Prognostic impact of anticardiolipin antibodies in women with recurrent miscarriage negative for the lupus anticoagulant

A predictive model of pregnancy loss using pre-pregnancy endocrine and immunological parameters in women with abnormal glucose/lipid metabolism and previous pregnancy loss

OBJECTIVE

To investigate the clinical and endocrine risk factors for pregnancy loss in women with abnormal glucose/lipid metabolism and a history of pregnancy loss, and to develop a predictive model to assess the risk of pregnancy loss in these women's subsequent pregnancies.

METHODS

Patients with a history of pregnancy loss who had abnormal glucose/lipid metabolism were retrospectively included in this study, and their pre-pregnancy baseline and clinical characteristics were collected. A predictive nomogram was constructed based on the results of the multivariable logistic regression model analysis, and its calibration and discriminatory capabilities were evaluated. The internal validation was then performed and the net benefits were assessed by the clinical decision curve.

RESULTS

The predictive model was eventually incorporated eight variables, including maternal age, previous pregnancy losses, anticardiolipin antibody (aCL) IgG, aCL IgM, thyroid peroxidase antibody, complement 4, free thyroxine and total cholesterol. The area under the curve (AUC) of the nomogram was 0.709, and Chi-square value and P value of the Hosmer-Lemeshow test were 12.786 and 0.119, respectively, indicating that the nomogram had a satisfactory calibration and discriminatory performance. The validation cohort showed a similar result for the discrimination of the nomogram (AUC = 0.715). The clinical decision curve demonstrated the nomogram had good positive net benefits.

CONCLUSIONS

This is the first study to predict the risks of subsequent pregnancy loss in women with abnormal glucose/lipid metabolism and history of pregnancy loss using pre-pregnancy clinical and endocrine parameters. This predictive nomogram may provide clinicians assistance to personalize the management of subsequent pregnancies in these patients.

Risk prediction model based on machine learning for predicting miscarriage among pregnant patients with immune abnormalities

Introduction: It is known that patients with immune-abnormal co-pregnancies are at a higher risk of adverse pregnancy outcomes. Traditional pregnancy risk management systems have poor prediction abilities for adverse pregnancy outcomes in such patients, with many limitations in clinical application. In this study, we will use machine learning to screen high-risk factors for miscarriage and develop a miscarriage risk prediction model for patients with immune-abnormal pregnancies. This model aims to provide an adjunctive tool for the clinical identification of patients at high risk of miscarriage and to allow for active intervention to reduce adverse pregnancy outcomes. Methods: Patients with immune-abnormal pregnancies attending Sichuan Provincial People's Hospital were collected through electronic medical records (EMR). The data were divided into a training set and a test set in an 8:2 ratio. Comparisons were made to evaluate the performance of traditional pregnancy risk assessment tools for clinical applications. This analysis involved assessing the cost-benefit of clinical treatment, evaluating the model's performance, and determining its economic value. Data sampling methods, feature screening, and machine learning algorithms were utilized to develop predictive models. These models were internally validated using 10-fold cross-validation for the training set and externally validated using bootstrapping for the test set. Model performance was assessed by the area under the characteristic curve (AUC). Based on the best parameters, a predictive model for miscarriage risk was developed, and the SHapley additive expansion (SHAP) method was used to assess the best model feature contribution. Results: A total of 565 patients were included in this study on machine learning-based models for predicting the risk of miscarriage in patients with immune-abnormal pregnancies. Twenty-eight risk warning models were developed, and the predictive model constructed using XGBoost demonstrated the best performance with an AUC of 0.9209. The SHAP analysis of the best model highlighted the total number of medications, as well as the use of aspirin and low molecular weight heparin, as significant influencing factors. The implementation of the pregnancy risk scoring rules resulted in accuracy, precision, and F1 scores of 0.3009, 0.1663, and 0.2852, respectively. The economic evaluation showed a saving of ¥7,485,865.7 due to the model. Conclusion: The predictive model developed in this study performed well in estimating the risk of miscarriage in patients with immune-abnormal pregnancies. The findings of the model interpretation identified the total number of medications and the use of other medications during pregnancy as key factors in the early warning model for miscarriage risk. This provides an important basis for early risk assessment and intervention in immune-abnormal pregnancies. The predictive model developed in this study demonstrated better risk prediction performance than the Pregnancy Risk Management System (PRMS) and also demonstrated economic value. Therefore, miscarriage risk prediction in patients with immune-abnormal pregnancies may be the most cost-effective management method.

Interplay of immune components and their association with recurrent pregnancy loss

Maintenance and progression of pregnancy is an intricate process governed by a variety of developmental cues. Recurrent pregnancy loss (RPL) is a complication experienced by expecting mothers that is defined as three or more consecutive pregnancy losses. This review focuses on the dysfunctions of the immune system as one of the key contributors towards RPL. The current data suggests that the alloimmune and autoimmune factors contribute to the loss of fetus. Such causes despite being recognized as a definitive reason for recurrent pregnancy loss, are still under extensive investigation with new parameters being discovered and scrutinized for their association with RPLs. More in-depth and high throughput studies are required for devising better diagnostic tools and management strategies for the affected female so that they can carry their pregnancy to term.

Pregnancy loss is associated with type 2 diabetes: a nationwide case-control study

AIMS/HYPOTHESIS

Type 2 diabetes is killing more people than ever, and early-life predictors remain critical for the development of effective preventive strategies. Pregnancy loss is a common event associated with later atherosclerotic disease and ischaemic heart failure and might constitute a predictor for type 2 diabetes. The objective of this study was to investigate whether pregnancy loss is associated with later development of type 2 diabetes.

METHODS

Using a Danish nationwide cohort, we identified all women born from 1957 through to 1997 and who had a diagnosis of type 2 diabetes during the period 1977 to 2017. The women were matched 1:10 on year of birth and educational level to women without diabetes in the general Danish population. Conditional logistic regression models provided odds ratios for type 2 diabetes with different numbers of pregnancy losses.

RESULTS

We identified 24,774 women with type 2 diabetes and selected 247,740 controls without diabetes. Women who had ever been pregnant (ever-pregnant women) with 1, 2 and ≥ 3 pregnancy losses had ORs of type 2 diabetes of 1.18 (95% CI 1.13, 1.23), 1.38 (95% CI 1.27, 1.49) and 1.71 (95% CI 1.53, 1.92) compared with ever-pregnant women with no pregnancy losses, respectively. Women who never achieved a pregnancy had an OR of type 2 diabetes of 1.56 (95% CI 1.51, 1.61) compared with ever-pregnant women with any number of losses. Similar results were found after adjustment for obesity and gestational diabetes.

CONCLUSIONS/INTERPRETATION

We found a significant and consistent association between pregnancy loss and later type 2 diabetes that increased with increasing number of losses. Thus, pregnancy loss and recurrent pregnancy loss are significant risk factors for later type 2 diabetes. Future studies should explore whether this association is due to common background factors or whether prediabetic metabolic conditions are responsible for this association. Graphical abstract.

Reproductive immunology

Much research has been done to investigate why the fetus in most pregnancies, in spite of being semi-allogenic, is not rejected by the immune system. Experiments in transgenic mice have suggested that dysfunctions in both the innate immune system (NK cells) and the adaptive immune system (T-cells and T regulatory cells) result in increased fetal loss rate. Many studies have suggested that women with pathological pregnancies such as recurrent miscarriages have signs of generally exaggerated inflammatory immune responses both before and during pregnancy and signs of breakage of tolerance to autoantigens and fetal antigens. In addition, several abnormalities of innate immune responses seem to characterize women with pathological pregnancies. These abnormalities involve disadvantageous interactions between uterine NK cells and HLA-G and HLA-C on the trophoblast that may have pro-inflammatory effects. Also, humoral factors belonging to the innate immune system such as mannose-binding lectin seem to be associated with pregnancy outcome probably by modifying the level of inflammation at the feto-maternal interface. The pro-inflammatory conditions at the feto-maternal interface characterizing pathological pregnancy are suggested to predispose to adaptive immunological processes against alloantigens on the trophoblast that may further increase the risk of pathological pregnancy outcome. The best documented adaptive immune reaction against fetal alloantigens is directed against male-specific minor histocompatibility (HY) antigens. Anti-HY immunity seems to play a role especially in women with secondary recurrent miscarriage.

The correlation of autoantibodies and uNK cells in women with reproductive failure

There is conflicting evidence on the role of autoimmune disorders in reproductive failure, including recurrent miscarriage (RM) and recurrent implantation failure (RIF), after in vitro fertilisation (IVF). Several commonly studied autoimmune markers in women with reproductive failure include antiphospholipid antibodies (APAs), thyroid peroxidase antibodies (TPA) and uterine natural killer (uNK) cells. However, there have not been any studies that have examined the correlation of these markers in women with reproductive failure. To determine if women who tested positive for autoantibodies (APA and thyroid peroxidase antibodies) have significantly higher uNK cell numbers than women who tested negative for these antibodies, the percentage of stromal cells that stained positive for CD56 was identified by immunocytochemistry in endometrial biopsies from 42 women with unexplained RM (29 women tested negative for autoantibodies and 13 women tested positive for autoantibodies) and 40 women with unexplained RIF (30 women tested negative for autoantibodies and 10 women tested positive for autoantibodies). Biopsies were obtained on days LH+7 to LH+9. There was no significant difference in uNK cell numbers between women with unexplained RM who tested negative and those who tested positive for autoantibodies. Similarly, there was no significant difference in uNK cell numbers between women with unexplained RIF who tested negative and those who tested positive for autoantibodies. In women with reproductive failure the presence of autoantibodies does not appear to affect the numbers of uNK cells in the endometrium around the time of implantation.

Thrombophilic dimension of recurrent fetal loss in Indian patients

We studied the prevalence of acquired and genetic thrombophilia in 198 women with recurrent fetal loss who were having three or more than three abortions. Seventy-nine women had only early pregnancy losses, that is, first trimester abortions, 30 women had only late pregnancy losses, that is, second and third trimester abortions whereas 89 had both early and late pregnancy losses. The control group included 100 age-matched fertile parous women who did not have any obstetric complications and had at least one normal healthy child. Several genetic and acquired thrombophilia markers were studied. The strongest association was observed with anticardiolipin (odds ratio 22.6, confidence interval 5.7-89, P = 0) followed by lupus anticoagulant, anti-beta2 glycoprotein-1, antiannexin. Association of antiphospholipid antibody syndromes was detected with the time of pregnancy loss in anticardiolipin, lupus anticoagulants, which was significantly associated with early pregnancy loss as compared with second and third trimester loss. In case of beta2 glycoprotein-1, antiannexin it was less significantly associated with early pregnancy loss as compared with second and third trimester loss. The risk of fetal loss with protein S deficiency was the highest risk observed for any heritable thrombophilia, followed by protein C, factor V Leiden, endothelial protein C receptor, antithrombin III deficiency and beta448 fibrinogen polymorphism. Modest risks were also observed with 5,10-methylenetetrahydrofolate reductase, plasminogen activator inhibitor 4G/4G polymorphisms and beta448 fibrinogen polymorphism. A combination of two or more than two genetic risk factors were observed in 55 (27.7%), whereas the genetic and acquired risk factors were observed in 107 (54%) of the cases. Thrombophilia is an important contributing factor for both early and late pregnancy losses; approximately two-thirds of our cases of unexplained fetal losses could be explained by acquired or heritable thrombophilia or both, which is in line with other western studies.

The obstetric antiphospholipid syndrome

The association of persistent presence of circulating antiphospholipid antibodies and thromboembolic events, (recurrent) pregnancy loss or both is termed antiphospholipid syndrome. Pregnancies in women with the syndrome should be regarded as at high-risk for complications. Optimal management consisting of close follow-up and pharmacological treatment can result in about 70-80% live births. Apart from the laboratory diagnosis of the syndrome and pathophysiology, this review will focus on treatment during pregnancy.

Fausses couches spontanées précoces répétées : quelle prise en charge proposer en 2006 ?

More than 1% of the couples whishing children suffer from recurrent miscarriage, but investigations and treatment are not consensual. Most patients have several risk factors, and a minimum investigation of known factors has to be undertaken: karyotyping of the couple, hysteroscopy for searching uterine anatomic anomalies, evaluation for thrombophilias (anticardiolipin antibodies, lupus anticoagulant, protein C activity, Proteine S activity, factor V Leiden and factor II mutations, activated protein C resistance), antinuclear antibodies. Systemic diseases (like lupus) and endocrine abnormalities (like thyroid diseases and diabetes mellitus) have to be detected by clinical examination and questioning. No endocrine investigation is recommended, unless irregular menstruations or sterility. Research in recurrent pregnancy loss are conducted in new associated factors, such as skewed-X-chromosome inactivation, maternal HLA types, modifications in specific immune molecules and cells regulation. Therapeutic proposals are preimplantation genetic diagnosis in case of abnormal karyotiping, hysteroscopic surgery for septate uterus, aspirin plus heparin in antiphospholipid-positive patients, and aspirin plus corticosteroids in systemic lupus. Heparin seems to improve obstetrical prognosis for patients with congenital or acquired thrombophilias, but there are only few studies carried out on the subject. This new therapeutic approach should incite the patients with a negative medical appraisal to be referred to specialized consultations in order to include them in eventual clinical tests. Finally, empathic listening and psychological support are necessary in a pathology with multiple etiological factors.

Evidence-based investigations and treatments of recurrent pregnancy loss

PURPOSE OF REVIEW

The majority of investigations and treatments offered to women with recurrent pregnancy loss are not evidence-based. In this review a critical analysis is given of the current management of recurrent pregnancy loss often recommended in meta-analyses and guidelines.

RECENT FINDINGS

Our knowledge of genetic, endocrine, thrombophilic and immunological causes of recurrent pregnancy loss has been improved significantly, primarily by the introduction of modern laboratory techniques. Most clinical trials in this area, however, are still subject to serious methodological flaws.

SUMMARY

At present, the clinician must base their clinical practice on the few high-quality observational studies and intervention trials available rather than on meta-analyses, as there is a scarcity of good clinical trials. More high-quality clinical studies are urgently needed in this area.

Future directions of failed implantation and recurrent miscarriage research

Recurrent implantation failure is today the major reason for women completing several IVF/intracytoplasmic sperm injection attempts without having achieved a child, and is probably also the explanation for many cases of unexplained infertility. Most causes of recurrent miscarriage are still poorly elucidated, but from a theoretical point of view recurrent implantation failure and recurrent miscarriage are suggested to have partly overlapping causes. Recent research has indeed documented that both syndromes can be caused by the same embryonic chromosomal abnormalities and the same maternal endocrine, thrombophilic and immunological disturbances. Consequently, many treatments attempting to normalize these abnormalities have been tested or are currently used in women with both recurrent implantation failure and recurrent miscarriage. However, no treatment for the two syndromes is at the moment sufficiently documented to justify its routine use. In this review, an overview is given regarding present knowledge about causes that may be common for recurrent implantation failure and recurrent miscarriage, and suggestions are put forward for future research that may significantly improve understanding and treatment options for the syndromes.