Obstetric and neonatal outcome in women with a history of recurrent miscarriage: a cohort study

Socioeconomic inequalities in adverse pregnancy outcomes in India: 2004-2019

Although India has made substantial improvements in public health, it accounted for one-fifth of global maternal and neonatal deaths in 2015. Stillbirth, abortion, and miscarriage contribute to maternal and infant morbidity and mortality. There are known socioeconomic inequalities in adverse pregnancy outcomes. This study estimated changes in socioeconomic inequalities in rates of stillbirth, abortion, and miscarriage in India across 15 years. We combined data from three nationally representative health surveys. Absolute inequalities were estimated using the slope index of inequality and risk differences, and relative inequalities were estimated using the relative index of inequalities and risk ratios. We used household wealth, maternal education, and Scheduled Caste and Scheduled Tribe membership as socioeconomic indicators. We observed persistent socioeconomic inequalities in abortion and stillbirth from rates of 2004-2019. Women at the top of the wealth distribution reported between 2 and 5 fewer stillbirths per 1,000 pregnancies over the study time period compared to women at the bottom of the wealth distribution. Women who completed primary school, and those at the top of the household wealth distribution, had, over the study period, 5 and 20 additional abortions per 1,000 pregnancies respectively compared to women who did not complete primary school and those at the bottom of the wealth distribution. Women belonging to a Scheduled Caste or Scheduled Tribe had 5 fewer abortions per 1,000 pregnancies compared to other women, although these inequalities diminished by the end of the study period. There was less consistent evidence for socioeconomic inequalities in miscarriage, which increased for all groups over the study period. Despite targeted investments by the Government of India to improve access to health services for socioeconomically disadvantaged groups, disparities in pregnancy outcomes persist.

Obstetric and perinatal outcomes of women with a history of recurrent pregnancy loss: a meta-analysis of cohort studies

PURPOSE

To assess the risk of adverse obstetric and perinatal outcomes in subsequent pregnancies among women with a history of recurrent pregnancy loss (RPL).

METHODS

Relevant studies were identified by searching the PubMed, Web of Science, and Embase databases. The pooled effect sizes were reported as odds ratios (OR) with their respective 95% confidence intervals (95% CI), and data analysis was performed using the random effects model.

RESULTS

A total of 26 studies involving 4,730,728 women were included in this meta-analysis. The results reveal a significant increase in the prevalence of placenta accreta cases after RPL compared to women without RPL (pooled OR 4.04; 95% CI 1.16-14.15; 2 studies; I2 = 94%; P = 0.03). However, no elevated risk of aneuploidies (pooled OR 1.69, 95% CI 0.73-3.90; 5 studies; I2 = 48%; P = 0.22) or congenital anomalies (pooled OR 1.12, 95% CI 0.97-1.30; 7 studies; I2 = 13%; P = 0.12) in subsequent pregnancies of women with RPL was observed. Additionally, a moderate increase in the risk of various other obstetric and perinatal outcomes was found. The magnitude of the elevated risk of these adverse outcomes varied depending on the region.

CONCLUSIONS

Women with a history of RPL exhibit a significantly elevated risk of placenta accreta in subsequent pregnancies, along with a moderate increase in the risk of various other adverse obstetric and perinatal outcomes. However, RPL does not signify an increased risk of aneuploidies or congenital anomalies in a consecutive pregnancy.

Finger pulse plethysmography predicts gestational hypertension, preeclampsia and gestational diabetes

BACKGROUND

Pregnancy complications related to hypertension can affect both mother and newborn. Pulse wave attenuation (PWA) captured through fingertip photoplethysmography (PPG) provide valuable insights into maternal acute hemodynamic and autonomic vascular function. Here, we quantify the nocturnal dynamics of PWA during early pregnancy and assess their association with the development of gestational hypertension, preeclampsia and gestational diabetes.

METHODS

PWA dynamics were assessed on overnight polysomnography-derived PPG signals from a cohort of 2714 pregnant women (mean age: 26.8 ± 5.5 years) enrolled in the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b). We determined the average duration (PWA duration ) and depth (PWA depth ) of PWA events in all women.

RESULTS

Odds ratio (OR) analysis-adjusted common confounders indicates that an average PWA duration greater than 8.74 s was associated with the increased risk of gestational hypertension [OR = 1.75 (1.27-2.39), P  < 0.001]. Similarly, average PWA depth greater than 1.19 was associated with an increased risk of preeclampsia [OR = 1.53 (1.01-2.33), P  = 0.045] and gestational diabetes [OR = 1.66 (1.01-2.73), P  = 0.044].

CONCLUSION

PWA attenuation dynamics during early pregnancy predict the risk of developing gestational hypertension and diabetes condition for women in their later trimesters. Potentially obtainable from smart wearable consumer devices, PWA analysis offers a low-cost, accessible and scalable marker that can enhance the management of pregnancy-induced cardiometabolic issues.

Adverse outcomes in subsequent pregnancies in women with history of recurrent spontaneous abortion: A meta-analysis

OBJECTIVE

This study aimed to investigate the association between a history of recurrent spontaneous abortion (RSA) and adverse outcomes in women with spontaneous conception.

METHODS

A search strategy from the inception to March 3, 2023 was run in PubMed, Embase, Cochrane Library, and Web of Science databases. The odds ratio (OR), and the 95% confidence interval (CI) or point estimation were used as the evaluation indexes. Each outcome measure tested was assessed for heterogeneity using the Cochran Q test. Sensitivity analyses were performed to test the credibility of the meta-analysis results.

RESULTS

Fifteen studies involving 1 475 389 pregnant women were included. A history of RSA was associated with gestational diabetes (OR: 2.21, 95% CI: 1.70-2.87, p < 0.001), preeclampsia (OR: 2.06, 95% CI: 1.49-2.86, p < 0.001), placenta previa (OR: 1.82, 95% CI: 1.09-3.02, p = 0.021), placental abruption (OR: 1.67, 95% CI: 1.36-2.06, p < 0.001), miscarriage (OR: 6.37, 95% CI: 3.83-10.57, p < 0.001), preterm birth (OR: 1.80, 95% CI: 1.36-2.37, p < 0.001), cesarean section (OR: 1.47, 95% CI: (1.13-1.91, p = 0.004), perinatal death (OR: 2.24, 95% CI: 1.39-3.60, p = 0.001), and neonatal intensive care unit admission (OR: 1.39, 95% CI: 1.01-1.92, p = 0.047). However, the associations of a history of RSA with gestational hypertension, small for gestational age, fetal anomalies, fetal growth restriction, and postpartum hemorrhage were not observed.

CONCLUSION

This meta-analysis indicates a history of RSA was associated with increased risks of several adverse outcomes in pregnant women with spontaneous conception.

Adverse obstetric and perinatal outcomes of patients with history of recurrent miscarriage: a retrospective cohort study

OBJECTIVE

To examine the associations between a history of recurrent miscarriage (RM) and adverse obstetric and perinatal outcomes in the subsequent pregnancy that progressed beyond 24 weeks.

DESIGN

Retrospective cohort study.

SETTING

A large tertiary maternity hospital.

PATIENT(S)

All women who booked for antenatal care and delivery between January 2014 and August 2021 were recorded. The study was limited to women with a singleton pregnancy, and to avoid intraperson correlation, we selected the first record of delivery from each mother in the study, leaving 108,792 deliveries for analysis. Obstetric and perinatal outcomes were compared among 1994 women (1.83%) with a history of ≥2 miscarriages (RM), 11,477 women (10.55%) with a history of 1 miscarriage, and 95,321 women (87.62%) with no history of miscarriage, respectively.

INTERVENTION(S)

Women with a history of ≥2 miscarriages or RM.

MAIN OUTCOME MEASURE(S)

Obstetric complications included gestational diabetes mellitus, preeclampsia (subclassified as preterm and term preeclampsia), placenta previa, placenta accreta, and fetal distress. Perinatal outcomes included emergency cesarean section, elective cesarean section, induction, postpartum hemorrhage, preterm birth, stillbirth, Apgar score <7 at 5 minutes, neonatal asphyxia, neonatal sex, congenital; malformation, low birth weight, and neonatal death.

RESULT(S)

After adjusting for relevant confounders, there was an increased risk of adverse obstetric and perinatal outcomes in a subsequent pregnancy for women with a history of RM, specifically for placental dysfunction disorders: preterm preeclampsia (risk ratio [RR] = 1.58; 95% confidence interval [CI], 1.03-2.32), preterm birth (RR = 1.34; 95% CI, 1.15-1.54)], and abnormal placentation, that is placenta previa (RR = 1.78; 95% CI, 1.36-2.28), and placenta accreta (RR = 4.19; 95% CI, 2.75-6.13).

CONCLUSION(S)

Significant associations existed between a history of RM and the occurrence of adverse obstetric and perinatal outcomes including placental dysfunction disorders and abnormal placentation. These findings may contribute to the early detection and appropriate intervention for placenta-associated diseases in women with a history of RM, with the goal of avoiding or reducing the associated detrimental effects.

Reproductive history does not compromise subsequent live birth and perinatal outcome following in-vitro fertilization: analysis of 25 329 first frozen-thawed embryo transfer cycles without preimplantation genetic testing for aneuploidy

OBJECTIVE

To investigate the effect of women's reproductive history on live-birth rate and perinatal outcome after first frozen-thawed embryo transfer (FET) without preimplantation genetic testing for aneuploidy.

METHODS

This was a retrospective cohort study of women who had undergone their first FET cycle between January 2014 and December 2020 at a university-affiliated fertility center. No transferred embryo underwent preimplantation genetic testing for aneuploidy. The women were categorized into five groups based on their reproductive history: no previous pregnancy; previous termination of pregnancy (TOP); previous pregnancy loss; previous ectopic pregnancy (EP); and previous live birth. The women with no previous pregnancy were considered as the reference group. The primary outcome was the live-birth rate and secondary endpoints included rates of positive pregnancy test, clinical pregnancy, pregnancy loss and EP as well as perinatal outcomes such as birth weight and preterm birth. Multivariable logistic regression analyses were used to control for a number of potential confounders, including age, body mass index, education level, duration and cause of infertility, insemination method, type of endometrial preparation, number of embryos transferred, embryo developmental stage, quality of the embryos transferred, year of treatment and endometrial thickness. Additionally, propensity score matching (PSM) was used to check the robustness of the main findings.

RESULTS

In total, 25 329 women were included in the final analysis. On univariate analysis, each reproductive-history type except for previous EP was significantly associated with worse pregnancy outcome following in-vitro fertilization (IVF), including rates of positive pregnancy test, clinical pregnancy, pregnancy loss and live birth, when compared with the group of women with no previous pregnancy. However, after correcting for several potential confounders, the differences in rates of live birth, pregnancy loss, positive pregnancy test and clinical pregnancy were no longer significant between the study and control groups on multivariable regression models, while the risk of EP after embryo transfer was elevated among women with a previous TOP or EP. There was no increased risk of adverse perinatal outcome associated with reproductive history compared with the control group. Notably, similar results were obtained from the PSM models, confirming the robustness of the main findings.

CONCLUSION

Relative to women without a previous pregnancy, those with a prior TOP, pregnancy loss, EP or live birth did not have compromised live-birth rate or perinatal outcomes following FET without preimplantation genetic testing for aneuploidy, with the exception of an increased risk of EP in those with prior TOP or EP. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Pathophysiological, immunogenetic, anatomopathological profile of thrombophilia in pregnancy

Thrombophilic states have been associated with early and/or late pregnancy loss and possibly other severe obstetrical complications. Pregnancy-induced hypercoagulability, increased stasis, and the consequences of inherited and acquired thrombophilia are just a few of the factors that contribute to the development of thrombosis in pregnancy. In this review, we illustrate the impact that these factors have on the development of thrombophilia during pregnancy. We also explore how thrombophilia impact pregnancy outcomes. Next, we discuss how human leukocyte antigen G plays a part in thrombophilia during pregnancy by regulating cytokine release to prevent trophoblastic cell invasion and maintain local immunotolerance constant. Human leukocyte antigen class E is briefly explored with thrombophilia in pregnancy. Regarding the anatomopathologic aspect, we describe the different histopathological lesions of the placenta found in women with thrombophilia.

Impact of Interleukin-10 Promoter Region Polymorphisms on Recurrent Miscarriage: A Case-Control Approach

Background

Recurrent miscarriage (RM), defined as two or more consecutive miscarriages prior to the 20th week of gestation is characterised by multifactorial aetiology. The prevalence of RM varies from 0.8% to 13.5% amongst women of reproductive age. The aetiological basis of RM has been traced to chromosomal, anatomic, hormonal and immunologic factors while half of the cases remain idiopathic.

Aims

This study aimed to investigate the association of interleukin-10 (IL-10) polymorphisms with RM amongst the Indian population.

Settings and Design

The present study included a total of 414 individuals including RM women (n = 199) with two or more pregnancy losses and healthy women (n = 215) without any previous history of pregnancy loss were taken as the control group.

Materials and Methods

Demographic features and reproductive history of women with RM and healthy women were taken. Genotype analysis of IL-10 polymorphisms rs1800872 and rs1800896 was performed using the polymerase chain reaction (PCR) restriction fragment length polymorphism and amplification mutation refractory system PCR, respectively.

Statistical Analysis Used

Student's t-test was used to compare the demographic features and reproductive history amongst both groups. Pearson's Chi-square was used to calculate the Hardy-Weinberg equilibrium, allelic and genotypic frequencies. All the statistical analyses were performed using the SPSS (version 21, IBM SPSS, NY, USA).

Results

Our results suggested that the genotypic and allelic frequency of rs1800872 polymorphism did not differ significantly between RM cases and control women (P = 0.07 and P = 0.23, respectively). The GG genotype (P = 0.007) and G allele (P = 0.003) of rs1800896 were significantly associated with an increased risk of RM. A statistically significant difference was also found for the distribution of genetic models (dominant and co-dominant model) between both groups for rs1800896. However, haplotype analysis revealed that none of the haplotypes provides a risk for the progression of RM.

Conclusion

The study is the first of its kind from our region and provides baseline data on the genetics of RM.

Histological Evaluation of Products of Conception, Who Benefits from It?

Background: Histopathological evaluation of the first trimester pregnancy loss has always been controversial. Although it is recommended, it is not a part of guidelines.Methods: Six hundred eighty-six samples in a referral infertility clinic were evaluated microscopically and categorized. Two hundred ninety-five cases were evaluated by genetic methods (Multiplex Ligation-dependent Probe Amplification).Results: From 569 samples with chorionic villi, 361 cases had history of three or more abortions. 18.3% of this group showed chronic intervillous of unknown etiology (CIUE) and 8.3% revealed intervilli fibrin deposition, both pathologies with a high risk of recurrence. History of a live child was significantly higher in CIUE group. 29% of genetically evaluated cases had a chromosomal abnormality.Conclusion: Histological evaluation of recurrent pregnancy loss could illuminate the cause of abortion in relatively acceptable percentage of cases, especially in mothers with higher number of previous abortion, mothers with a history of live child and in referral centers.

Association between Abortion History and Perinatal and Neonatal Outcomes of Singleton Pregnancies after Assisted Reproductive Technology

IMPORTANCE

At present, few people have studied the associations between abortion history before pregnancy on the outcomes of women and their infants after assisted reproductive technology (ART).

OBJECTIVE

To explore the association between the history of abortion and the outcomes of singleton pregnancies after ART.

DESIGN

This was a retrospective study in a hospital from 2015 to 2020 in Shanghai, China. Pregnant women with live singleton births through ART were included (n = 3043). Abortion was classified into spontaneous abortion (SAB) and induced abortion. We compared the maternal and fetal outcomes of singleton pregnancies obtained through ART with different abortion histories. Logistic regression analysis was used to evaluate the associations between the history of pre-pregnancy abortion with perinatal complications and neonatal outcomes.

RESULTS

We observed that compared with those who had no abortion history and obtained singleton pregnancies through ART, women who had an abortion history before pregnancy (including SAB or induced abortion history) and only SAB history were more likely to have gestational diabetes mellitus (GDM), thyroid-related diseases, and placenta-related diseases. After adjusting the potential confounding factors, these differences still existed. The adjusted odds ratios (ORs) and 95% confidence interval (CI) of GDM, thyroid-related diseases, and placenta-related diseases in women with a history of abortion and only a history of SAB were 1.239 (1.030-1.492) and 1.240 (1.010-1.522), 1.589 (1.261-2.002) and 1.724 (1.344-2.213), 1.465 (1.183-1.815) and 1.433 (1.132-1.814), respectively. However, we did not observe the association between the history of induced abortion and GDM and thyroid-related diseases.

CONCLUSIONS AND RELEVANCE

Our research showed that pregnant women with singleton pregnancies through ART who had a history of abortion or only a history of SAB were more likely to have GDM, thyroid-related diseases, and placenta-related diseases. Pregnant women who had both SAB and induced abortion before pregnancy had a higher risk of thyroid-related diseases and placenta-related diseases, while women who had only a history of induced abortion had a higher risk of placenta-related diseases. Further research is needed to explore the biological mechanism of different types of abortion related to subsequent pregnancy.

Understanding recurrent pregnancy loss: recent advances on its etiology, clinical diagnosis, and management

Recurrent pregnancy loss (RPL) has become an important reproductive health issue worldwide. RPL affects about 2%-3% of reproductive-aged women, and makes serious threats to women's physical and mental health. However, the etiology of approximately 50% of RPL cases remains unknown (unexplained RPL), which poses a big challenge for clinical management of these patients. RPL has been widely regarded as a complex disease where its etiology has been attributed to numerous factors. Heretofore, various risk factors for RPL have been identified, such as maternal ages, genetic factors, anatomical structural abnormalities, endocrine dysfunction, prethrombotic state, immunological factors, and infection. More importantly, development and applications of next generation sequencing technology have significantly expanded opportunities to discover chromosomal aberrations and single gene variants responsible for RPL, which provides new insight into its pathogenic mechanisms. Furthermore, based upon patients' diagnostic evaluation and etiologic diagnosis, specific therapeutic recommendations have been established. This review will highlight current understanding and recent advances on RPL, with a special focus on the immunological and genetic etiologies, clinical diagnosis and therapeutic management.

Plasma level of mannose-binding lectin is associated with the risk of recurrent pregnancy loss but not pregnancy outcome after the diagnosis

STUDY QUESTION

Are low or high plasma mannose-binding lectin (p-MBL) levels associated with recurrent pregnancy loss (RPL) and the reproductive and perinatal outcomes before and after RPL?

SUMMARY ANSWER

The prevalence of low p-MBL levels was significantly higher in RPL patients, while high levels were significantly less prevalent. No association was found between p-MBL level and reproductive and perinatal outcomes before and after RPL.

WHAT IS KNOWN ALREADY

Mannose-binding lectin (MBL) is an important component in the innate immune system. Low p-MBL levels have been associated with RPL, while the correlation with high levels has been poorly studied. Adverse perinatal outcomes are generally more frequent among RPL patients, but reports concerning the association between maternal p-MBL levels and perinatal outcomes, including birth weight (BW) and gestational age (GA), are conflicting.

STUDY DESIGN, SIZE, DURATION

This study was a combined cross-sectional and cohort study of 267 RPL patients admitted to the RPL Center of Western Denmark between January 2016 and March 2020. RPL patients were followed until birth of a liveborn child or until end of follow-up, March 2021. A sample of 185 healthy female blood donors of reproductive age was used as a MBL reference group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All RPL patients had ≥3 consecutive pregnancy losses, a regular menstrual cycle and no known significant chromosomal or uterine malformations. At the first consultation, routine blood samples including p-MBL measurement and detailed obstetrical and perinatal information were collected. p-MBL levels in RPL patients were compared to the MBL reference group. A logistic regression analysis adjusted for relevant confounders assessed the association between low p-MBL levels and an unsuccessful reproductive outcome in RPL patients in first pregnancy after admission. Perinatal outcomes before and after RPL were compared between RPL subgroups according to low (≤500 µg/l), intermediate (501–3000 µg/l) and high (>3000 µg/l) p-MBL levels.

MAIN RESULTS AND THE ROLE OF CHANCE

Significantly more RPL patients had low p-MBL levels (prevalence proportion ratio (PPR): 1.79, 95% CI: 1.34–2.38) and fewer had high p-MBL levels (PPR: 0.56, 95% CI: 0.40–0.79) compared to the reference group, while the prevalence of intermediate p-MBL level was not different between the groups (PPR: 0.86, 95% CI: 0.69–1.08). In the prospective study, low p-MBL level was not a significant risk factor for a pregnancy loss in the first pregnancy after admission after adjustment for age, BMI and smoking. Neither before nor after the RPL diagnosis were maternal p-MBL levels significantly associated with BW or GA.

LIMITATIONS, REASONS FOR CAUTION

Only 161 (60.3%) patients had given birth after RPL during the follow-up period, which limited the possibility to detect clear associations between p-MBL levels and perinatal outcomes after RPL.

WIDER IMPLICATIONS OF THE FINDINGS

In agreement with several previous studies, low p-MBL levels are strongly associated with RPL, while this study for the first time documents that high levels may play a protective role, which suggests a causal relationship. We suggest that larger prospective studies evaluate the association between p-MBL levels and RPL prognosis.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received. We acknowledge the Department of Obstetrics and Gynaecology at Aalborg University Hospital for financial support. U.S.K. has reported personal fees from Merck, consulting fees from IBSA Nordic, and a grant from Gedeon Richter, Merck and IBSA Nordic outside of the submitted work.

TRIAL REGISTRATION NUMBER

ID from clinicaltrials.gov is NCT04017754.

Grandmothers' endocrine disruption during pregnancy, low birth weight, and preterm birth in third generation

BACKGROUND

Diethylstilbestrol (DES) is an endocrine-disrupting pharmaceutical prescribed to pregnant women to prevent pregnancy complications between the 1940s and 1970s. Although DES has been shown in animal studies to have multigenerational effects, only two studies have investigated potential multigenerational effects in humans on preterm birth (PTB), and none on low birthweight (LBW)-major determinants of later life health.

METHODS

Nurses' Health Study (NHS) II participants (G1; born 1946-64) reported their mothers' (G0) use of DES while pregnant with them. We used cluster-weighted generalized estimating equations to estimate odds ratios (OR) and 95% confidence intervals (CI) for risk of LBW and PTB among the grandchildren by grandmother use of DES. G1 birthweight and gestational age were considered to explore confounding by indication.

RESULTS

Among 54 334 G0-G1/grandmother-mother pairs, 973 (1.8%) G0 used DES during pregnancy with G1. Of the 128 275 G2 children, 4369 (3.4%) were LBW and 7976 (6.2%) premature. Grandmother (G0) use of DES during pregnancy was associated with an increased risk of G2 LBW [adjusted OR (aOR) = 3.09; 95% CI: 2.57, 3.72], that was reduced when restricted to term births (aOR = 1.59; 95% CI: 1.08, 2.36). The aOR for PTB was 2.88 (95% CI: 2.46, 3.37). Results were essentially unchanged when G1 birthweight and gestational age were included in the model, as well as after adjusting for other potential intermediate variables, such as G2 pregnancy-related factors.

CONCLUSIONS

Grandmother use of DES during pregnancy is associated with an increased risk of LBW, predominantly through an increased risk of PTB. Results when considering G1 birth outcomes suggest this does not result from confounding by indication.

Maternal and fetal safety of intravenous immunoglobulin in women with reproductive failure

PROBLEM

Intravenous immunoglobulin G (IVIG) is an emerging regimen for women with reproductive failures (RF) during- or pre-pregnancy who have aberrant cellular immune reactions. Studies investigating teratogenicity of IVIG have been limited. Herein, we evaluated the fetal teratogenicity of IVIG and IVIG-related obstetric complications.

METHOD OF STUDY

Women who used IVIG during pregnancy due to RF with cellular immune aberrances were enrolled from four medical centers in Korea. The pregnancy outcomes were collected.

RESULTS

A total of 370 RF women who used IVIG during their pregnancy were enrolled. Most of the patients started the IVIG therapy before 12 weeks of gestation and 229 women continued IVIG treatment beyond 12 weeks of gestation. The mean age of the subjects was 34.8 years and the mean total dosage of IVIG was 125.3 g. A total of 307 women had livebirths and six of them were twins. Of 301 singleton livebirths, obstetric complications were developed as follows: preterm births (12.0%), gestational diabetes (7.0%), preeclampsia (4.0%), placental abruption (1.3%), placenta previa (4.3%), and placenta accrete (1.7%). Total six cases (1.99%) had major fetal anomalies in livebirths. The incidence of birth defects is similar to those of the general population in Korea and the previous report in infertile women. No IVIG -related viral contamination was noted.

CONCLUSION

IVIG use during pregnancy did not increase obstetric complications and fetal teratogenicity. This study can be an evidence of maternal and fetal safety of IVIG administration during pregnancy.

Maternal spontaneous abortion and the risk of attention-deficit/hyperactivity disorder in offspring: a population-based cohort study

STUDY QUESTION

Is a maternal history of spontaneous abortion (SA) associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD) in offspring?

SUMMARY ANSWER

Our results suggest an association between maternal history of SA and ADHD in offspring, with the risk increasing with the number of maternal SA and highest in the firstborn children whose mothers had had recurrent SAs after adjusting for a number of potential confounders.

WHAT IS KNOWN ALREADY

A history of SA has been associated with more complications in next pregnancies and adverse childbirth outcomes, which are risk factors for ADHD in the offspring. However, no previous study has investigated whether maternal SA increases risk of ADHD in the offspring.

STUDY DESIGN, SIZE, DURATION

This population-based study included all live-born children in Denmark from 1 January 1995 to 31 December 2012 (n = 1 062 667). All children were followed from 3 years of age until the day of ADHD diagnosis, death, emigration or 31 December 2016, whichever came first.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There were 130 206 (12.2%) children born to mothers who had at least one SA. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

MAIN RESULTS AND THE ROLE OF CHANCE

During a median follow-up of 9.4 years (interquartile range, 5.4-14.3), 25 747 children were diagnosed with ADHD. Overall, children of mothers with a history of SA had an increased rate of ADHD (HR, 1.11; 95% CI, 1.07 to 1.15). The HRs increased with the number of maternal SA, 1.09 (95% CI, 1.05 to 1.13) for one SA and 1.22 (95% CI, 1.12 to 1.33) for at least two SAs, respectively. These findings were consistent when we took into consideration a number of factors, such as maternal socioeconomic status, type of SA, birth order, parental history of psychiatric disorders, pregnancy characteristics and adverse birth outcomes.

LIMITATIONS, REASONS FOR CAUTION

Misclassification of SA was possible as we used population-based register data to capture maternal history of SA. However, any misclassification of maternal history of SA would be non-differential with regard to the diagnosis of ADHD in offspring, which generally leads to underestimation of the associations. Furthermore, probabilistic sensitivity analysis suggested that only 1% of change in the estimate may have been due to misclassification of SA.

WIDER IMPLICATIONS OF THE FINDINGS

SA is quite frequent (varying from 15 to 20%), and a small increase of neurodevelopmental problems in offspring could have major public health implications.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by grants from the National Natural Science Foundation of China (No. 81703237, No. 81530086 and No. 81761128035), National Key Research and Development Program (2018YFC1002801, 2016YFC1000505), Shanghai Municipal Commission of Health and Family Planning (No. 2017ZZ02026, No. 2017EKHWYX-02), the Novo Nordisk Foundation (NNF18OC0052029), the Danish Council for Independent Research (DFF-6110-00019), the Nordic Cancer Union (176673, 186200 and R217-A13234-18-S65), Karen Elise Jensens Fond (2016) and Xinhua Hospital of Shanghai Jiao Tong University School of Medicine (2018YJRC03). All authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.

Women with a History of Recurrent Pregnancy Loss Are a High-Risk Population for Adverse Obstetrical Outcome: A Retrospective Cohort Study

Recurrent pregnancy loss (RPL), defined as three or more consecutive miscarriages, is hypothesized to share some of the same pathogenic factors as placenta-associated disorders. It has been hypothesized that a defect implantation causes pregnancy loss, while a partially impaired implantation may lead to late pregnancy complications. The aim of this retrospective register-based cohort study was to study the association between RPL and such disorders including pre-eclampsia, stillbirth, small for gestational age (SGA) birth, preterm birth and placental abruption. Women registered with childbirth(s) in the Swedish Medical Birth Register (MFR) were included in the cohort. Pregnancies of women diagnosed with RPL (exposed) in the National Patient Register (NPR), were compared with pregnancies of women without RPL (unexposed/reference). Obstetrical outcomes, in the first pregnancy subsequent to the diagnosis of RPL (n = 4971), were compared with outcomes in reference-pregnancies (n = 57,410). Associations between RPL and placental dysfunctional disorders were estimated by odds ratios (AORs) adjusting for confounders, with logistic regression. RPL women had an increased risk for pre-eclampsia (AOR 1.45; 95% CI; 1.24-1.69), stillbirth <37 gestational weeks (GWs) (AOR 1.92; 95% CI; 1.22-3.02), SGA birth (AOR 1.97; 95% CI; 1.42-2.74), preterm birth (AOR 1.46; 95% CI; 1.20-1.77), and placental abruption <37 GWs (AOR 2.47; 95% CI; 1.62-3.76) compared with pregnancies by women without RPL. Women with RPL had an increased risk of pregnancy complications associated with placental dysfunction. This risk population is, therefore, in need of improved antenatal surveillance.

Perinatal Outcomes in Women with a History of Recurrent Pregnancy Loss

OBJECTIVE

This study aimed to evaluate perinatal outcomes in women with a history of recurrent pregnancy loss.

STUDY DESIGN

Retrospective cohort study of singleton and nonanomalous gestations at ≥ 20 weeks who delivered at our academic institution. The exposed group was defined as women with a history of ≥ 2 consecutive spontaneous abortions (SABs) at < 12 weeks. These women were compared with women with a history of ≤ 1 SAB at < 12 weeks. The primary outcome was preterm birth (PTB) at < 37 weeks. Secondary outcomes included gestational age at delivery, gestational diabetes, small for gestational age birth weight, hypertensive diseases of pregnancy, fetal demise, cesarean delivery, and a composite of neonatal complications (5-minute Apgar score < 5, perinatal death, and NICU admission). Multivariable logistic regression was performed to adjust for confounders.

RESULTS

Of 17,670 women included, 235 (1.3%) had a history of ≥ 2 consecutive SABs. Compared with women with a history of ≤ 1 SAB, women with ≥ 2 consecutive SABs were not more likely to have a PTB (19.6 vs. 14.0%, p = 0.01, adjusted odds ratios (AOR): 0.91, 95% confidence interval [CI]: 0.62-1.33). However, they were more likely to deliver at an earlier mean gestational age (37.8 ± 3.4 vs. 38.6 ± 2.9 weeks, p < 0.01) and to have gestational diabetes (12.3 vs. 6.6%, p < 0.01, AOR: 1.69, 95% CI: 1.10-2.59). Other outcomes were similar between the two groups.

CONCLUSION

A history of ≥ 2 consecutive SABs was not associated with an increased incidence of PTB but may be associated with gestational diabetes in a subsequent pregnancy.

KEY POINTS

· This was a retrospective cohort study.. · Women with a history of recurrent pregnancy loss (RPL) were studied.. · RPL was associated with an increase in preterm birth..

Impact of Recurrent Miscarriage on Maternal Outcomes in Subsequent Pregnancy: The Mutaba'ah Study

Purpose

To estimate the prevalence of recurrent miscarriage (RM) and investigate the association between RM and adverse maternal outcomes in subsequent pregnancies.

Participants and Methods

This is an interim analysis of a prospective study of 1737 pregnant women with gravidity of two or more prior to the current pregnancy. These women joined the Mutaba’ah Study between May 2017 and April 2019 and were followed up until they delivered. Hospital medical records were used to extract data on past pregnancy history and the progress and outcomes of the current pregnancy, such as gestational diabetes, preeclampsia, mode of delivery, preterm delivery, and complications at birth.

Results

Amongst pregnant women with at least two previous pregnancies (n=1737), there were 234 (13.5%) women with a history of two or more consecutive miscarriages. Women with RM were slightly older, more parous, and more likely to have had previous infertility treatment (all p-values <0.05). Women with a history of RM had independently significant increased odds of cesarean section (adjusted odds ratio (aOR) 1.81, 95% CI 1.24–2.65) and preterm (<37 weeks, aOR: 2.52, 95% CI 1.56–4.08) or very preterm delivery (<32 weeks, aOR: 7.02 95% CI 2.41–20.46) in subsequent pregnancies than women who did not have a history of RM.

Conclusion

Women with a history of RM were twice as likely to undergo cesarean section and seven times more likely to deliver prior to 32 weeks of gestation than women without a history of RM. The study findings support the need for early pregnancy monitoring or assessment units to ensure better follow-up and customized care for at-risk pregnant women with a history of RM.

Pregnancy-Related Complications in Women with Recurrent Pregnancy Loss: A Prospective Cohort Study

The aim of this prospective cohort study was to determine whether women with recurrent pregnancy loss (RPL) have an increased risk of pregnancy complications compared to normal pregnant women. A total of 1092 singleton pregnancies were followed, 431 in women with RPL and 661 in normal healthy women. The prevalence of the following complications was observed: threatened miscarriage, miscarriage, cervical insufficiency, chromosomal/genetic abnormalities, fetal anomalies, oligohydramnios, polyhydramnios, fetal growth restriction, intrauterine fetal death, gestational diabetes mellitus (GDM), preeclampsia, placenta previa, abruptio placentae, pregnancy-related liver disorders, and preterm premature rupture of the membranes. The odds ratio and 95% CI for each pregnancy complication considered were determined by comparing women with RPL and normal healthy women. Women with RPL had an overall rate of pregnancy complications higher than normal women (OR = 4.37; 95% CI: 3.353–5.714; p < 0.0001). Their risk was increased for nearly all the conditions considered. They also had an increased risk of multiple concomitant pregnancy complications (OR = 4.64; 95% CI: 3.10–6.94, p < 0.0001). Considering only women with RPL, women with ≥3 losses had a higher risk of pregnancy complications than women with two losses (OR = 1.269; 95% CI: 1.112–2.386, p < 0.02). No differences were found in the overall risk of pregnancy complications according to the type, explained or unexplained, of RPL. Women with secondary RPL had an increased risk of GDM than women with primary RPL. Pregnancy in women with RPL should be considered at high risk.

Evaluation of etiology and pregnancy outcome in recurrent miscarriage patients

The purpose of this study was to evaluate etiology and pregnancy outcome of recurrent miscarriage women. The enrolled patients (280) were evaluated for Triiodothyronine, Thyroxine, Thyroid stimulating hormone, prolactin, chromosomal analysis, Haemoglobin A1C, blood sugar, Magnetic resonance imaging, 3D-ultrasound, auto-antibodies profile (antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulant, antinuclear antibodies, anti-thyroid antibodies and β2 glycoprotein1), torch profile (Toxoplasmo gondii, rubella, cytomegalo virus and herpes simplex virus), blood vitamin D3 levels, psychological factors, Body mass index and thrombotic factors (protein S and C deficiency, Prothrombin G20210A mutation, anti-thrombin III, Factor V Leiden and Methylenetetrahydrofolate reductase mutation), uterosalpingography (hysteronsalpingography) and hysteroscopy. The therapeutic regimens either singly or combined were employed for the treatment of recurrent miscarriage patients on the basis of etiology (single or multiple) and include intravenous immunoglobulin, low molecular weight heparin, low dose aspirin, levothyroxine, progesterone, folic acid, human chorionic gonadotrophin, vitamin D3, psychotherapy, genetic counselling. However, patients with idiopathic recurrent miscarriage were treated with progesterone supplementation, anticoagulation and/or immune modulatory agents. The incidence of primary recurrent miscarriage was highest and most of the women experienced recurrent miscarriage during first trimester. Endocrinological disorders (39%) were found as the major pathological factor for recurrent miscarriage. Other factors include uterine abnormalities (5.7%), vitamin D3 deficiency (3.5%), psychological factors (3.2%) infection (3.6%), autoimmune abnormalities (1.8%) and protein S deficiency (1.8%). However, 40% cases were idiopathic. The overall live birth rate achieved after the management of recurrent miscarriage patients was 75.7%. Enocrinopathy was the major cause of recurrent miscarriage. The overall live birth rate achieved was 75.7% with highest pregnancy outcome in secondary recurrent miscarriage patients after the management.

The live birth and neonatal outcomes in the subsequent pregnancy among patients with adverse pregnancy outcomes in first frozen embryo transfer cycles

PURPOSE

To explore whether the adverse pregnancy outcomes in first frozen embryo transfer (FET) cycles affect live birth and neonatal outcomes in the subsequent pregnancy?

METHODS

This was a retrospective study. Women with a history of adverse pregnancy outcomes in first FET cycles started their subsequent embryo transfer cycles. The adverse pregnancy outcomes included biochemical pregnancy, ectopic pregnancy, and first-trimester pregnancy loss. The main outcomes of present study were live birth rate and neonatal outcomes.

RESULTS

Results showed patients with first-trimester pregnancy loss in first FET cycles had a 95 percent greater chance of live birth in subsequent FET cycles (OR 1.95, 95% CI 1.33-2.88). However, the biochemical pregnancy/ectopic pregnancy in initial FET cycles did not affect the chance of live birth in second cycles (biochemical pregnancy: OR 1.21, 95% CI 0.82-1.77; ectopic pregnancy: OR 1.06, 95% CI 0.55-2.05). The neonatal outcomes of singletons were not affected by the number of embryo transfer cycles.

CONCLUSIONS

Patients with first-trimester pregnancy loss in first FET cycle had a greater chance of live birth in second FET cycles, but the biochemical pregnancy/ectopic pregnancy in first FET cycles did not significantly affect the live birth in second FET cycles. The three types of adverse pregnancy outcomes in first FET cycles did not affect neonatal outcomes in the second cycles.

Pregnancy complications recur independently of maternal vascular malperfusion lesions

BACKGROUND

Spontaneous abortions, intrauterine growth restriction, and preeclampsia are thought to be caused by defective placentation and are associated with increased risk of adverse outcomes in subsequent pregnancies. However, it is not known whether the recurrence of adverse outcomes is associated with the recurrence of placental pathology. We hypothesized that recurrent maternal vascular malperfusion (MVM) underlies the recurrence of adverse outcomes.

METHODS

Using data from the National Collaborative Perinatal Project, we assessed the recurrence of pregnancy complications and MVM lesions (N = 3865), associations between a history of spontaneous abortions and MVM lesions or adverse outcomes in subsequent pregnancies (N = 8312), and whether the recurrence of pregnancy complications occurred independently of the presence of MVM lesions.

RESULTS

The odds of an MVM lesion were higher for a woman who had had an MVM lesion in a previous pregnancy (aOR = 1.6; 95% CI 1.3-1.9), although this was marginally non-significant after adjusting for covariates such as gestational age, race and BMI. The odds of preeclampsia, a small-for-gestational-age infant, premature delivery and early pregnancy loss were 2.7-5.0 times higher if there had been that same adverse outcome in a previous pregnancy. A history of spontaneous abortions was associated with higher risk of a small-for-gestational-age baby (aOR = 2.4; 95% CI 1.7-3.4) and prematurity (aOR = 5.1; 95% CI 2.3-11.5 for extremely preterm), but not preeclampsia. The recurrence of adverse outcomes was significant when restricting analyses to women without MVM lesions. Similarly, associations between adverse outcomes and previous spontaneous abortions were significant when statistically controlling for the presence of MVM lesions, or excluding pregnancies with MVM lesions.

CONCLUSIONS

Women with adverse outcomes in one pregnancy are at higher risk of complications in subsequent pregnancies. However, there is significant recurrence of adverse outcomes even in the absence of MVM.

Intravenously Injected Pluripotent Stem Cell-derived Cells Form Fetomaternal Vasculature and Prevent Miscarriage in Mouse

Miscarriage is the most common complication of pregnancy, and about 1% of pregnant women suffer a recurrence. Using a widely used mouse miscarriage model, we previously showed that intravenous injection of bone marrow (BM)-derived endothelial progenitor cells (EPCs) may prevent miscarriage. However, preparing enough BM-derived EPCs to treat a patient might be problematic. Here, we demonstrated the generation of mouse pluripotent stem cells (PSCs), propagation of sufficient PSC-derived cells with endothelial potential (PSC-EPs), and intravenous injection of the PSC-EPs into the mouse miscarriage model. We found that the injection prevented miscarriage. Three-dimensional reconstruction images of the decidua after tissue cleaning revealed robust fetomaternal neovascularization induced by the PSC-EP injection. Additionally, the injected PSC-EPs directly formed spiral arteries. These findings suggest that intravenous injection of PSC-EPs could become a promising remedy for recurrent miscarriage.

Upregulation of ADAMTS‑7 and downregulation of COMP are associated with spontaneous abortion

A disintegrin and metalloproteinase with thrombospondin motifs 7 (ADAMTS-7) has been revealed to serve an important role in inflammation-associated diseases. However, the role of ADAMTS-7 in spontaneous abortion (SA) remains unclear. In the present study, human and mouse decidual tissues were used to detect the expression of ADAMTS-7 and cartilage oligomeric matrix protein (COMP) in mice with lipopolysaccharide (LPS)-induced abortion (10 mice/group), and in SA humans and the corresponding control group (21 participants in the SA group and 15 participants in the control group). The results revealed that ADAMTS-7 expression was upregulated and that COMP expression was downregulated in the mouse decidual tissue of the LPS-induced abortion group, when compared with that of the normal control group. The results were further confirmed by western blot analysis and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis, which revealed increased ADAMTS-7 and decreased COMP expression at the protein and mRNA levels in mice treated with LPS. Additionally, the expression of ADAMTS-7 was negatively correlated with the expression of COMP in mice, with a correlation coefficient of −0.936 (P<0.001). In addition, the expression of ADAMTS-7 and COMP exhibited was similar in the decidual tissue of SA patients when compared with the levels observed in the tissues of the normal control participants, as demonstrated by increased ADAMTS-7 expression and decreased COMP expression. Western blotting and RT-qPCR analysis revealed that ADAMTS-7 was increased and COMP was decreased in the decidual tissue of SA subjects. The correlation analysis of ADAMTS-7 and COMP in human decidual tissue also revealed a similar result, with a correlation coefficient of −0.836 (P<0.001). The results of the present study demonstrated that ADAMTS-7 was upregulated and COMP was downregulated in the decidual tissues of humans and mice with SA, and a negative correlation was identified between the expression levels of ADAMTS-7 and COMP, thereby providing novel evidence for a better understanding of the pathogenesis of SA, which may lead to improvements in the clinical pregnancy outcomes of these individuals.

Prior abortion history and pregnancy hypertensive disorders in primiparous gravidae

OBJECTIVES

To explore the relationship between prior abortion history with incidence of pregnancy hypertensive disorders (PHD), including gestational hypertension (GH) and pre-eclampsia (PE), to determine whether the secular increases in GH and PE in developed countries could be related in part to the decreased incidence of abortion.

STUDY DESIGN

A single center retrospective cohort study on primiparous Chinese gravidae managed in 1997-2015 in our hospital.

MAIN OUTCOME MEASURES

The occurrence of PHD, GH and PE with respect to the presence or otherwise of prior abortions, with the analysis stratified for risk factors that include advanced age, high body mass index (BMI), history of medical disorders, birth before 34 weeks, and maternal hepatitis B virus (HBV) infection and rubella non-immunity which have been shown to influence the occurrence of PHD in our population.

RESULTS

The 23,698 (39.3%) of the 60,335 gravidae in the cohort with ≥ one prior abortion had higher incidence of advanced age, HBV infection, rubella non-immunity, and high BMI, but lower incidence of PHD, GH, PE and birth before 34 weeks gestation. The difference in the incidence of GH and PE between gravidae having one versus those with two or more abortions was minimal, and the effect of abortion on PHD was influenced by the other risk factors. On regression analysis, prior abortion reduced PHD (aRR 0.761, 95% CI 0.684-0.846), GH (aRR 0.660, 95% CI 0.563-0.773), and PE (aRR 0.857, 95% CI 0.745-0.987).

CONCLUSIONS

Prior abortion reduces the subsequent development of GH and PE in primiparous women.

Pregnancy outcomes among patients with recurrent pregnancy loss and uterine anatomic abnormalities

Background:

Different etiologies for recurrent pregnancy loss have been identified, among them are: anatomical, endocrine, genetic, chromosomal and thrombophilia pathologies.

Aims:

To assess medical and obstetric characteristics, and pregnancy outcomes, among women with uterine abnormalities and recurrent pregnancy loss (RPL). This study also aims to assess the impact of uterine anatomic surgical correction on pregnancy outcomes.

Methods:

A retrospective case control study of 313 patients with two or more consecutive pregnancy losses followed by a subsequent (index) pregnancy. Anatomic abnormalities were detected in 80 patients. All patients were evaluated and treated in the RPL clinic at Soroka University Medical Center. Out of 80 patients with uterine anatomic abnormalities, 19 underwent surgical correction, 32 did not and 29 had no clear record of surgical intervention, and thus were excluded from this study.

Results:

Women with anatomic abnormalities had a higher rate of previous cesarean section (18.8% vs. 8.6%, P=0.022), tended to have a lower number of previous live births (1.05 vs. 1.37, P=0.07), and a higher rate of preterm delivery (22.9% vs. 10%, P=0.037). Using multivariate logistic regression analysis, anatomic abnormality was identified as an independent risk factor for RPL in patients with previous cesarean section after controlling for place of residence, positive genetic/autoimmune/endocrine workup, and fertility problems (OR 7.22; 95% CI 1.17–44.54, P=0.03). Women suffering from anatomic abnormalities tended to have a higher rate of pregnancy loss compared to those without anatomic abnormalities (40% vs. 30.9%, P=0.2). The difference in pregnancy loss rate among women who underwent surgical correction compared to those who did not was not statistically significant.

Conclusion:

In patients with previous cesarean section, uterine abnormality is an independent risk factor for pregnancy loss. Surgical correction of uterine abnormalities among RPL patients might have the potential to improve live birth rate.

Increased cardiovascular disease risk in women with a history of recurrent miscarriage

INTRODUCTION

Cardiovascular disease is the leading cause of death in women. Observational studies suggest that women with a history of recurrent miscarriage have an increased risk of cardiovascular disease.

MATERIAL AND METHODS

Women who visited the recurrent miscarriage clinic at Leiden University Medical Center between 2000 and 2010 and who had their third consecutive miscarriage before the age of 31 years, were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and no miscarriage, matched by zip code, age, and date of pregnancy. All women were invited for risk factor screening, including physical examination and blood collection. Main outcome measures were the (extrapolated) 10- and 30-year cardiovascular risk scores using the Framingham risk score. A subanalysis was performed for women with idiopathic recurrent miscarriage.

RESULTS

Thirty-six women were included in both groups. Mean follow up was 7.5 years. Women with recurrent miscarriage had a significantly higher extrapolated 10-year cardiovascular risk score (mean 6.24%, SD 5.44) compared with women with no miscarriage (mean 3.56%, SD 1.82, P = .007) and a significantly higher 30-year cardiovascular risk score (mean 9.86%, SD 9.10) compared with women with no miscarriage (mean 6.39%, SD 4.20, P = .04). Similar results were found in women with idiopathic recurrent miscarriage (n = 28).

CONCLUSIONS

Women with a history of recurrent miscarriage differ in cardiovascular risk profile at a young age compared with women with no miscarriage. The findings support an opportunity to identify women at risk of cardiovascular disease later in life and a possible moment for intervention.

History of spontaneous miscarriage and the risk of diabetes mellitus among middle-aged and older Chinese women

AIMS

Epidemiological studies of the long-term maternal health outcomes of spontaneous miscarriages have been sparse and inconsistent. The objective of our study is to examine the association between spontaneous miscarriages and diabetes among middle-aged and older Chinese women.

METHODS

A total of 19,539 women from the Dongfeng-Tongji cohort study who completed a questionnaire and had medical examinations performed on were included in the analysis. History of spontaneous miscarriage was obtained by self-reporting in the first follow-up questionnaire interview. The presence of diabetes was determined by a fasting plasma glucose level, self-reported physician diagnosis and use of antidiabetic medication. A series of multivariate logistic regression models were used to calculate the odds ratios and 95% CI across spontaneous miscarriage categories (0, 1, 2, ≥ 3) after adjustment for potential confounding factors.

RESULTS

The prevalence rate of diabetes was 18.8% among the participants. In the fully adjusted logistic regression model, women who had 1, 2 or ≥ 3 spontaneous miscarriages had 0.86 times (95% CI 0.68, 1.08), 1.30 times (95% CI 0.82, 2.04) and 2.11 times (95% CI 1.08, 4.11) higher risk of diabetes, respectively, compared with women who had no history of spontaneous miscarriage.

CONCLUSIONS

There is an increased risk of diabetes among women with a history of a higher number of spontaneous miscarriages. History of multiple spontaneous miscarriages should be taken into consideration when assessing the risk of diabetes.

Recombinant human soluble thrombomodulin as an anticoagulation therapy improves recurrent miscarriage and fetal growth restriction due to placental insufficiency - The leading cause of preeclampsia

INTRODUCTION

Placental insufficiency is one of the major risk factors for growth restriction and preeclampsia. The aim of this study is to investigate whether recombinant human Thrombomodulin(r-TM) improves fetal conditions and physiological outcomes.

METHODS

We used CBA/J × BALB/C mice as a control and CBA/J × DBA/2 mice - a well-studied model of recurrent spontaneous miscarriage. Pregnant mice received daily subcutaneous injections of r-TM or saline from day 0-15. The fetal resorption rate, fetal weight, and litter size were calculated at day 15. Additionally, we analyzed the mRNA expression of angiogenic factors and the concentration of soluble Flt-1 (sFlt-1) using the ELISA kit.

RESULTS

The rate of fetal resorption in CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with mice without r-TM treatment. Additionally, fetal weight and litter size were also significantly higher in the r-TM treated mice. Fibrinogen deposition in the labyrinth area of the CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with deposits in the mice untreated with r-TM. As well, r-TM significantly increased the gene expression level of VEGF and Flt-1 mRNA in the placentas of the CBA/J × DBA/2 mice. r-TM treatment also significantly decreased the production of sFlt-1 protein in the placentas of preeclampsia-like diseased mice.

CONCLUSION

r-TM as an anticoagulation therapy has the potential for the medical treatment of recurrent miscarriage and fetal growth restriction due to improved angiogenic factors. Additionally, r-TM treatment has the potential for the recovery of preeclampsia.

Assessment of novel cardiovascular biomarkers in women with a history of recurrent miscarriage

OBJECTIVES

A history of recurrent miscarriage is associated with future cardiovascular disease. The aim of this study was to determine novel cardiovascular biomarkers in women with a history of recurrent miscarriage as this might lead to a better understanding of the association.

STUDY DESIGN

Women who visited the recurrent miscarriage clinic at Leiden University Medical Centre (between 2000 and 2010), and had three consecutive miscarriages ≤30 years were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and a history of no miscarriage, matched on zip code, age, and date of pregnancy.

MAIN OUTCOME MEASURES

Cardiovascular biomarkers were determined, classified into; inflammation (HsCRP, lipoprotein-associated phospholipase A2), thrombosis (homocysteine, folate, anti-cardiolipin antibodies and anti-ß-2-glycoprotein antibodies), lipid metabolism (lipoprotein(a)), renal function (creatinine, microalbuminuria), myocardial damage (N-terminal pro-brain natriuretic peptide, high sensitive TroponineT) and multiple mechanisms (albumin, vitamin D).

RESULTS

In both groups, 36 women were included. Women with recurrent miscarriage had a significantly higher median HsCRP (1.49 mg/L) compared to women with no miscarriage (1.01 mg/L, p = 0.03) and a significantly lower mean albumin (46.0 vs 47.6g/L, p = 0.004) and vitamin D (55.6 vs 75.4nmol/L, p = 0.007), respectively. Differences remained after adjustments for classic cardiovascular risk factors (BMI, smoking, diabetes mellitus, and hypertension).

CONCLUSIONS

Our findings suggest a proinflammatory state in women with a history of recurrent miscarriage, which suggests a less optimal health, compared to women with no miscarriage. More research (observational and intervention) is warranted to investigate the association with vitamin D.

Pregnancy before recurrent pregnancy loss more often complicated by post-term birth and perinatal death

INTRODUCTION

The cause of recurrent pregnancy loss often remains unknown. Possibly, pathophysiological pathways are shared with other pregnancy complications.

MATERIAL AND METHODS

All women with secondary recurrent pregnancy loss (SRPL) visiting Leiden University Medical Center (January 2000-2015) were included in this retrospective cohort to assess whether women with SRPL have a more complicated first pregnancy compared with control women. SRPL was defined as three or more consecutive pregnancy losses before 22 weeks of gestation, with a previous birth. The control group consisted of all Dutch nullipara delivering a singleton (January 2000-2015). Information was obtained from the Dutch Perinatal Registry. Outcomes were preeclampsia, preterm birth, post-term birth, intrauterine growth restriction, breach position, induction of labor, cesarean section, congenital abnormalities, perinatal death and severe hemorrhage in the first ongoing pregnancy. Subgroup analyses were performed for women with idiopathic SRPL and for women ≤35 years.

RESULTS

In all, 172 women with SRPL and 1 196 178 control women were included. Women with SRPL were older and had a higher body mass index; 29.7 years vs. 28.8 years and 25.1 kg/m² vs. 24.1 kg/m² , respectively. Women with SRPL more often had a post-term birth (OR 1.86, 95% CI 1.10-3.17) and more perinatal deaths occurred in women with SRPL compared with the control group (OR 5.03, 95% CI 2.48-10.2). Similar results were found in both subgroup analyses.

CONCLUSIONS

The first ongoing pregnancy of women with (idiopathic) SRPL is more often complicated by post-term birth and perinatal death. Revealing possible links between SRPL and these pregnancy complications might lead to a better understanding of underlying pathophysiology.

Two miscarriages, consecutive or non-consecutive, does it change something?

OBJECTIVES

To assess the rate of anomalies in the etiological evaluation of patients presenting recurrent early miscarriages (RM) according to miscarriage chronology (number of miscarriages, history of live birth and succession of RM).

METHODS

Retrospective single centre study including RM, defined as at least 2 miscarriages at less than 14 weeks of gestation (WG) between the 1st January 2012 and the 31st December 2015. Clinical data and etiological evaluation include blood glucose levels, screening for antiphospholipid syndrome (APS), endocrine assessment, vitamin levels, pelvic imaging, karyotyping of both partners, chronic endometritis and thrombophilia screening.

RESULTS

Two hundred and eighty-eight patients were included over this period, 118 (41%) patients had no history of live birth. Two hundred and twenty-three (77%) patients had consecutive RM and 65 (22%) patients had non-consecutive RM. For consecutive RM, 62,8% had thrombophilic disorders versus 69,8% for non-consecutive RM (P>0,05); 44,7% had endocrine disorders or vitamin deficiencies versus 39,7%; 34,6% of patients with consecutive RM had uterine anomalies versus 45,5% respectively. No difference was found depending on the recurrence of RM or the history of live birth (P>0.05) apart from the age of the patient. Fifty-nine (17.4%) patients had uterine anomalies. There are 24 chronic endometritis on 31 biospsies performed. Seventy-eight (27%) patients were offered treatment. Ninety-four (90%) patients showed good therapy compliance. Eighty-one (78%) patients became pregnant.

CONCLUSION

An etiological evaluation provides, for over half of the cases, an etiology or the identification of risk factors responsible for RM, as well as in some cases offering an adapted, efficient, therapeutic approach. This evaluation should be offered regardless of the obstetric history of the patient.

Comparison of two preventive treatments for patients with recurrent miscarriages carrying a C677T methylenetetrahydrofolate reductase mutation: 5-year experience

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.

The role of prophylactic use of low dose aspirin and calheparin in patients with unexplained recurrent abortion

OBJECTIVE

To study the effect of prophylactic use of low dose aspirin and heparin on patients with recurrent unexplained pregnancy loss.

METHODS

Prospective case control study conducted on 180 pregnant women randomized into two equal groups. Group 1 received low-dose aspirin 75 mg and heparin 5000 IU subcutaneous every 12 h. Group 2 received no treatment.

RESULTS

There was a statistically significant difference between the two study groups regarding number of patients who completed their first trimester (66 versus 39) (p values 0.018). The outcome regarding completion of first trimester was not related to age, BMI or number of previous abortions in both the study groups. Complications of the use of aspirin calheparin occurred in 60% of the patients. The most common complication was bruising at injection site occurring in 60% of the patients followed by bleeding gums (14.4%), gastrointestinal troubles (12.2%), epistaxis (10%) and transient thrombocytopenia in only 2.22% of the patients (Table 4).

CONCLUSION

The use of prophylactic dose of calheparin and aspirin is associated with increased chance of passing 1st trimester safely regardless the age, body mass index or number of abortion in women with unexplained recurrent spontaneous abortion.

Immunogenetic contributions to recurrent pregnancy loss

While sporadic pregnancy loss is common, occurring in 15 % of pregnancies, recurrent pregnancy loss (RPL) impacts approximately 5 % of couples. Though multiple causes are known (including structural, hormonal, infectious, autoimmune, and thrombophilic causes), after evaluation, roughly half of all cases remain unexplained. The idiopathic RPL cases pose a challenging therapeutic dilemma in addition to incurring much physical and emotional morbidity. Immunogenetic causes have been postulated to contribute to these cases of RPL. Natural Killer cell, T cell expression pattern changes in the endometrium have both been shown in patients with RPL. Human leukocyte antigen (HLA) and cytokine allelic variations have also been studied as etiologies for RPL. Some of the results have been promising, however the studies are small and have not yet put forth outcomes that would change our current diagnosis and management of RPL. Larger database studies are needed with stricter control criteria before reasonable conclusions can be drawn.

Do women with recurrent miscarriage constitute a high-risk obstetric population?

The aim of this study was to examine if women with history of recurrent miscarriage have a higher risk of maternal and foetal complications in future pregnancies. This was a retrospective case control study that analysed data collected prospectively between 2001 and 2007 from 400 women with history of recurrent miscarriage who achieved pregnancies progressing beyond 24 weeks gestation compared to 39,860 deliveries from the general obstetric database within the same time period. Results showed that women with recurrent miscarriage had significantly increased odds of low Apgar scores at one (odds ratios (OR) 1.57, 95% CI 1.20-2.05) and five minutes (OR 2.0, 95% CI 1.23-3.27), small for gestational age (OR 1.96, 95% CI 1.12-3.43), preterm delivery (OR 1.64, 95% CI 1.22-2.19) and antepartum haemorrhage (OR 7.67, 95% CI 4.23-13.91). The risks were increased in the presence of a male foetus but no difference was observed between primary and secondary miscarriage patients. In conclusion, women with recurrent miscarriage have an increased risk of several maternal and foetal complications and therefore may require closer monitoring during the antenatal period particularly when pregnant with a male foetus.

Viable pregnancies beyond 28 weeks gestation in women with a history of unexplained recurrent miscarriage have reduced platelet function

OBJECTIVE

The aim of this study was to characterize platelet function in pregnant patients with a history of unexplained recurrent miscarriage (RM) in the third trimester of a subsequent viable pregnancy, a time at which platelet dysfunction may be associated with an increased obstetric risk.

STUDY DESIGN

A prospective study was performed comparing 30 viable pregnancies that had reached at least 28 weeks' gestation amongst patients who had a background history of unexplained RM, with 30 healthy pregnant controls at a similar gestational age. Platelet function was determined by means of platelet aggregation in response to 5 different agonists at multiple concentrations.

RESULTS

Amongst the 30 RM patients with ongoing viable pregnancies, we demonstrated significantly reduced platelet aggregation compared to the pregnant controls in the third trimester. For three out of five agonists, we demonstrated statistically significantly decreased platelet aggregation and for all five agonists we demonstrated significantly decreased platelet aggregation in the postnatal period. There were no obvious differences in obstetric outcomes.

CONCLUSION

This study shows that women with a history of unexplained RM have reduced platelet function after 28 weeks' gestation in their subsequent pregnancies compared to healthy pregnant controls, but without this difference leading to any obvious increase in adverse obstetric risk.

Inherited thrombophilia and reproductive disorders

Apart from its established role in the pathogenesis of venous thromboembolism (VTE), inherited thrombophilia has been proposed as a possible cause of pregnancy loss and vascular gestational complications. There is a lot of controversy in the literature on the relationship between inherited prothrombotic defects and these obstetric complications. This is a review of the literature on inherited thrombophilia and reproductive disorders. Factor V Leiden, prothrombin G20210A mutation, and protein S deficiency seem to be associated with late and recurrent early pregnancy loss, while their impact on other pregnancy complications is conflicting. No definite association has been established between protein C and antithrombin deficiency and adverse pregnancy outcome, primarily due to their low prevalence. Screening is suggested only for women with early recurrent loss or late pregnancy loss. Anticoagulant treatment during pregnancy should be considered for women with complications who were tested positive for thrombophilia.

Association between miscarriage and cardiovascular disease in a Scottish cohort

OBJECTIVE

To assess if miscarriage, whether consecutive or not, is associated with an increased risk of subsequent cardiovascular disease.

METHODS

A cohort study was performed using women with at least one miscarriage or live birth recorded from 1950 to 2010 in the Aberdeen Maternity and Neonatal Databank. The exposed groups consisted of women with non-consecutive, two consecutive or three or more consecutive miscarriages; the unexposed group consisted of all women with at least one live birth and no miscarriages. Women were linked to Scottish Morbidity Records for hospital admissions for cardiovascular conditions, cardiac surgery and death registrations. Main outcome measures were ischaemic heart disease, cerebrovascular disease and a composite outcome of any disease of circulatory system. A sensitivity analysis was performed dividing the women into those who had one, two or three or more miscarriages irrespective of whether these events were consecutive or not.

RESULTS

After excluding women with pre-existing hypertension, type 1 diabetes mellitus, kidney disease and 'disease of circulatory system', 60,105 women were analysed; 9419 with non-consecutive, 940 with two consecutive, 167 with three or more consecutive miscarriages and 49,579 with no miscarriage. In the multivariate analyses, a significant association was found between ischaemic heart disease and women with two (HRs 1.75 (95% CI 1.22 to 2.52)) or three or more (HR 3.18 (95% CI 1.49 to 6.80)) consecutive miscarriages. Similar patterns of risk were observed in the sensitivity analysis.

CONCLUSION

Women with a history of two or more miscarriages, irrespective of whether consecutive or not, appear to have an increased risk of ischaemic heart disease.

Clinical characteristics of pregnancies with a history of recurrent miscarriage at a Japanese perinatal center

OBJECTIVE

We examined obstetric and fetal/neonatal outcomes in women with a history of recurrent miscarriage.

METHODS

We reviewed the obstetric records of all 5,829 nulliparous pregnant women who delivered at #8805;14 weeks' gestation from 2008 through 2013 at our perinatal center. Of these women, 74 had a history of recurrent miscarriage (1.3%). The control population consisted of 4,176 nulliparous women without a history of miscarriage. Demographic information and characteristics of labor were extracted from patient charts.

RESULTS

The rate of maternal age #8805;40 years (p<0.01) and the rate of in vitro fertilization use (p<0.01) were higher in women with recurrent miscarriage than in women without miscarriage. Eleven women with recurrent miscarriage (14.9%) were treated with low-dose aspirin with and without subcutaneous heparin. In addition, the rate of cesarean delivery was higher in women with recurrent miscarriage than in women without miscarriage (p=0.02). However, fetal/neonatal outcomes did not differ significantly between the populations.

CONCLUSION

The pregnancy of women with a history of recurrent miscarriage is not associated with adverse outcomes at our perinatal center.

Adverse pregnancy outcomes among women with prior spontaneous or induced abortions

OBJECTIVE

The aim of the article is to determine whether prior spontaneous abortion (SAB) or induced abortion (IAB), or the interpregnancy interval are associated with subsequent adverse pregnancy outcomes in nulliparous women.

METHODS

We performed a secondary analysis of data collected from nulliparous women enrolled in a completed trial of vitamins C and E or placebo for preeclampsia prevention. Adjusted odds ratios (ORs) for maternal and fetal outcomes were determined for nulliparous women with prior SABs and IABs as compared with primigravid participants.

RESULTS

Compared with primigravidas, women with one prior SAB were at increased risk for perinatal death (adj. OR, 1.5; 95% CI, 1.1-2.3) in subsequent pregnancies. Two or more SABs were associated with an increased risk for spontaneous preterm birth (PTB) (adj. OR, 2.6, 95% CI, 1.7-4.0), preterm premature rupture of membranes (PROM) (adj. OR, 2.9; 95% CI, 1.6-5.3), and perinatal death (adj. OR, 2.8; 95% CI, 1.5-5.3). Women with one previous IAB had higher rates of spontaneous PTB (adj. OR, 1.4; 95% CI, 1.0-1.9) and preterm PROM (OR, 2.0; 95% CI, 1.4-3.0). An interpregnancy interval less than 6 months after SAB was not associated with adverse outcomes.

CONCLUSION

Nulliparous women with a history of SAB or IAB, especially multiple SABs, are at increased risk for adverse pregnancy outcomes.

Recurrent miscarriage is a useful and valid clinical concept

Although epidemiological, clinical and biochemical risk factors are known for recurrent miscarriage (RM), the etiology is mainly unknown. Two main hypotheses dominate: that RM is mainly caused by aneuploid conceptions and other conception errors and that the recurrence rate is explained by the combination of chance and increased risk, or that maternal endocrinological, thrombophilic or immunological abnormalities play a main role in causing loss of euploid conceptions. Believers of the former hypothesis advocate that management of RM should be conservative and that the spontaneous prognosis is very favorable. Believers of the latter hypothesis think that treatments aimed at the woman may improve pregnancy outcome, but that testing of such treatments in randomized controlled trials is needed. In this article in favor of RM being a specific and useful clinical concept, arguments are advanced that a significant subset of RM patients exhibit a poor spontaneous prognosis and should be offered relevant investigations, close surveillance during pregnancy, and treatment, preferably as part of randomized controlled trials.

Preterm birth in the first pregnancy and risk of neonatal death in the second pregnancy: a propensity score-weighted matching approach

The study purpose was to assess the relationship between various grades of preterm birth (moderate preterm: 33-36 weeks; severe preterm: 27-32 weeks; extreme preterm: ≤ 26 weeks) in the first pregnancy and neonatal mortality (death within 28 days of birth; early: 0-7 days; late: 8-28 days) in the second pregnancy. Using the Missouri maternally-linked dataset (1989-2005), a population-based, retrospective cohort analysis with propensity score-weighted matching was conducted on mothers with two consecutive singleton live births (n = 310,653 women). Women with a prior preterm birth were more likely to subsequently experience neonatal death. The odds increased in a dose-dependent pattern with ascending severity of the preterm event in the first pregnancy (moderate preterm: AOR = 1.32; 95% CI: 1.10-1.60; severe preterm: AOR = 2.62; 95% CI: 2.01-3.41; extreme preterm: AOR = 5.84; 95% CI: 4.28-7.97; p value for trend < 0.001). However, the pathway for the relationship between prior preterm birth and subsequent neonatal mortality may be the recurrence of preterm birth.

Risk of placental dysfunction disorders after prior miscarriages: a population-based study

OBJECTIVE

The objective of the investigation was to study the association between prior miscarriages and the risks of placental dysfunction disorders, including preeclampsia, stillbirth, birth of a small for gestational age (SGA) infant, placental abruption, and spontaneous preterm birth.

STUDY DESIGN

In a population-based cohort study including 619,587 primiparous women, we estimated risks of placental dysfunction disorders for women with 1 (n = 68,185), 2 (n = 11,410) and 3 or more (n = 3823) self-reported prior miscarriages. Risks were calculated as odds ratios by unconditional logistic regression analysis and adjustments were made for maternal age, early pregnancy body mass index, height, smoking habits, country of birth, years of formal education, in vitro fertilization, chronic hypertension, pregestational diabetes, hypothyroidism, systemic lupus erythematosis, fetal sex, and year of childbirth.

RESULTS

Compared with women with no prior miscarriage, women with 1 prior miscarriage had almost no increased risks. Women with 2 prior miscarriages had increased risks of spontaneous preterm birth, preterm (<37 weeks) SGA infant, and placental abruption. The rates of all disorders were higher for women with 3 or more prior miscarriages compared with women without prior miscarriages: preeclampsia, 5.83% vs 4.27%; stillbirth, 0.69% vs 0.33%, SGA infant, 5.09% vs 3.22%, placental abruption, 0.81% vs 0.41%; and spontaneous preterm birth, 6.45% vs 4.40%. The adjusted odds ratios for preterm (<37 weeks) disorders in women with 3 prior miscarriages were approximately 2.

CONCLUSION

History of 2 or more miscarriages is associated with an increased risk of placental dysfunction disorders and should be regarded as a risk factor in antenatal care.