMWH) is often prescribed to women with unexplained recurrent pregnancy loss (RPL), although evidence suggesting a benefit is questionable. OBJECTIVE To determine whether LMWH increases ongoing pregnancy and live-birth rates in women with unexplained RPL. DESIGN Controlled, multicenter trial with randomization using minimization conducted from 2006 to 2013. (ClinicalTrials.gov: NCT00400387). SETTING 14 university hospitals and perinatal care centers in Germany and Austria. PATIENTS 449 women with at least 2 consecutive early miscarriages or 1 late miscarriage were included during 5 to 8 weeks' gestation after a viable pregnancy was confirmed by ultrasonography. INTERVENTION Women in the control group received multivitamin pills, and the intervention group received vitamins and 5000 IU of dalteparin-sodium for up to 24 weeks' gestation. MEASUREMENTS Primary outcome was ongoing pregnancy at 24 weeks' gestation. Secondary outcomes included the live-birth rate and late pregnancy complications. RESULTS At 24 weeks' gestation, 191 of 220 pregnancies (86.8%) and 188 of 214 pregnancies (87.9%) were intact in the intervention and control groups, respectively (absolute difference, -1.1 percentage points [95% CI, -7.4 to 5.3 percentage points]). The live-birth rates were 86.0% (185 of 215 women) and 86.7% (183 of 211 women) in the intervention and control groups, respectively (absolute difference, -0.7 percentage point [CI, -7.3 to 5.9 percentage points]). There were 3 intrauterine fetal deaths (1 woman had used LMWH); 9 cases of preeclampsia or the hemolysis, elevated liver enzyme level, and low platelet count (HELLP) syndrome (3 women had used LMWH); and 11 cases of intrauterine growth restriction or placental insufficiency (5 women had used LMWH). LIMITATION Placebo injections were not used, and neither trial staff nor patients were blinded. CONCLUSION Daily LMWH injections do not increase ongoing pregnancy or live-birth rates in women with unexplained RPL. Given the burden of the injections, they are not recommended for preventing miscarriage. PRIMARY FUNDING SOURCE Pfizer Pharma.
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Affiliation(s)
- Ekkehard Schleussner
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Gabriele Kamin
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Gregor Seliger
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Nina Rogenhofer
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Susanne Ebner
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Bettina Toth
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Michael Schenk
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Melanie Henes
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Michael K. Bohlmann
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Thorsten Fischer
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Oana Brosteanu
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - Rupert Bauersachs
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
| | - David Petroff
- From Friedrich Schiller University Hospital, Jena, Germany; University Hospital Carl Gustav Carus, Dresden, Germany; St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany; Ludwig Maximilians University, Munich, Germany; Centre for Human Genetics, Regensburg, Germany; Ruprecht-Karls University of Heidelberg, Heidelberg, Germany; University of Tübingen, Tübingen, Germany; University Hospital Schleswig-Holstein, Lübeck, Germany; Leipzig University, Leipzig, Germany
- Klinikum Darmstadt, Darmstadt, Germany; Center for Thrombosis and Hemostasis, Mainz, Germany; Das Kinderwunsch Institut, Dobl, Austria; and Paracelsus Medical University, Salzburg, Austria
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Garrido-Gimenez C, Alijotas-Reig J. Recurrent miscarriage: causes, evaluation and management. Postgrad Med J 2015; 91:151-62. [DOI: 10.1136/postgradmedj-2014-132672] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Yuksel H, Kayatas S, Boza AT, Api M, Ertekin AA, Cam C. Low molecular weight heparin use in unexplained recurrent miscarriage. Pak J Med Sci 2015; 30:1232-7. [PMID: 25674114 PMCID: PMC4320706 DOI: 10.12669/pjms.306.5477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/29/2022] Open
Abstract
Objective: The aim of the study was to investigate whether the use of low molecular weight heparin (LMWH) improve live birth rates when compared with control group in patients with unexplained recurrent miscarriages (URM). Methods: In this prospective observational study 150 women with a history of two or more previous unexplained first trimester pregnancy loss who received LMWH; either enoxaparin (n=50), tinzaparin (n=50) or nothing (n=50) were followed for the pregnancy outcome measures. Only the patients who have used standardized dosage of LMWH (4000 IU/day enoxaparin or 3500 IU/day tinzaparin ) were included to the study. The primary end point was the live birth rate and secondary end points were the side effects, late pregnancy complications and neonatal outcome in the study cohorts. Results: Live birth was achieved 85% of the LMWH group and 66% of the control group (p=0.007). According to the subgroup analysis; live birth rates did not differ significantly between the enoxaparin and tinzaparin group (84% and 86%, respectively). Maternal and neonatal side effects were not statistically significant among the study participants. Conclusion: Thromboprophylaxis with LMWH resulted in a improved live-birth rate in patient with 2 or more consecutive unexplained recurrent pregnancy loss. Nevertheless these findings need to be confirmed in larger randomized trials.
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Affiliation(s)
- Halide Yuksel
- Halide Yuksel, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Semra Kayatas
- Semra Kayatas, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Aysen Telce Boza
- Aysen Telce Boza, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Murat Api
- Murat Api, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - A Aktug Ertekin
- A.Aktug Ertekin, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Cetin Cam
- Cetin Cam, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
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Enoxaparin for prevention of unexplained recurrent miscarriage: a multicenter randomized double-blind placebo-controlled trial. Blood 2015; 125:2200-5. [PMID: 25636341 DOI: 10.1182/blood-2014-11-610857] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/26/2015] [Indexed: 01/06/2023] Open
Abstract
It is common practice in many centers to offer antithrombotic medications to women with unexplained recurrent miscarriage, in the presence or absence of inherited thrombophilia. Although no benefit of aspirin vs placebo has been clearly demonstrated, a double-blind placebo-controlled trial on the effect of low-molecular-weight heparin is lacking. We enrolled 258 pregnant women with a history of unexplained recurrent miscarriage (≥2 consecutive miscarriages before 15 weeks' gestation) and a negative thrombophilia workup. They were randomly assigned to receive one daily subcutaneous injection of enoxaparin 40 mg or placebo until 35 weeks' gestation. We included 256 women (mean age 32 years, ≥3 miscarriages: 72%; mean gestational age 39 days of amenorrhea) in the intention-to-treat analysis; 66.6% of 138 who received enoxaparin had a live birth vs 72.9% of 118 who received placebo. The absolute difference was -6% (95% CI, -17.1 to 5.1), excluding a 10% increase in the rate of live-birth on enoxaparin (P = .34). In this first randomized, double-blind, placebo-controlled trial, enoxaparin (40 mg once daily) did not improve the chance of a live birth in nonthrombophilic women with unexplained recurrent miscarriage. This trial is registered at www.ClinicalTrials.gov as #NCT00740545 and the French National Health and Drug Safety Agency (EudraCT #2006-003350-18).
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Duffett L, Rodger M. LMWH to prevent placenta-mediated pregnancy complications: an update. Br J Haematol 2014; 168:619-38. [DOI: 10.1111/bjh.13209] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Lisa Duffett
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
| | - Marc Rodger
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
- Clinical Epidemiology Program; The Ottawa Hospital Research Institute; Ottawa ON Canada
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Rodger MA, Hague WM, Kingdom J, Kahn SR, Karovitch A, Sermer M, Clement AM, Coat S, Chan WS, Said J, Rey E, Robinson S, Khurana R, Demers C, Kovacs MJ, Solymoss S, Hinshaw K, Dwyer J, Smith G, McDonald S, Newstead-Angel J, McLeod A, Khandelwal M, Silver RM, Le Gal G, Greer IA, Keely E, Rosene-Montella K, Walker M, Wells PS. Antepartum dalteparin versus no antepartum dalteparin for the prevention of pregnancy complications in pregnant women with thrombophilia (TIPPS): a multinational open-label randomised trial. Lancet 2014; 384:1673-83. [PMID: 25066248 DOI: 10.1016/s0140-6736(14)60793-5] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thrombophilias are common disorders that increase the risk of pregnancy-associated venous thromboembolism and pregnancy loss and can also increase the risk of placenta-mediated pregnancy complications (severe pre-eclampsia, small-for-gestational-age infants, and placental abruption). We postulated that antepartum dalteparin would reduce these complications in pregnant women with thrombophilia. METHODS In this open-label randomised trial undertaken in 36 tertiary care centres in five countries, we enrolled consenting pregnant women with thrombophilia at increased risk of venous thromboembolism or with previous placenta-mediated pregnancy complications. Eligible participants were randomly allocated in a 1:1 ratio to either antepartum prophylactic dose dalteparin (5000 international units once daily up to 20 weeks' gestation, and twice daily thereafter until at least 37 weeks' gestation) or to no antepartum dalteparin (control group). Randomisation was done by a web-based randomisation system, and was stratified by country and gestational age at randomisation day with a permuted block design (block sizes 4 and 8). At randomisation, site pharmacists (or delegates) received a randomisation number and treatment allocation (by fax and/or e-mail) from the central web randomisation system and then dispensed study drug to the local coordinator. Patients and study personnel were not masked to treatment assignment, but the outcome adjudicators were masked. The primary composite outcome was independently adjudicated severe or early-onset pre-eclampsia, small-for-gestational-age infant (birthweight <10th percentile), pregnancy loss, or venous thromboembolism. We did intention-to-treat and on-treatment analyses. This trial is registered with ClinicalTrials.gov, number NCT00967382, and with Current Controlled Trials, number ISRCTN87441504. FINDINGS Between Feb 28, 2000, and Sept 14, 2012, 292 women consented to participate and were randomly assigned to the two groups. Three women were excluded after randomisation because of ineligibility (two in the antepartum dalteparin group and one in the control group), leaving 146 women assigned to antepartum dalteparin and 143 assigned to no antepartum dalteparin. Some patients crossed over to the other group during treatment, and therefore for on-treatment and safety analysis there were 143 patients in the dalteparin group and 141 in the no dalteparin group. Dalteparin did not reduce the incidence of the primary composite outcome in both intention-to-treat analysis (dalteparin 25/146 [17·1%; 95% CI 11·4-24·2%] vs no dalteparin 27/143 [18·9%; 95% CI 12·8-26·3%]; risk difference -1·8% [95% CI -10·6% to 7·1%)) and on-treatment analysis (dalteparin 28/143 [19·6%] vs no dalteparin 24/141 [17·0%]; risk difference +2·6% [95% CI -6·4 to 11·6%]). In safety analysis, the occurrence of major bleeding did not differ between the two groups. However, minor bleeding was more common in the dalteparin group (28/143 [19·6%]) than in the no dalteparin group (13/141 [9·2%]; risk difference 10·4%, 95% CI 2·3-18·4; p=0·01). INTERPRETATION Antepartum prophylactic dalteparin does not reduce the occurrence of venous thromboembolism, pregnancy loss, or placenta-mediated pregnancy complications in pregnant women with thrombophilia at high risk of these complications and is associated with an increased risk of minor bleeding. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and Pharmacia and UpJohn.
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Affiliation(s)
- Marc A Rodger
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - William M Hague
- Obstetric Medicine, Robinson Institute, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Susan R Kahn
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada
| | - Alan Karovitch
- Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Mathew Sermer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Suzette Coat
- Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Wee Shian Chan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Joanne Said
- Maternal Fetal Medicine, NorthWest Academic Center, University of Melbourne, Melbourne, Australia
| | - Evelyne Rey
- Departments of Medicine and Obstetrics and Gynecology, University of Montreal, and CHU Sainte-Justine Research Center, Montreal, QC, Canada
| | - Sue Robinson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Rshmi Khurana
- Departments of Medicine and Obstetrics and Gynecology, University of Alberta, Royal Alexandra Hospital, Edmonton, AB, Canada
| | | | - Michael J Kovacs
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Susan Solymoss
- Department of Medicine, McGill University, St Mary's Hospital Center, Montreal, QC, Canada
| | - Kim Hinshaw
- Department of Obstetrics, Sunderland Royal Hospital, Sunderland, Tyne and Wear, UK
| | - James Dwyer
- Department of Obstetrics and Gynaecology, York Hospital, York, UK
| | - Graeme Smith
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON, Canada
| | - Sarah McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Department of Radiology, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | - Anne McLeod
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University/Cooper Hospital, Camden, NJ, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Ian A Greer
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Erin Keely
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Karen Rosene-Montella
- Department of Medicine, The Warren Alpert Medical School of Brown University, Women's Medicine Collaborative, Providence, RI, USA
| | - Mark Walker
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Philip S Wells
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
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Koo HS, Kwak-Kim J, Yi HJ, Ahn HK, Park CW, Cha SH, Kang IS, Yang KM. Resistance of uterine radial artery blood flow was correlated with peripheral blood NK cell fraction and improved with low molecular weight heparin therapy in women with unexplained recurrent pregnancy loss. Am J Reprod Immunol 2014; 73:175-84. [PMID: 25339113 DOI: 10.1111/aji.12316] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/06/2014] [Indexed: 01/17/2023] Open
Abstract
PROBLEM To investigate whether peripheral blood natural killer (pbNK) cell levels are associated with uterine blood flow, and low molecular weight heparin (LMWH) treatment is effective to improve uterine blood flow in women with decreased uterine blood flow and unexplained recurrent pregnancy loss (RPL). METHOD OF STUDY This was a prospective controlled study. Study population included 33 pregnant women (between 5 and 7 weeks gestation) with ≥ 2 RPL and controls were 47 healthy pregnant women. pbNK cell fractions (CD3(-)/56(+)/16(+)) of peripheral blood mononuclear cells were measured by flow cytometry. Uterine color-pulsed Doppler ultrasound was performed to evaluate uterine radial artery resistance index (URa-RI). In RPL women with elevated URa-RI (≥ 0.5), LMWH (ranges 40-60 mg/day) was administered subcutaneously daily and URa-RI was reassessed 1 week later. Pregnancy outcome was analyzed at 12 weeks gestation. RESULTS URa-RI was significantly higher in pregnant women with RPL than controls (0.60 ± 0.14 versus 0.54 ± 0.12, P = 0.039). In pregnant women with RPL, pbNK cell fractions displayed a positive correlation with URa-RI (Pearson's r = 0.429, P = 0.013). URa-RI was significantly decreased 1 week after LMWH treatment as compared to that of pretreatment (pretreatment RI: 0.65 ± 0.11 versus post-treatment RI: 0.56 ± 0.13, P = 0.011). Pregnancy outcome of RPL women with LMWH treatment was not different from that of pregnant controls (73.3% versus 85.0%, P = NS). CONCLUSION Increased pbNK cells are associated with decreased uterine radial artery blood flow. LMWH treatment effectively decreases URa-RI with improved pregnancy outcome in women with RPLs and elevated URa-RI. A larger scale study is needed to verify these findings.
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Affiliation(s)
- Hwa Seon Koo
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
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de Jong PG, Kaandorp S, Di Nisio M, Goddijn M, Middeldorp S. Aspirin and/or heparin for women with unexplained recurrent miscarriage with or without inherited thrombophilia. Cochrane Database Syst Rev 2014; 2014:CD004734. [PMID: 24995856 PMCID: PMC6769058 DOI: 10.1002/14651858.cd004734.pub4] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Since hypercoagulability might result in recurrent miscarriage, anticoagulant agents could potentially increase the chance of live birth in subsequent pregnancies in women with unexplained recurrent miscarriage, with or without inherited thrombophilia. OBJECTIVES To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2013) and scanned bibliographies of all located articles for any unidentified articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that assessed the effect of anticoagulant treatment on live birth in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia were eligible. Interventions included aspirin, unfractionated heparin (UFH), and low molecular weight heparin (LMWH) for the prevention of miscarriage. One treatment could be compared with another or with no-treatment (or placebo). DATA COLLECTION AND ANALYSIS Two review authors (PJ and SK) assessed the studies for inclusion in the review and extracted the data. If necessary they contacted study authors for more information. We double checked the data. MAIN RESULTS Nine studies, including data of 1228 women, were included in the review evaluating the effect of either LMWH (enoxaparin or nadroparin in varying doses) or aspirin or a combination of both, on the chance of live birth in women with recurrent miscarriage, with or without inherited thrombophilia. Studies were heterogeneous with regard to study design and treatment regimen and three studies were considered to be at high risk of bias. Two of these three studies at high risk of bias showed a benefit of one treatment over the other, but in sensitivity analyses (in which studies at high risk of bias were excluded) anticoagulants did not have a beneficial effect on live birth, regardless of which anticoagulant was evaluated (risk ratio (RR) for live birth in women who received aspirin compared to placebo 0.94, (95% confidence interval (CI) 0.80 to 1.11, n = 256), in women who received LMWH compared to aspirin RR 1.08 (95% CI 0.93 to 1.26, n = 239), and in women who received LMWH and aspirin compared to no-treatment RR 1.01 (95% CI 0.87 to 1.16) n = 322).Obstetric complications such as preterm delivery, pre-eclampsia, intrauterine growth restriction and congenital malformations were not significantly affected by any treatment regimen. In included studies, aspirin did not increase the risk of bleeding, but treatment with LWMH and aspirin increased the risk of bleeding significantly in one study. Local skin reactions (pain, itching, swelling) to injection of LMWH were reported in almost 40% of patients in the same study. AUTHORS' CONCLUSIONS There is a limited number of studies on the efficacy and safety of aspirin and heparin in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia. Of the nine reviewed studies quality varied, different treatments were studied and of the studies at low risk of bias only one was placebo-controlled. No beneficial effect of anticoagulants in studies at low risk of bias was found. Therefore, this review does not support the use of anticoagulants in women with unexplained recurrent miscarriage. The effect of anticoagulants in women with unexplained recurrent miscarriage and inherited thrombophilia needs to be assessed in further randomised controlled trials; at present there is no evidence of a beneficial effect.
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Affiliation(s)
- Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Stef Kaandorp
- WestfriesgasthuisObstetrics and GynaecologyMaelsonstraat 3P.O. Box 600HoornNoord HollandNetherlands1620 AR
| | - Marcello Di Nisio
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
| | - Mariëtte Goddijn
- Academic Medical Center University of AmsterdamCenter for Reproductive Medicine, Department of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1100 DE
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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de Jong PG, Kaandorp S, Di Nisio M, Goddijn M, Middeldorp S. Aspirin and/or heparin for women with unexplained recurrent miscarriage with or without inherited thrombophilia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [PMID: 24995856 DOI: 10.1002/14651858.cd004734.pub4.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Since hypercoagulability might result in recurrent miscarriage, anticoagulant agents could potentially increase the chance of live birth in subsequent pregnancies in women with unexplained recurrent miscarriage, with or without inherited thrombophilia. OBJECTIVES To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2013) and scanned bibliographies of all located articles for any unidentified articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that assessed the effect of anticoagulant treatment on live birth in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia were eligible. Interventions included aspirin, unfractionated heparin (UFH), and low molecular weight heparin (LMWH) for the prevention of miscarriage. One treatment could be compared with another or with no-treatment (or placebo). DATA COLLECTION AND ANALYSIS Two review authors (PJ and SK) assessed the studies for inclusion in the review and extracted the data. If necessary they contacted study authors for more information. We double checked the data. MAIN RESULTS Nine studies, including data of 1228 women, were included in the review evaluating the effect of either LMWH (enoxaparin or nadroparin in varying doses) or aspirin or a combination of both, on the chance of live birth in women with recurrent miscarriage, with or without inherited thrombophilia. Studies were heterogeneous with regard to study design and treatment regimen and three studies were considered to be at high risk of bias. Two of these three studies at high risk of bias showed a benefit of one treatment over the other, but in sensitivity analyses (in which studies at high risk of bias were excluded) anticoagulants did not have a beneficial effect on live birth, regardless of which anticoagulant was evaluated (risk ratio (RR) for live birth in women who received aspirin compared to placebo 0.94, (95% confidence interval (CI) 0.80 to 1.11, n = 256), in women who received LMWH compared to aspirin RR 1.08 (95% CI 0.93 to 1.26, n = 239), and in women who received LMWH and aspirin compared to no-treatment RR 1.01 (95% CI 0.87 to 1.16) n = 322).Obstetric complications such as preterm delivery, pre-eclampsia, intrauterine growth restriction and congenital malformations were not significantly affected by any treatment regimen. In included studies, aspirin did not increase the risk of bleeding, but treatment with LWMH and aspirin increased the risk of bleeding significantly in one study. Local skin reactions (pain, itching, swelling) to injection of LMWH were reported in almost 40% of patients in the same study. AUTHORS' CONCLUSIONS There is a limited number of studies on the efficacy and safety of aspirin and heparin in women with a history of at least two unexplained miscarriages with or without inherited thrombophilia. Of the nine reviewed studies quality varied, different treatments were studied and of the studies at low risk of bias only one was placebo-controlled. No beneficial effect of anticoagulants in studies at low risk of bias was found. Therefore, this review does not support the use of anticoagulants in women with unexplained recurrent miscarriage. The effect of anticoagulants in women with unexplained recurrent miscarriage and inherited thrombophilia needs to be assessed in further randomised controlled trials; at present there is no evidence of a beneficial effect.
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Affiliation(s)
- Paulien G de Jong
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ
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Chan WS, Rey E, Kent NE, Chan WS, Kent NE, Rey E, Corbett T, David M, Douglas MJ, Gibson PS, Magee L, Rodger M, Smith RE. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:527-53. [DOI: 10.1016/s1701-2163(15)30569-7] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ghidini A. Overview of low molecular weight heparin for preventative treatment of adverse obstetric outcomes related to abnormal placentation. Prenat Diagn 2014; 34:649-54. [PMID: 24752745 DOI: 10.1002/pd.4385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 11/10/2022]
Abstract
Different proportions of cases of preterm and severe preeclampsia, placental abruption, fetal growth restriction, and fetal death share a common causal pathway of abnormal placental implantation. Documentation of an association between the risk of such adverse pregnancy outcomes (APOs) and inherited thrombophilias prompted initial studies to evaluate the benefit of anticoagulants for the prevention of recurrences both in patients with and without inherited thrombophilias. Prenatal administration of low molecular weight heparin (LMWH) has been evaluated in case control, cohort and randomized clinical trials. The evidence suggests a benefit of LMWH in the reduction of recurrences of APOs, with a number needed to treat of 6 (95% confidence interval: 4-10) to prevent one case of recurrent APOs. Such benefit is independent of the presence of inherited thrombophilias or the administration of low dose aspirin. Further studies are needed to establish the optimal duration for the prophylaxis, to better delineate the mechanism of action of LMWH and to explore the role, if any, of maternal serum markers and uterine artery Doppler findings in the modulation of the LMWH prophylaxis.
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Affiliation(s)
- Alessandro Ghidini
- Perinatal Diagnostic Center, Inova Alexandria Hospital, Alexandria, VA, USA
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Combined oral prednisolone and heparin versus heparin: the effect on peripheral NK cells and clinical outcome in patients with unexplained recurrent miscarriage. A double-blind placebo randomized controlled trial. Arch Gynecol Obstet 2014; 290:757-62. [PMID: 24818590 PMCID: PMC4156968 DOI: 10.1007/s00404-014-3262-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 04/16/2014] [Indexed: 11/28/2022]
Abstract
Purpose To evaluate the efficacy of the use of oral Prednisolone and heparin versus the use of heparin alone in treatment of patients with unexplained recurrent miscarriage. Methodology The study was a double-blind placebo randomized control trial conducted on 160 patients with unexplained recurrent miscarriage. Patients recruited were randomized into two groups. The first group received oral Prednisolone in addition to low dose aspirin and heparin, while the other group received a placebo in addition to low dose aspirin and heparin. A peripheral venous blood sample was taken from all included patients before starting treatment and collected in heparinized tubes. Natural Killer (NK) cells were checked in each sample and then re-checked in another sample at 20 weeks of gestation. Results We found that in the prednisolone group, 70.3 % of women had successful outcome (defined as an ongoing pregnancy beyond 20 weeks gestation), while 29.7 % miscarried before this gestation. On the contrary, among women in the placebo group, 9.2 % had successful outcome while 90.8 % miscarried before 20 weeks, which was statistically significant. On the other hand, we found that there were no significant paired differences between initial serum levels of the NK cells markers CD16 and CD56 and their levels at 20 weeks gestation in both groups. Conclusion The addition of prednisolone to heparin and low dose aspirin might be beneficial in patients with unexplained recurrent miscarriage, and this effect might be due to a suppressive effect of steroids on the peripheral CD16 NK cells concentration.
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