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Guan D, Sun W, Gao M, Chen Z, Ma X. Immunologic insights in recurrent spontaneous abortion: Molecular mechanisms and therapeutic interventions. Biomed Pharmacother 2024; 177:117082. [PMID: 38972152 DOI: 10.1016/j.biopha.2024.117082] [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: 05/02/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024] Open
Abstract
Recurrent spontaneous abortion refers to the occurrence of two or more spontaneous abortions before or during the early stages of pregnancy. The immune system plays a crucial role in the maintenance of pregnancy and embryo implantation. Various immune cells, cytokines, and immune regulatory pathways are involved in the complex immune balance required for a stable pregnancy. Studies suggest that immune abnormalities may be associated with some recurrent spontaneous abortion cases, particularly those involving the dysregulation of immune cell function, autoimmune responses, and placental immunity. In terms of treatment, interventions targeting immune mechanisms are crucial. Various therapeutic approaches, including immunomodulatory drugs, immunoadsorption therapies, and immunocellular therapies, are continually being researched and developed. These approaches aim to restore the immune balance, enhance the success rate of pregnancies, and provide more effective treatment options for patients with recurrent spontaneous abortion.
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Affiliation(s)
- Defeng Guan
- The First Clinical Medical School of Lanzhou University, Lanzhou, China; The First Hospital of Lanzhou University, Lanzhou, China; Gansu key Laboratory of Reproductive Medicine and Embryology, Lanzhou, China
| | - Wenjie Sun
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Mingxia Gao
- The First Clinical Medical School of Lanzhou University, Lanzhou, China; The First Hospital of Lanzhou University, Lanzhou, China; Gansu key Laboratory of Reproductive Medicine and Embryology, Lanzhou, China
| | - Zhou Chen
- The First Clinical Medical School of Lanzhou University, Lanzhou, China; The First Hospital of Lanzhou University, Lanzhou, China.
| | - Xiaoling Ma
- The First Clinical Medical School of Lanzhou University, Lanzhou, China; The First Hospital of Lanzhou University, Lanzhou, China; Gansu key Laboratory of Reproductive Medicine and Embryology, Lanzhou, China.
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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Simmons DP, Herskovits AZ, Battinelli EM, Schur PH, Lemire SJ, Dorfman DM. Lupus anticoagulant testing using two parallel methods detects additional cases and predicts persistent positivity. ACTA ACUST UNITED AC 2018; 56:1289-1296. [DOI: 10.1515/cclm-2015-0790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/23/2015] [Indexed: 01/29/2023]
Abstract
AbstractBackground:Antiphospholipid antibody syndrome (APS) is characterized by laboratory evidence of antiphospholipid antibodies (aPL) [e.g. lupus anticoagulant (LA), anticardiolipin (ACL), and/or antiβ2-glycoprotein I (aB2GPI)] in a clinical setting of thrombosis or pregnancy morbidity. The International Society on Thrombosis and Haemostasis recommends two different testing modalities to detect LA. To evaluate these recommendations in a clinical setting, our hospital, a tertiary care center with a specialized coagulation laboratory, added the dilute Russell’s viper venom time to be performed in parallel with the PTT-lupus anticoagulant to detect LA.Methods:Results of aPL testing were collected on all patients who had LA testing for one year. Chart review was performed to correlate LA results with ACL, aB2GPI, and clinical history.Results:Patients who were initially LA positive by both PTT-lupus anticoagulant and dilute Russell’s viper venom time were more likely to be persistently positive. Patients who were positive for ACL and aB2GPI were likely to be positive by both LA methodologies. No single method was absolutely sensitive, as cases of APS were detected by PTTLA only, DRVVT only, and both methods.Conclusions:The addition of a second testing method for LA provides additional diagnostic information and may be helpful in stratifying risk of thrombosis.
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Mekinian A, Bourrienne MC, Carbillon L, Benbara A, Noémie A, Chollet-Martin S, Tigaizin A, Montestruc F, Fain O, Nicaise-Roland P. Non-conventional antiphospholipid antibodies in patients with clinical obstetrical APS: Prevalence and treatment efficacy in pregnancies. Semin Arthritis Rheum 2016; 46:232-237. [DOI: 10.1016/j.semarthrit.2016.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 04/16/2016] [Accepted: 05/20/2016] [Indexed: 11/29/2022]
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Chen X, Yang X, Wu R, Chen W, Xie H, Qian X, Zhang Y. Therapeutic effects of Wharton jelly-derived mesenchymal stem cells on rat abortion models. J Obstet Gynaecol Res 2016; 42:972-82. [PMID: 27147487 DOI: 10.1111/jog.12984] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/13/2016] [Accepted: 01/31/2016] [Indexed: 01/05/2023]
Affiliation(s)
- Xiaojing Chen
- Department of Obstetrics and Gynecology; Affiliated Hospital of Nantong University; Nantong China
- Department of Gynecology; Tumor Hospital of Nantong; Nantong China
| | - Xiaoqing Yang
- Department of Obstetrics and Gynecology; Affiliated Hospital of Nantong University; Nantong China
| | - Rongrong Wu
- Department of Obstetrics and Gynecology; Affiliated Hospital of Nantong University; Nantong China
| | - Weiwei Chen
- Department of Social Security; Medical University of Chongqing; Chongqing China
| | - Huihui Xie
- Department of Obstetrics and Gynecology; Affiliated Hospital of Nantong University; Nantong China
| | - Xia Qian
- Department of Gynecology; Tumor Hospital of Nantong; Nantong China
| | - Yuquan Zhang
- Department of Obstetrics and Gynecology; Affiliated Hospital of Nantong University; Nantong China
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Ziegelmüller B, Vattai A, Kost B, Kuhn C, Hofmann S, Bayer B, Toth B, Jeschke U, Ditsch N. Expression of Thyroid Hormone Receptors in Villous Trophoblasts and Decidual Tissue at Protein and mRNA Levels Is Downregulated in Spontaneous and Recurrent Miscarriages. J Histochem Cytochem 2015; 63:511-23. [DOI: 10.1369/0022155415582052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 03/18/2015] [Indexed: 11/22/2022] Open
Abstract
Thyroid hormones are essential for the maintenance of pregnancy, and a deficiency in maternal thyroid hormones has been associated with early pregnancy losses. The expression of THRα1, THRβ1 and THRα2 increases with gestational age. The aim of this study was the investigation of the protein and mRNA-levels of THR isoforms THRα1, THRα2, THRβ1 and THRβ2 in normal, spontaneous and recurrent miscarriages. The identification of THR-expressing cells in the decidua was done with double immunofluorescence. The nuclear expression of THRα1, THRα2, THRβ1 and THRβ2 is downregulated at protein level in spontaneous and recurrent miscarriages in villous trophoblast tissue. In decidual tissue, we found a significant downregulation only for THRα1 in spontaneous miscarriages. For recurrent miscarriages, THRα1 and THRβ1 were both significantly downregulated in decidual tissue. By applying HLA-G as a trophoblast marker, we found a significant co-expression only for THRβ2. The results of our study show that thyroid hormone receptors THRα1, THRα2, THRβ1 and THRβ2 are downregulated in spontaneous and recurrent miscarriages. The majority of cells expressing the thyroid hormone receptors in the decidua are decidual stromal cells.
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Affiliation(s)
- Brigitte Ziegelmüller
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Aurelia Vattai
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Bernd Kost
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Christina Kuhn
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Simone Hofmann
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Birgit Bayer
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Bettina Toth
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Udo Jeschke
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
| | - Nina Ditsch
- Department of Obstetrics and Gynaecology-Innenstadt (BZ, AV, BK, CK, SH, UJ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Urology (BZ), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Legal Medicine (BB), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Obstetrics Gynaecology-Großhadern (ND), Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Gynaecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany (BT)
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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: 56] [Impact Index Per Article: 5.6] [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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Kumar A. Immunomodulation in recurrent miscarriage. J Obstet Gynaecol India 2014; 64:165-8. [PMID: 24966498 DOI: 10.1007/s13224-014-0541-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/22/2014] [Indexed: 11/29/2022] Open
Abstract
There are many etiological factors responsible for recurrent abortions. However, no explanation can be identified in approximately 40-50 % of women with recurrent miscarriage (RM). Several studies demonstrated that successful pregnancy is dependant on shifting of maternal immune response from (proinflammatory) Th1 toward (anti-inflammatory) Th2 phenotypes. It was suggested that unexplained RM might be due to immunologic factors. Recently, there is improved understanding regarding the role of the different immune cells and proteins that are important at each stage of a normal pregnancy. Various immune-based therapies with variable clinical evidences have been reported in women with RM with variable efficacy. Still there is lack of information about the mode of action and possible adverse effects of the treatment and a reliable marker for patient selection for immunopotentiation. Adequately powered placebo-controlled studies are required to study and treat couples with the so-called idiopathic recurrent miscarriage.
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Affiliation(s)
- Ashok Kumar
- Department of Obstetrics & Gynecology, Maulana Azad Medical College & Lok Nayak Hospital, 13 B, DDA Flats, Ber Sarai, New Delhi, 110016 India
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Budenhofer BK, Ditsch N, Jeschke U, Gärtner R, Toth B. Thyroid (dys-)function in normal and disturbed pregnancy. Arch Gynecol Obstet 2012; 287:1-7. [DOI: 10.1007/s00404-012-2592-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 10/01/2012] [Indexed: 11/29/2022]
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Han AR, Ahn H, Vu P, Park JC, Gilman-Sachs A, Beaman K, Kwak-Kim J. Obstetrical Outcome of Anti-Inflammatory and Anticoagulation Therapy in Women with Recurrent Pregnancy Loss or Unexplained Infertility. Am J Reprod Immunol 2012; 68:418-27. [DOI: 10.1111/j.1600-0897.2012.01178.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 06/21/2012] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ae Ra Han
- Reproductive Medicine Program; Department of Obstetrics and Gynecology; The Chicago Medical School at Rosalind Franklin University of Medicine and Science; Vernon Hills; IL; USA
| | - Hyunkyong Ahn
- Maternal-fetal medicine; Department of Obstetrics and Gynecology; Cheil General Hospital & Women's Healthcare Center; Kwandong University; College of Medicine; Seoul; Korea
| | - Peter Vu
- Reproductive Medicine Program; Department of Obstetrics and Gynecology; The Chicago Medical School at Rosalind Franklin University of Medicine and Science; Vernon Hills; IL; USA
| | - Joon Cheol Park
- Department of Obstetrics and Gynecology; School of Medicine; Keimyung University; Daegu; Korea
| | - Alice Gilman-Sachs
- Department of Microbiology and Immunology; The Chicago Medical School at Rosalind Franklin University of Medicine and Science; Vernon Hills; IL; USA
| | - Kenneth Beaman
- Department of Microbiology and Immunology; The Chicago Medical School at Rosalind Franklin University of Medicine and Science; Vernon Hills; IL; USA
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Mekinian A, Loire-Berson P, Nicaise-Roland P, Lachassinne E, Stirnemann J, Boffa MC, Chollet-Martin S, Carbillon L, Fain O. Outcomes and treatment of obstetrical antiphospholipid syndrome in women with low antiphospholipid antibody levels. J Reprod Immunol 2012; 94:222-6. [DOI: 10.1016/j.jri.2012.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/22/2011] [Accepted: 02/02/2012] [Indexed: 10/28/2022]
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Bansal A, Bajardeen B, Thum M. The basis and value of currently used immunomodulatory therapies in recurrent miscarriage. J Reprod Immunol 2012; 93:41-51. [DOI: 10.1016/j.jri.2011.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/25/2011] [Accepted: 10/27/2011] [Indexed: 10/14/2022]
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Factor V Leiden G1691A and factor II G20210A point mutations and pregnancy in North-West of Iran. Arch Gynecol Obstet 2011; 284:1311-5. [DOI: 10.1007/s00404-011-2008-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 07/08/2011] [Indexed: 10/18/2022]
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Stagnaro-Green A. Thyroid antibodies and miscarriage: where are we at a generation later? J Thyroid Res 2011; 2011:841949. [PMID: 21687610 PMCID: PMC3112530 DOI: 10.4061/2011/841949] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 03/10/2011] [Indexed: 11/24/2022] Open
Abstract
In 1990, an association between thyroid antibody positivity and spontaneous miscarriage was first reported. A generation has passed since the initial observation. Over that time a robust literature has developed which has confirmed the initial finding and expanded upon it. The present paper reviews the literature that has been generated over the last twenty years on the following topics: (1) thyroid antibodies and spontaneous miscarriage, (2) thyroid antibodies and recurrent abortion, (3) etiology of pregnancy loss in thyroid antibody positive women, and (4) discussion of future research directions.
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Affiliation(s)
- Alex Stagnaro-Green
- George Washington University School of Medicine and Health Sciences, 2300 Eye Street, Ross Hall, Suite 712, Washington, DC 20037, USA
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16
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Abstract
OBJECTIVE To investigate whether thyroid autoimmunity (TAI) is associated with increased risk of miscarriage in euthyroid women. METHODS An electronic search was conducted using the databases Medline, PubMed, EMBASE and the Cochrane library, from inception to October 2010. A systematic review of the studies on the association between TAI and miscarriage was performed. The odd ratios of case-control studies and relative risks of cohort studies were pooled respectively. The software Review Manager (version 4.3.1) was applied for meta-analysis. RESULTS The search strategy identified 53 potentially relevant publications, 22 of which were included in the meta-analysis. A clear association between thyroid autoimmunity and miscarriage was observed with a pooled odds ratio of 2·55 (95% CI 1·42-4·57, P=0·002) in eight case-control studies and a pooled relative risk of 2·31 (95% CI 1·90-2·82, P<0·000 01) in 14 cohort studies. Women with TAI were found to have slightly higher age [age difference, 1·29 years] (95% CI 0·43-2·16, P=0·003) and thyroid-stimulating hormone (TSH) levels [TSH difference, 0·61 mIU/l] (95% CI 0·51-0·71, P<0·000 01) compared with those without TAI. CONCLUSION Based on the currently available evidence, it appears that the presence of thyroid autoimmunity is associated with an increased risk of spontaneous miscarriage in euthyroid women.
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Affiliation(s)
- Lili Chen
- Department of Endocrinology, Huashan Hospital, Fudan University, No. 12 Middle Wulumuqi Road, Shanghai, P. R. China
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Branch DW, Silver RM, Porter TF. Obstetric antiphospholipid syndrome: current uncertainties should guide our way. Lupus 2010; 19:446-52. [PMID: 20353986 DOI: 10.1177/0961203310361490] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The subject of obstetric antiphospholipid syndrome (APS) has been reviewed dozens of times, and there is little doubt that the international APS community has done well in bringing APS to the attention of clinicians around the world. However, the evolution of clinical practice, at least in the US, also has convinced us that our field would benefit from further clinical study. For example, the number of women diagnosed with 'APS', but who do not meet the revised Sapporo criteria, seems to have increased. It is now common practice for women with recurrent miscarriage or prior fetal death to be treated with heparin, even in the presence of indeterminate or low titer antiphospholipid antibody (aPL) levels and even after only one positive test. In part, this common practice derives from confusion on the part of many clinicians and patients regarding the diagnosis of APS as well as the clinical and laboratory criteria for the syndrome. In part, this derives from the common practice of so-called 'empiric treatment' in US reproductive medicine, often driven as much by patients as by clinicians. This brief commentary focuses on areas of uncertainty that we see as deserving of new or renewed study for the sake of improving our understanding of APS and best patient care.
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Affiliation(s)
- D W Branch
- University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah, USA.
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Kaandorp S, Di Nisio M, Goddijn M, Middeldorp S. Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome. Cochrane Database Syst Rev 2009:CD004734. [PMID: 19160241 DOI: 10.1002/14651858.cd004734.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Since hypercoagulability might result in recurrent miscarriage, anticoagulant agents could potentially increase the live-birth rate in subsequent pregnancies in women with either inherited thrombophilia or unexplained recurrent miscarriage. OBJECTIVES To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two miscarriages without apparent causes other than inherited thrombophilia. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 1), MEDLINE (January 1966 to March 2007), and EMBASE (1980 to March 2007). We 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 the live-birth rate in women with a history of at least two miscarriages (up to 20 weeks of amenorrhoea) without apparent causes other than inherited thrombophilia were eligible. Interventions included aspirin, unfractionated heparin, and low molecular weight heparin for the prevention of miscarriage. One treatment could be compared with another or with placebo. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review and extracted the data. We double checked the data. MAIN RESULTS Two studies (189 participants) were included in the review. In one study, 54 pregnant women with recurrent miscarriage (RM) but no detectable anticardiolipin antibodies were randomised to low-dose aspirin or placebo. RM was defined as three or more consecutive miscarriages (occurring before 22 weeks' gestational age (based on last menstrual period)). Similar live-birth rates were observed with aspirin and placebo, both 81% (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.78 to 1.29). In the other study, 107 women with consecutive recurrent miscarriage without any apparent cause and no hereditary thrombophilia were randomised between enoxaparin and aspirin. Here RM was stated as three or more consecutive first trimester miscarriages or at least two consecutive second trimester miscarriages. Similar live birth rates were observed with enoxaparin and aspirin, respectively 82% and 84% (RR 0.97, 95% CI 0.81 to 1.16). AUTHORS' CONCLUSIONS There is a paucity in studies on the efficacy and safety of aspirin and heparin in women with a history of at least two miscarriages without apparent causes other than inherited thrombophilia. The two reviewed trials studied different treatments and only one study was placebo-controlled. Neither of the studies showed a benefit of one treatment over the other. Therefore, the use of anticoagulants in this setting is not recommended. However, large randomised placebo-controlled trials are still urgently needed.
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Affiliation(s)
- Stef Kaandorp
- Obstetrics and Gynaecology, Academic Medical Center, Meibergdreef 9, P.O. Box 22660, Amsterdam, Netherlands, 1100 DD.
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Mahmoud FF, Abul HT, Haines DD, Omu AE, Diejomaoh M, Wise JA, Abu Donia MB. Butyrylcholinesterase activity and lymphocyte subpopulations in peripheral blood of Kuwaiti women experiencing recurrent spontaneous abortion. J Reprod Immunol 2008; 77:186-94. [PMID: 17884179 DOI: 10.1016/j.jri.2007.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Revised: 06/27/2007] [Accepted: 07/30/2007] [Indexed: 10/22/2022]
Abstract
This study has evaluated the hypothesis that activity of the detoxifying enzyme butyrylcholinesterase (BuChE) correlates with levels of serum anti-cardiolipin antibodies (ACA) and T lymphocytes in peripheral blood of women experiencing recurrent spontaneous abortion (RSA). Peripheral venous blood from 16 non-pregnant, RSA-afflicted women and 8 healthy non-pregnant women was analyzed for frequency of T lymphocyte subpopulations by two-color flow cytometry and for serum BuChE using butyrylthiocholine iodide/spectrophotometry. RSA-afflicted women with high serum ACA, but not those with normal ACA levels, exhibited significantly increased percentages of CD4+CD25+ cells (p<0.01) and CD4+HLA-DR+ cells (p<0.05) relative to healthy women. CD4+CD25+(high) cells were significantly lower (p<0.05), while CD4+CD25+(low) cells were significantly higher (p<0.01), in women with elevated ACA compared to healthy women and to RSA women with normal ACA. Relative to healthy, non-pregnant subjects, serum BuChE activity in RSA patients was elevated, both for those with normal ACA (p<0.001) and elevated ACA levels (p<0.01). Among healthy controls, a significant positive correlation was observed between frequency of CD3+NK cells and BuChE activity (p<0.01), but not for RSA-afflicted subjects. A positive correlation between BuChE activity and frequency of CD4+CD25+ cells, as well as CD4+CD25+(high) cells, was observed in the RSA-afflicted subject group with elevated ACA (p<0.05), which may be related to induction of BuChE by toxic metabolites resulting from pathogenic T cell activity. It is concluded that, among RSA patients, high serum ACA correlates with elevated levels of activated T cells and reduced CD4+CD25+(high)/CD4+CD25+(low) cells in comparison to healthy women or those afflicted with RSA but with normal ACA. BuChE activity is observed to be elevated in RSA patients irrespective of serum ACA status.
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Affiliation(s)
- F F Mahmoud
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences and Nursing, Kuwait University, Kuwait.
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Clark DA. REVIEW ARTICLE: Immunological Factors in Pregnancy Wastage: Fact or Fiction. Am J Reprod Immunol 2008; 59:277-300. [DOI: 10.1111/j.1600-0897.2008.00580.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Mezzesimi A, Florio P, Reis FM, D'Aniello G, Sabatini L, Razzi S, Fineschi D, Petraglia F. The detection of anti-β2-glycoprotein I antibodies is associated with increased risk of pregnancy loss in women with threatened abortion in the first trimester. Eur J Obstet Gynecol Reprod Biol 2007; 133:164-8. [PMID: 17046145 DOI: 10.1016/j.ejogrb.2006.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 05/23/2006] [Accepted: 08/09/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study was designed to evaluate whether the detection of serum antiphospholipid autoantibodies may be useful in predicting pregnancy outcome in women with threatened abortion in the first trimester. STUDY DESIGN A group of 77 pregnant women of between 8 and 12 weeks' gestation with vaginal bleeding was tested for serum antiphospholipid, lupus anticoagulants, anticardiolipin, antinuclear antibodies, and anti-beta2-glycoprotein I antibodies, and was followed up until the spontaneous end of pregnancy. A control group composed of 15 healthy women with uncomplicated gestation was tested contemporarily for the same antibody panel. RESULTS Of the 77 patients with threatened abortion, 32 (41.5%) progressed to deliver at term and 45 (58.5%) experienced early pregnancy loss. Among the antibodies evaluated, only anti-beta2-glycoprotein I was significantly more frequent in those women whose pregnancy resulted in spontaneous abortion (22/45, 49%) than in those who progressed to term (6/32, 19%) or in the control group (2/15, 13%; p=0.004). This difference was specific to the IgM isotype (p=0.001). After adjustment by multivariate analysis, the odds ratio for pregnancy loss associated with a positive beta2-glycoprotein I antibody test was 5.18 (p=0.001). CONCLUSION The detection of anti-beta2-glycoprotein I antibodies is associated with an increased risk of pregnancy loss in women with threatened abortion in the first trimester.
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Affiliation(s)
- A Mezzesimi
- Chair of Obstetrics and Gynecology, Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy
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Lett C, Case A, Baerwald A. Matched designs--intuitively attractive, but the analysis can be problematic. Fertil Steril 2007; 87:1500-1; author reply 1501. [PMID: 17544661 DOI: 10.1016/j.fertnstert.2007.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Indexed: 11/26/2022]
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Tempfer CB, Kurz C, Bentz EK, Unfried G, Walch K, Czizek U, Huber JC. A combination treatment of prednisone, aspirin, folate, and progesterone in women with idiopathic recurrent miscarriage: a matched-pair study. Fertil Steril 2006; 86:145-8. [PMID: 16716321 DOI: 10.1016/j.fertnstert.2005.12.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 12/10/2005] [Accepted: 12/10/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare a combination treatment of prednisone, aspirin, folate, and progesterone with no treatment in women with idiopathic recurrent miscarriage (IRM). DESIGN Matched-pair study. SETTING Academic research institution. SUBJECT(S) Women with a history of IRM, defined as three or more consecutive miscarriages before 20 weeks' gestation without associated anatomic, cytogenetic, hormonal, and infectious pathologies or antiphospholipid syndrome. INTERVENTION(S) Eighty of 210 eligible women consented to participate and were treated with prednisone (20 mg/d) and progesterone (20 mg/d) for the first 12 weeks of gestation, aspirin (100 mg/d) for 38 weeks of gestation, and folate (5 mg every second day) throughout their pregnancies. Fifty of 80 women became pregnant; they were compared with 52 women with IRM (matched for age and number of miscarriages), who became pregnant without treatment during the same observation period. MAIN OUTCOME MEASURE(S) Live birth rate, complications of pregnancy, such as preeclampsia, premature birth, and intrauterine growth restriction, and therapy-related side effects. RESULT(S) The overall live birth rates of the treatment and control groups were 77% (40 of 52) and 35% (18 of 52) (P=.04). The rates of first and second trimester miscarriage among the treatment and control groups were 19% (10 of 52) and 0 (0 of 52), and 63% (33 of 52) and 2% (1 of 52), respectively (P=.09 and P=1.0, respectively). The median gestational age at birth and median birth weight did not differ between the groups. We observed two and three cases of premature birth among the treatment and control groups, respectively (P=.3) and no cases of intrauterine growth restriction and Cushing's disease. Of 80 women who started treatment, one woman had an ectopic pregnancy and one woman terminated her pregnancy due to fetal chromosome aberration (trisomy 18). Three women stopped treatment due to nausea, depression, and tachycardia. CONCLUSION(S) A combination treatment of prednisone, aspirin, folate, and progesterone is associated with a higher live birth rate compared with no treatment in women with IRM.
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Affiliation(s)
- Clemens B Tempfer
- Department of Gynecologic Endocrinology and Reproductive Medicine, University of Vienna School of Medicine, Vienna, Austria.
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Abstract
One hundred and eighty women with a history of recurrent, unexplained spontaneous abortion (mean 3.5 abortions) were randomised to receive oral dydrogesterone (10 mg b.i.d.), intramuscular human chorionic gonadotrophin (hCG; 5000 IU every 4 days) or no additional treatment (controls). Treatment was started as soon as possible after confirmation of pregnancy and continued until the 12th gestational week. All women received standard supportive care. Abortions were significantly (p < or = 0.05) less common in the dydrogesterone group (13.4%) than in the control group (29%); there were no statistically significant differences between the hCG group and the control group. There were no differences between the groups with respect to pregnancy complications or congenital abnormalities. In conclusion, hormonal support with dydrogesterone can increase the chances of a successful pregnancy in women with a history of recurrent spontaneous abortion.
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Affiliation(s)
- M Y El-Zibdeh
- Department of Obstetrics and Gynaecology, Islamic Hospital, Amman, P.O. Box 910201, Jordan.
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Empson M, Lassere M, Craig J, Scott J. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Cochrane Database Syst Rev 2005; 2005:CD002859. [PMID: 15846641 PMCID: PMC6768987 DOI: 10.1002/14651858.cd002859.pub2] [Citation(s) in RCA: 198] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND A range of treatments have been proposed to improve pregnancy outcome in recurrent pregnancy loss associated with antiphospholipid antibody (APL). Small studies have not resolved uncertainty about benefits and risks. OBJECTIVES To examine outcomes of all treatments given to maintain pregnancy in women with prior miscarriage and APL. SEARCH STRATEGY We searched the Pregnancy and Childbirth Group's Trials Register (30 May 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1966 to June 2003), EMBASE (1988 to June 2003), Lupus (volume one to eight, 1991 to 1999) and conference proceedings from the International Symposium on APL up to 1999. SELECTION CRITERIA Randomised or quasi-randomised, controlled trials of interventions in pregnant women with a history of pregnancy loss and APL. DATA COLLECTION AND ANALYSIS Two review authors independently assessed quality and extracted data for studies up to December 1999. One review author performed this for studies after 1999. MAIN RESULTS Thirteen studies were found (849 participants). The quality was not high; 50% had clear evidence of allocation concealment. Participant characteristics varied between trials. Unfractionated heparin combined with aspirin (two trials; n = 140) significantly reduced pregnancy loss compared to aspirin alone (relative risk (RR) 0.46, 95% confidence interval (CI) 0.29 to 0.71). Low molecular weight heparin (LMWH) combined with aspirin compared to aspirin (one trial; n = 98) did not significantly reduce pregnancy loss (RR 0.78, 95% CI 0.39 to 1.57). There was no advantage in high-dose, over low-dose, unfractionated heparin (one trial; n = 50). Three trials of aspirin alone (n = 135) showed no significant reduction in pregnancy loss (RR 1.05, 95% CI 0.66 to 1.68). Prednisone and aspirin (three trials; n = 286) resulted in a significant increase in prematurity when compared to placebo, aspirin, and heparin combined with aspirin, and an increase in gestational diabetes, but no significant benefit. Intravenous immunoglobulin +/- unfractionated heparin and aspirin (two trials; n = 58) was associated with an increased risk of pregnancy loss or premature birth when compared to unfractionated heparin or LMWH combined with aspirin (RR 2.51, 95% CI 1.27 to 4.95). When compared to prednisone and aspirin, intravenous immunoglobulin (one trial; n = 82) was not significantly different in outcomes. AUTHORS' CONCLUSIONS Combined unfractionated heparin and aspirin may reduce pregnancy loss by 54%. Large, randomised controlled trials with adequate allocation concealment are needed to explore potential differences between unfractionated heparin and LMWH.
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Affiliation(s)
- M Empson
- Department of Clinical Immunology, Auckland Hospital, Level 14, Support Building, Private Bag 92024, Park Road, Grafton, Auckland, New Zealand.
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Di Nisio M, Peters L, Middeldorp S. Anticoagulants for the treatment of recurrent pregnancy loss in women without antiphospholipid syndrome. Cochrane Database Syst Rev 2005:CD004734. [PMID: 15846729 DOI: 10.1002/14651858.cd004734.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Since hypercoagulability might result in recurrent pregnancy loss, anticoagulant agents could potentially increase the live-birth rate in subsequent pregnancies in women with either inherited thrombophilia or unexplained pregnancy loss. OBJECTIVES To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (March 2004), the Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to March 2004), and EMBASE (1980 to March 2004). We 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 the live-birth rate in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias were eligible. Interventions included aspirin, unfractionated heparin, and low molecular weight heparin for the prevention of birth loss. One treatment could be compared with another or with placebo. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review and extracted the data. Data were entered into the Review Manager software and double checked. MAIN RESULTS Two studies (242 participants) were included in the review and for both of them data were extracted for the subgroups of women fulfilling the inclusion criteria of the review. In one study, 54 pregnant women with recurrent spontaneous abortion without detectable anticardiolipin antibodies were randomised to low-dose aspirin or placebo. Similar live-birth rates were observed with aspirin and placebo (relative risk (RR) 1.00, 95% confidence interval (CI) 0.78 to 1.29). In another study, a subgroup of 20 women who had had a previous fetal loss after the 20th week and had a thrombophilic defect were randomised to enoxaparin or aspirin. Enoxaparin treatment resulted in an increased live-birth rate, as compared to low-dose aspirin, RR 10.00, 95% CI 1.56 to 64.20). AUTHORS' CONCLUSIONS The evidence on the efficacy and safety of thromboprophylaxis with aspirin and heparin in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias is too limited to recommend the use of anticoagulants in this setting. Large, randomised, placebo-controlled trials are urgently needed.
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Abstract
Approximately one-third of all pregnancies end in miscarriage. The etiology of recurrent abortion remains unknown in approximately 50% of all women. In the early 1990s it was discovered that unselected euthyroid women who present with thyroid antibodies (thyroid peroxidase and thyroglobulin) in the first trimester of pregnancy have a two-four-fold increase in their miscarriage rates. The majority of studies investigating women with recurrent abortion have also found a significant increase in thyroid antibody positivity compared with controls. Although the etiology of miscarriage in thyroid antibody women remains unknown, recent data have revealed a potential direct effect of thyroglobulin antibodies on pregnancy loss in a murine model. Uncontrolled studies assessing the effect of levothyroxine on decreasing the miscarriage rate in euthyroid antibody positive women, have demonstrated a decreased miscarriage rate.
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Affiliation(s)
- Alex Stagnaro-Green
- UMDNJ-New Jersey Medical School, Division of Endocrinology and Metabolism, Department of Medicine, 185 South Orange Avenue, MSB C-652, Newark, NJ 07101, USA.
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Mertens D. Antibody-mediated thrombosis and pregnancy loss. Nurse Pract 2003; 28:55-7. [PMID: 12861098 DOI: 10.1097/00006205-200307000-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Geenen V, Perrier de Hauterive S, Puit M, Hazout A, Goffin F, Frankenne F, Moutschen M, Foidart JM. Autoimmunity and pregnancy: theory and practice. Acta Clin Belg 2002; 57:317-24. [PMID: 12723249 DOI: 10.1179/acb.2002.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- V Geenen
- Liege Center of Immunology, Institute of Pathology CHU-B23, B-4000 Liège 1-Sart Tilman, Belgium.
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Reznikoff-Etiévant MF, Zittoun J, Vaylet C, Pernet P, Milliez J. Low Vitamin B(12) level as a risk factor for very early recurrent abortion. Eur J Obstet Gynecol Reprod Biol 2002; 104:156-9. [PMID: 12206930 DOI: 10.1016/s0301-2115(02)00100-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the relationship between Vitamin B(12) deficiency and early recurrent abortion (ERA) or very early recurrent abortion (VERA) abortion around 5 weeks of amenorrhea. STUDY DESIGN Serum B(12), folate and homocysteine levels were carried out in 110 consecutive women with unexplained ERA or VERA and in 96 women with one or more children and no abortion history. RESULTS Ten women were found to have low serum B(12) levels versus one in the control group. A total of 50% of these had raised homocysteine. No difference was noticed between cases and controls for folate. Among women with low serum B(12) level and ERA, 87.5% of the abortions were VERA. Vitamin B(12) supplementation led to four normal pregnancies in five women who became pregnant again. In a statistical analysis performed on five studies in which serum B(12) was assayed in ERA, including ours, a significant relationship was found between ERA and Vitamin B(12) deficiency. CONCLUSION Vitamin B(12) deficiency may be involved in ERA. Vitamin B(12) assay should be done in ERA women whether or not hematological abnormalities are present.
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Reznikoff-Etiévan MF, Cayol V, Carbonne B, Robert A, Coulet F, Milliez J. Factor V Leiden and G20210A prothrombin mutations are risk factors for very early recurrent miscarriage. BJOG 2001; 108:1251-4. [PMID: 11843387 DOI: 10.1111/j.1471-0528.2001.00298.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether there is an association between early recurrent miscarriage (before 10 weeks of pregnancy) and Factor V Leiden and G20210A prothrombin mutations. DESIGN A prospective study. SETTING Department of Gynaecology and Obstetrics, Saint Antoine Hospital, Paris, France. POPULATION Two groups of women: those with early unexplained recurrent miscarriage before 10 weeks of pregnancy (n = 260) and control healthy women without a previous history of thromboembolism (n = 240). METHODS Screening for defects in the protein C anticoagulant pathway was performed using the anticoagulant response to agkistrodon confortrix venom (ACV test). Protein C and Factor V Leiden mutation testing was performed for each low ACV level. Each sample was tested for the G20210A prothrombin mutation. RESULTS Factor V Leiden and G20210A mutations were found to be associated with early recurrent spontaneous miscarriage before 10 weeks of pregnancy, the odds ratios being 2.4 (95% CI 1-5) and 2.7 (95% CI 1-7), respectively. Similar results were found whether or not women had had a previous live birth. CONCLUSIONS Early recurrent miscarriage before 10 weeks of pregnancy is significantly associated with Factor V or G20210A prothrombin mutations. These results indicate a possible role for anticoagulant prevention in these early miscarriages.
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Reznikoff-Etiévant M, Cayol V, Carbonne B, Robert A, Coulet F, Milliez J. Factor V Leiden and G20210A prothrombin mutations are risk factors for very early recurrent miscarriage. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0306-5456(01)00298-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Unfried G, Tempfer C, Schneeberger C, Widmar B, Nagele F, Huber JC. Interleukin 1 receptor antagonist polymorphism in women with idiopathic recurrent miscarriage. Fertil Steril 2001; 75:683-7. [PMID: 11287019 DOI: 10.1016/s0015-0282(01)01675-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Proinflammatory cytokines have been described as etiologic factors in idiopathic recurrent miscarriage. We investigated the relation between idiopathic recurrent miscarriage and polymorphisms in the gene encoding for the interleukin 1 receptor antagonist, an indigenous modulator of proinflammatory immune response. DESIGN Prospective case control study. SETTING Academic research institution. PATIENT(S) One hundred five women with a history of three or more consecutive pregnancy losses before 20 weeks of gestation and 91 healthy, postmenopausal controls with at least two live births and no history of pregnancy loss. INTERVENTION(S) Peripheral venous puncture. MAIN OUTCOME MEASURE(S) Polymerase chain reaction was performed to identify the different alleles of the gene encoding for interleukin 1 receptor antagonist. RESULT(S) Allele frequencies among women with idiopathic recurrent miscarriage and controls were 0.34 and 0.11, respectively, for the polymorphic allele 2 (P=.002; odds ratio: 7.4, confidence interval: 2.9--10.8) and.05 and.05, respectively, for the polymorphic allele 3 (P=.6; odds ratio: 1.3, confidence interval: 0.8--2.3). Allele 2 was present in homozygous form in 9% of women with idiopathic recurrent miscarriage. In contrast, 1% of the control women were homozygous for this allele (P<.001; odds ratio: 13.5, confidence interval: 7.5--21.8). CONCLUSION(S) These data support a role for allele 2 of the gene encoding for interleukin 1 receptor antagonist as genetic determinant of idiopathic recurrent miscarriage.
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Affiliation(s)
- G Unfried
- Department of Gynecologic Endocrinology and Reproductive Medicine, University Hospital of Vienna, Vienna, Austria
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Abstract
This article reviews the literature on thyroid antibodies and miscarriage. In 1990, in a study designed to determine the incidence and etiology of postpartum thyroiditis, a serendipitous finding emerged revealing an association between thyroid antibodies and spontaneous miscarriage. Subsequently, four other studies, performed on three different continents, have confirmed the correlation. Six studies have evaluated the relationship between thyroid antibodies and recurrent abortion, defined as three or more spontaneous miscarriages. The majority of the studies (67%) reported a statistically significant increase in the incidence of thyroid antibodies in the recurrent abortion group as compared to controls. Four intervention trials have evaluated the impact of immunosuppressive therapy in women with thyroid antibodies. Although all of the trials revealed a decrease in the incidence of recurrent abortion, each study was limited by methodological concerns. A recently developed murine model of pregnancy has also demonstrated increased fetal loss in female mice immunized with thyroglobulin when mated with allogeneic males. The implications of these data generated over the last decade are discussed.
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Affiliation(s)
- J Abramson
- Mount Sinai School of Medicine, New York, New York 10029, USA
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