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Youssef A, Lashley EELO, Vermeulen N, van der Hoorn MLP. Identifying discrepancies between clinical practice and evidence-based guideline in recurrent pregnancy loss care, a tool for clinical guideline implementation. BMC Pregnancy Childbirth 2023; 23:544. [PMID: 37507697 PMCID: PMC10386208 DOI: 10.1186/s12884-023-05869-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 07/23/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Practice variation in recurrent pregnancy loss (RPL) care is common. International guidelines vary in their recommendations for the management of RPL couples, which could lead to an increase of cross border reproductive care. Currently, the Dutch RPL guideline is being adapted from the European Society for Human Reproduction and Embryology (ESHRE) guideline. We aim to identify discrepancies between RPL guidelines and RPL practice. These discrepancies could be considered in the development of a new guideline and implementation strategies to promote adherence to new recommendations. METHODS A nationwide survey on the management of RPL patients was conducted across all 107 hospital-based obstetrics and gynaecology practices in the Netherlands. The survey was sent via the Dutch Society for Obstetricians and Gynaecologists to all affiliated clinicians. The questionnaire consisted of 36 questions divided in four sections: clinician's demographics, RPL definition, investigations and therapy. The data were compared to the recommendations given by the Dutch national guideline and the most recent guideline of the ESHRE. RESULTS All hospital-based practices (100%; n = 107) filled in the online questionnaire. The majority of respondents defined RPL similarly, as two or more pregnancy losses (87.4%), not obligatory consecutive (93.1%). More than half of respondents routinely perform thrombophilia screening ( 58%), although not advised by the ESHRE, while thyroid function (57%), thyroid auto-immunity (27%) and β2-glycoprotein antibodies (42%) in the context of antiphospholipid syndrome (APS) are recommended but investigated less often. Regarding parental karyotyping, 20% of respondents stated they always perform parental karyotyping, without prior risk assessment. because of RPL. Treatment for hereditary thrombophilia was frequently (43.8% (n = 137)) prescribed although not recommended. And finally, a considerable part (12-16%) of respondents prescribe medication in case of unexplained RPL. CONCLUSION While many clinicians perform investigations recommended by the ESHRE, there is a considerable variation of RPL practice in the Netherlands. We identified discrepancies between RPL guidelines and RPL practice, providing possibilities to focus on multifaceted implementation strategies, such as educational intervention, local consensus processes and auditing and feedback. This will improve the quality of care provided to RPL patients and may diminish the necessity felt by patients to turn to multiple opinions or cross border reproductive care.
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Affiliation(s)
- A Youssef
- Leiden University Medical Centre, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands.
| | - E E L O Lashley
- Leiden University Medical Centre, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands
| | - N Vermeulen
- European Society of Human Reproduction and Embryology, Nijverheidslaan 3 (BXL 7 - Gebouw 1), Strombeek, Bever, B - 1853, Belgium
| | - M L P van der Hoorn
- Leiden University Medical Centre, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands
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Flannery C, Burke LA, Gillespie P, O'Donoghue K. Estimating the costs associated with the implementation of a best practice model of care for recurrent miscarriage clinics in Ireland: a cost analysis. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13625.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Recurrent miscarriage (RM) affects 1%-5% of the reproductive age population. Given increasing calls for dedicated recurrent miscarriage clinics (RMC), decision makers will require data on the resultant budgetary implications. The aim of this study was to identify the potential costs to the Irish healthcare system of implementing a best practice RMC model of care. Methods A ‘best practice’ RMC was developed as part of the RE:CURRENT Project. A micro-costing approach was employed by identifying, measuring, and valuing resource usage by unit costs for the RMC for ≥2 consecutive losses. Per patient costs were estimated using two care pathway scenarios: typical and complex. Per patient costs were extrapolated, using population data and published prevalence rates for RM, to estimate the total cost to the Irish health system. A sensitivity analysis was also performed. Results The cost for a RM patient who has another pregnancy after receiving investigations, treatment and reassurance scans ranges between €1,634 (typical) and €4,818 (complex). For a RM patient who does not conceive again, costs range from €1,384 (typical) to €4,318 (complex). Using population estimates for ≥2 losses, the total cost to the Irish health service ranges from €20,336,229 (complex) to €61,927,630 (typical) for those who progress to pregnancy, and from €7,789,437 (complex) to €22,480,630 (typical) for those who do not progress to another pregnancy. Together, the total cost of the proposed best practice RMC is €112,533,926 with an average cost per patient €1,871. Conclusions This study advocates for a new model of care for RMCs in Ireland and provides a set of cost estimates at the patient and healthcare system level. While future studies should explicitly consider the cost effectiveness of this or similar models of care, this analysis provides a valuable first step in providing a detailed breakdown of the associated costs and budget implications.
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Habets DHJ, Schlütter A, van Kuijk SMJ, Spaanderman MEA, Al‐Nasiry S, Wieten L. Natural killer cell profiles in recurrent pregnancy loss: Increased expression and positive associations with TACTILE and LILRB1. Am J Reprod Immunol 2022; 88:e13612. [PMID: 36004818 PMCID: PMC9787570 DOI: 10.1111/aji.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/15/2022] [Accepted: 08/12/2022] [Indexed: 12/30/2022] Open
Abstract
PROBLEM NK cells are important for healthy pregnancy and aberrant phenotypes or effector functions have been associated with RPL. We compared expression of a broad panel of NK cell receptors, including immune checkpoint receptors, and investigated their clinical association with RPL as this might improve patient stratification and prediction of RPL. METHOD OF STUDY Peripheral blood mononuclear cells were isolated from 52 women with RPL and from 2 women with an uncomplicated pregnancy for flowcytometric analysis and plasma was used to determine anti-CMV IgG antibodies. RESULTS Between RPL and controls, we observed no difference in frequencies of T-, NKT or NK cells, in CD56dimCD16+ or CD56brightCD16- NK cell subsets or in the expression of KIRs, NKG2A, NKG2C, NKG2D, NKp30, NKp44, NKp46 or DNAM1. NK cells from women with RPL had a higher expression of LILRB1 and TACTILE and this was associated with the number of losses. The immune checkpoint receptors PD1, TIM3 and LAG3 were not expressed on peripheral blood NK cells. In RPL patients, there was a large variation in NKG2C expression and higher levels could be explained by CMV seropositivity. CONCLUSION Our study identified LILRB1 and TACTILE as NK cell receptors associated with RPL. Moreover, we provide first support for the potential role of CMV in RPL via its impact on the NK cell compartment. Thereby our study could guide future studies to confirm the clinical association of LILRB1, TACTILE and NKG2C with RPL in a larger cohort and to explore their functional relevance in reproductive success.
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Affiliation(s)
- Denise H. J. Habets
- Department of Obstetrics and GynecologyMaastricht University Medical CentreMaastrichtthe Netherlands,Department of Transplantation ImmunologyMaastricht University Medical CentreMaastrichtthe Netherlands,GROW school for Oncology and Developmental BiologyMaastricht UniversityMaastrichtthe Netherlands
| | - Anna Schlütter
- Department of Obstetrics and GynecologyMaastricht University Medical CentreMaastrichtthe Netherlands
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CentreMaastrichtthe Netherlands
| | - Marc E. A. Spaanderman
- Department of Obstetrics and GynecologyMaastricht University Medical CentreMaastrichtthe Netherlands,GROW school for Oncology and Developmental BiologyMaastricht UniversityMaastrichtthe Netherlands,Department of Obstetrics and GynecologyRadboud University Medical CentreNijmegenthe Netherlands
| | - Salwan Al‐Nasiry
- Department of Obstetrics and GynecologyMaastricht University Medical CentreMaastrichtthe Netherlands,GROW school for Oncology and Developmental BiologyMaastricht UniversityMaastrichtthe Netherlands
| | - Lotte Wieten
- Department of Transplantation ImmunologyMaastricht University Medical CentreMaastrichtthe Netherlands,GROW school for Oncology and Developmental BiologyMaastricht UniversityMaastrichtthe Netherlands
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Hennessy M, Dennehy R, Meaney S, Linehan L, Devane D, Rice R, O'Donoghue K. Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review. Reprod Biomed Online 2021; 42:1146-1171. [PMID: 33895080 DOI: 10.1016/j.rbmo.2021.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.
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Affiliation(s)
- Marita Hennessy
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; College of Medicine and Health, University College Cork Cork T12 EKDO, Ireland.
| | - Rebecca Dennehy
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; College of Medicine and Health, University College Cork Cork T12 EKDO, Ireland
| | - Sarah Meaney
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; College of Medicine and Health, University College Cork Cork T12 EKDO, Ireland; National Perinatal Epidemiology Centre, University College Cork, Cork University Maternity Hospital Cork T12 DC4A, Ireland
| | - Laura Linehan
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; College of Medicine and Health, University College Cork Cork T12 EKDO, Ireland
| | - Declan Devane
- The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; School of Nursing and Midwifery, National University of Ireland, Galway, Galway H91 E3YV, Ireland; Evidence Synthesis Ireland, National University of Ireland, Galway, Galway H91 E3YV, Ireland
| | - Rachel Rice
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; School of Applied Social Studies, University College Cork, Cork T12 D726, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork T12 DC4A, Ireland; The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork T12 DC4A, Ireland; College of Medicine and Health, University College Cork Cork T12 EKDO, Ireland
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Manning R, Iyer J, Bulmer JN, Maheshwari A, Choudhary M. Are we managing women with Recurrent Miscarriage appropriately? A snapshot survey of clinical practice within the United Kingdom. J OBSTET GYNAECOL 2020; 41:807-814. [DOI: 10.1080/01443615.2020.1803241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Rashmi Manning
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Janani Iyer
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Judith N Bulmer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Royal Hospitals NHS Trust, Aberdeen, UK
| | - Meenakshi Choudhary
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
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6
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Zhu X, Li J, Zhu Y, Wang W, Wu X, Yang Y, Gu L, Gu Y, Hu Y. Application of chromosomal microarray analysis in products of miscarriage. Mol Cytogenet 2018; 11:44. [PMID: 30140311 PMCID: PMC6098645 DOI: 10.1186/s13039-018-0396-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background Chromosomal abnormality is one of the major cause of spontaneous abortion. Most available guidelines suggest genetic testing after three miscarriages, which has been proved to be difficult to adhere to and somewhat of low cost-effectiveness. As chromosomal microarray analysis has been recommended to be applied on miscarriage products, we managed a retrospective study on our experience investigate the potential impact of this technique on previous guidelines and our present management on miscarried couples and products. Results Of the 405 products of conceptions, the overall detection rate of pathogenetic results was 55.3% (224/405), including 7.1% (16/224) copy number changes which could be missed by conventional karyotyping analysis. Of the 222 natural conception samples, abnormal genetic results were found in 126 cases (56.8%). The detection rate in the assistant reproductive treatment group was 53.6% (98/183). No significant difference was found between these two groups (p = 0.645, OR = 1.110 with 95% CI: 0.713–1.726). The detection rate was 53.2% (75/141) in 141 product-of-conceptions (POCs) of mothers with adverse pregnancy histories. Of the 264 POC samples of mothers without abnormal pregnancy histories, 56.4% (149/264) were genetically abnormal. The detection rate and maternal age between these two groups were all compatible. Conclusions Chromosomal microarray testing should be referred to couples at their first miscarriage regardless of the way how they get pregnant.
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Affiliation(s)
- Xiangyu Zhu
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Jie Li
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Yujie Zhu
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Wanjun Wang
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Xing Wu
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Ying Yang
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Leilei Gu
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Yuanyuan Gu
- 1Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, 210008 Jiangsu China
| | - Yali Hu
- 2Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008 Jiangsu China
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Rasmark Roepke E, Matthiesen L, Rylance R, Christiansen OB. Is the incidence of recurrent pregnancy loss increasing? A retrospective register-based study in Sweden. Acta Obstet Gynecol Scand 2017; 96:1365-1372. [DOI: 10.1111/aogs.13210] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/02/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Emma Rasmark Roepke
- Department of Obstetrics and Gynecology; Skåne University Hospital; Lund University; Malmö Sweden
| | - Leif Matthiesen
- Department of Obstetrics and Gynecology; Helsingborg Hospital; Affiliated Lund University; Helsingborg Sweden
| | - Rebecca Rylance
- Department of Research and Development; Skåne University Hospital; Lund Sweden
| | - Ole Bjarne Christiansen
- Fertility Clinic 4071; University Hospital Rigshospitalet; Copenhagen Denmark
- Department of Obstetrics and Gynecology; Aalborg University Hospital; Clinical Institute at Aalborg University; Aalborg Denmark
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8
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Ismail AM, Abbas AM, Ali MK, Amin AF. Peri-conceptional progesterone treatment in women with unexplained recurrent miscarriage: a randomized double-blind placebo-controlled trial. J Matern Fetal Neonatal Med 2017; 31:388-394. [DOI: 10.1080/14767058.2017.1286315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Alaa M. Ismail
- Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Assiut, Egypt
| | - Ahmed M. Abbas
- Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Assiut, Egypt
| | - Mohammed K. Ali
- Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Assiut, Egypt
| | - Ahmed F. Amin
- Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Assiut, Egypt
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Vissenberg R, Fliers E, van der Post JAM, van Wely M, Bisschop PH, Goddijn M. Live-birth rate in euthyroid women with recurrent miscarriage and thyroid peroxidase antibodies. Gynecol Endocrinol 2016; 32:132-5. [PMID: 26430806 DOI: 10.3109/09513590.2015.1092513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Thyroid autoimmunity with normal thyroid function is associated with recurrent miscarriage (RM), but the association with live birth is less clear. Therefore, we determined the association between thyroid peroxidase antibodies (TPO-Ab) and live-birth rate (LBR) in a retrospective cohort of euthyroid women with unexplained RM. We included 202 women of which 28 were TPO-Ab positive (13.9%) and 174 were TPO-Ab negative. TPO-Ab positive women (n = 10) without levothyroxine treatment had a lower LBR (29%) compared to TPO-Ab negative women (51%) (HR 0.23, 0.07-0.72, p = 0.012). The LBR in women with TPO-Ab receiving levothyroxine was not different compared women without TPO-Ab (60% versus 51%, p = 0.50). In conclusion, TPO-Ab are associated with a lower LBR in euthyroid women with unexplained RM and these women may benefit from treatment with levothyroxine.
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Affiliation(s)
- Rosa Vissenberg
- a Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Eric Fliers
- b Department of Endocrinology and Metabolism , Academic Medical Center, University of Amsterdam , The Netherlands , and
| | - Joris A M van der Post
- c Department of Obstetrics and Gynecology , Academic Medical Center, University of Amsterdam , The Netherlands
| | - Madelon van Wely
- a Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Peter H Bisschop
- b Department of Endocrinology and Metabolism , Academic Medical Center, University of Amsterdam , The Netherlands , and
| | - Mariette Goddijn
- a Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, The Netherlands
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10
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Early pregnancy care over time: should we promote an early pregnancy assessment unit? Reprod Biomed Online 2015; 31:192-8. [DOI: 10.1016/j.rbmo.2015.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 03/09/2015] [Accepted: 04/24/2015] [Indexed: 11/22/2022]
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Karaer A, Cigremis Y, Celik E, Urhan Gonullu R. Prokineticin 1 and leukemia inhibitory factor mRNA expression in the endometrium of women with idiopathic recurrent pregnancy loss. Fertil Steril 2014; 102:1091-1095.e1. [PMID: 25128195 DOI: 10.1016/j.fertnstert.2014.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/13/2014] [Accepted: 07/02/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the expression patterns of prokineticin 1 (PROK1) and leukemia inhibitory factor (LIF) mRNA differ in peri-implantation endometrial tissue of women with idiopathic recurrent pregnancy loss (RPL) from normal fertile women. DESIGN A case-control study. SETTING University-based tertiary care center. PATIENT(S) 30 women with idiopathic RPL and 30 fertile controls. INTERVENTION(S) Endometrial biopsies. MAIN OUTCOME MEASURE(S) Real-time polymerase chain reaction analysis for expression of PROK1 and LIF mRNA. RESULT(S) The expression of PROK1 and LIF was statistically significantly increased in the endometrium of the women with idiopathic RPL compared with the controls. Furthermore, increased LIF expression was observed in the endometrium of women with idiopathic RPL compared with controls. CONCLUSION(S) An increased mRNA expression of PROK1 and LIF could be one of the several abnormalities characterizing the endometrium in women with RPL.
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Affiliation(s)
- Abdullah Karaer
- Department of Obstetrics and Gynecology, Inonu University, School of Medicine, Malatya, Turkey.
| | - Yilmaz Cigremis
- Department of Medical Biology and Genetics, Inonu University, School of Medicine, Malatya, Turkey
| | - Ebru Celik
- Department of Obstetrics and Gynecology, Inonu University, School of Medicine, Malatya, Turkey
| | - Rukiye Urhan Gonullu
- Department of Obstetrics and Gynecology, Inonu University, School of Medicine, Malatya, Turkey
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van den Boogaard E, Hermens RPMG, Kremer JAM, van der Veen F, Goddijn M. Reply: Recurrent miscarriage: guidelines could be improved. Hum Reprod 2014; 29:1345. [DOI: 10.1093/humrep/deu062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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Guzel AI, Erkılınç S, Özer I, Celik Y, Yılmaz N, Doğanay M. Diagnostic value of screening tests in subgroups of women with recurrent pregnancy loss. J Matern Fetal Neonatal Med 2014; 28:443-7. [PMID: 24783967 DOI: 10.3109/14767058.2014.920811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the diagnostic value of screening laboratory tests in women who had recurrent pregnancy loss (RPL). METHODS A total of 252 women with RPL managed in our tertiary referral research and education hospital were included in the study. Risk factors recorded involved age, gravidity, parity, number of prior live births, number of pregnancy losses, and thrombophlia tests. The cases were divided into three different groups and each group was analyzed separately. RESULTS There was no statistically significant difference between the first and second groups in terms of clinical and laboratory parameters (p > 0.05). In the third group, there was a statistically significant difference among cases in terms of parity, gravidity, number of pregnancy losses, serum AT III levels, APCR, and age of the women. According to the logistic regression model, odds ratios (95% CI) were 6.116 (3.797-9.852), 5.665 (2.657-12.079), 4.763 (3.099-7.321), 4.729 (3.080-7.260), 2.820 (1.836-4.333), and 1.911 (1.232-2.965), respectively. CONCLUSIONS We do not recommend the screening of all women with RPL, but in women with high parity and those who had prior live birth pregnancies, increased AT III, and APCR may be diagnostic markers for subsequent pregnancy loss.
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Affiliation(s)
- Ali Irfan Guzel
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Research and Education Hospital , Ankara , Turkey and
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Abstract
A recurrent miscarriage clinic offers specialist investigation and treatment of women with recurrent first- and second-trimester miscarriages. Consultant-led clinics provide a dedicated and focused service to couples who have experienced at least two prior miscarriages. The best treatment strategy for couples with recurrent miscarriage is to discuss a treatment plan for a future pregnancy. Evidence-based up-to-date guidelines are required to reduce ineffective management of recurrent miscarriage couples, including overdiagnostics and underdiagnostics. Scientific research is necessary to study the effectiveness of new interventions, to study patient preferences, and to evaluate health care and costs or other outcomes.
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Affiliation(s)
- M M J Van den Berg
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Academic Medical Center, H4-205, PO Box 22660, Amsterdam 1100 DD, The Netherlands
| | - Rosa Vissenberg
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Academic Medical Center, H4-205, PO Box 22660, Amsterdam 1100 DD, The Netherlands
| | - Mariëtte Goddijn
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Academic Medical Center, H4-205, PO Box 22660, Amsterdam 1100 DD, The Netherlands.
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15
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van den Boogaard E, Hermens RPMG, Franssen AMHW, Doornbos JPR, Kremer JAM, van der Veen F, Goddijn M. Recurrent miscarriage: do professionals adhere to their guidelines. Hum Reprod 2013; 28:2898-904. [DOI: 10.1093/humrep/det329] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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van Leeuwen M, Vansenne F, Korevaar JC, van der Veen F, Goddijn M, Mol BWJ. Economic analysis of chromosome testing in couples with recurrent miscarriage to prevent handicapped offspring. Hum Reprod 2013; 28:1737-42. [PMID: 23613277 DOI: 10.1093/humrep/det067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Which strategy is least expensive to prevent the birth of a handicapped child in couples with recurrent miscarriage (RM); parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents, or amniocentesis in all ongoing pregnancies without the knowledge of parental carrier status? SUMMARY ANSWER For virtually all couples with RM amniocentesis in all ongoing pregnancies without the knowledge of parental carrier status is less expensive in preventing the birth of a handicapped child than parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents. WHAT IS KNOWN ALREADY One of the causes of RM is a balanced chromosome abnormality in one of the partners. If one of the partners is carrier of a balanced structural chromosomal abnormality, the risk of offspring with an unbalanced structural chromosome abnormality is increased. Like all couples, couples with RM also have an age-dependent risk for fetal aneuploidy, of which trisomy 21 is most common. STUDY DESIGN, SIZE, DURATION Model-based economic analysis to compare costs and effects of two strategies in couples with RM to prevent the birth of a handicapped child in case of ongoing pregnancy. PARTICIPANTS/MATERIALS, SETTING, METHODS Comparison of two strategies in women with RM: strategy (I) parental chromosome analysis followed by amniocentesis in pregnancy in case of carrier status of one of the parents and strategy (II) amniocentesis in all ongoing pregnancies without the knowledge of carrier status. No testing was the reference strategy. Data on probabilities and costs were derived from the literature. Incremental costs and effects were calculated [incremental cost-effectiveness ratio (ICER)]. Effectiveness was expressed as the number of prevented births of handicapped child equivalents compared with no testing. In these calculations, the birth of a handicapped child was valued 10 times worse than the loss of a viable pregnancy due to amniocentesis. MAIN RESULTS AND THE ROLE OF CHANCE Depending on the risk for carrier status, the ICER for Strategy I (parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents) varied between € 226,000 and € 6,556,000 per prevented handicapped child equivalent. For Strategy II (amniocentesis in all ongoing pregnancies without the knowledge of carrier status), the ICER varied between € 2000 and € 233 000 per prevented handicapped child equivalent. Strategy I was less expensive than Strategy II only for a small subgroup of couples with maternal age <23 years, three or more previous miscarriages and a family history of RM. LIMITATIONS, REASONS FOR CAUTION Our analysis is not a plea for amniocentesis in all women with RM. Individual risk assessment with serum markers and nuchal translucency is probably more effective at lower cost. WIDER IMPLICATIONS OF THE FINDINGS This analysis can be used by clinicians to explain the chances of adverse pregnancy outcome in couples with RM, as well as by policy makers in health-care economics. Future guidelines on RM might be more restrictive from the perspective of the limited health-care resources that we have available.
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Affiliation(s)
- M van Leeuwen
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, PO Box 22700, Amsterdam 1105 DE, The Netherlands.
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van den Boogaard E, Cohn DM, Korevaar JC, Dawood F, Vissenberg R, Middeldorp S, Goddijn M, Farquharson RG. Number and sequence of preceding miscarriages and maternal age for the prediction of antiphospholipid syndrome in women with recurrent miscarriage. Fertil Steril 2013; 99:188-192. [DOI: 10.1016/j.fertnstert.2012.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/05/2012] [Accepted: 09/05/2012] [Indexed: 10/27/2022]
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Glutathione S-transferase genes and the risk of recurrent miscarriage in Italian women. Fertil Steril 2012; 98:396-400. [DOI: 10.1016/j.fertnstert.2012.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 04/12/2012] [Accepted: 05/01/2012] [Indexed: 11/20/2022]
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van Dijk LJEW, Nelen WLDM, D'Hooghe TM, Dunselman GAJ, Hermens RPMG, Bergh C, Nygren KG, Simons AHM, de Sutter P, Marshall C, Burgers JS, Kremer JAM. The European Society of Human Reproduction and Embryology guideline for the diagnosis and treatment of endometriosis: an electronic guideline implementability appraisal. Implement Sci 2011; 6:7. [PMID: 21247418 PMCID: PMC3034686 DOI: 10.1186/1748-5908-6-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 01/19/2011] [Indexed: 11/30/2022] Open
Abstract
Background Clinical guidelines are intended to improve healthcare. However, even if guidelines are excellent, their implementation is not assured. In subfertility care, the European Society of Human Reproduction and Embryology (ESHRE) guidelines have been inventoried, and their methodological quality has been assessed. To improve the impact of the ESHRE guidelines and to improve European subfertility care, it is important to optimise the implementability of guidelines. We therefore investigated the implementation barriers of the ESHRE guideline with the best methodological quality and evaluated the used instrument for usability and feasibility. Methods We reviewed the ESHRE guideline for the diagnosis and treatment of endometriosis to assess its implementability. We used an electronic version of the guideline implementability appraisal (eGLIA) instrument. This eGLIA tool consists of 31 questions grouped into 10 dimensions. Seven items address the guideline as a whole, and 24 items assess the individual recommendations in the guideline. The eGLIA instrument identifies factors that influence the implementability of the guideline recommendations. These factors can be divided into facilitators that promote implementation and barriers that oppose implementation. A panel of 10 experts from three European countries appraised all 36 recommendations of the guideline. They discussed discrepancies in a teleconference and completed a questionnaire to evaluate the ease of use and overall utility of the eGLIA instrument. Results Two of the 36 guideline recommendations were straightforward to implement. Five recommendations were considered simply statements because they contained no actions. The remaining 29 recommendations were implementable with some adjustments. We found facilitators of the guideline implementability in the quality of decidability, presentation and formatting, apparent validity, and novelty or innovation of the recommendations. Vaguely defined actions, lack of facilities, immeasurable outcomes, and inflexibility within the recommendations formed barriers to implementation. The eGLIA instrument was generally useful and easy to use. However, assessment with the eGLIA instrument is very time-consuming. Conclusions The ESHRE guideline for the diagnosis and treatment of endometriosis could be improved to facilitate its implementation in daily practice. The eGLIA instrument is a helpful tool for identifying obstacles to implementation of a guideline. However, we recommend a concise version of this instrument.
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Affiliation(s)
- Lotte J E W van Dijk
- Department of Obstetrics & Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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VAN DEN BOOGAARD EMMY, HERMENS ROSELLAP, LESCHOT NICOJ, BARON RUTH, VOLLEBERGH JOSH, BERNARDUS ROBE, VAN DER VEEN FULCO, KREMER JANA, GODDIJN MARIËTTE. Identification of barriers for good adherence to a guideline on recurrent miscarriage. Acta Obstet Gynecol Scand 2010; 90:186-91. [DOI: 10.1111/j.1600-0412.2010.01000.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cabello Y, Gómez-Palomares J, Castilla J, Hernández J, Marqueta J, Pareja A, Luceño F, Hernández E, Coroleu B. Impact of the Spanish Fertility Society guidelines on the number of embryos to transfer. Reprod Biomed Online 2010; 21:667-75. [DOI: 10.1016/j.rbmo.2010.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 05/25/2010] [Accepted: 05/27/2010] [Indexed: 10/19/2022]
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Musters AM, Twisk M, Leschot NJ, Oosterwijk C, Korevaar JC, Repping S, van der Veen F, Goddijn M. Perspectives of couples with high risk of transmitting genetic disorders. Fertil Steril 2010; 94:1239-1243. [DOI: 10.1016/j.fertnstert.2009.08.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 07/20/2009] [Accepted: 08/07/2009] [Indexed: 10/20/2022]
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Treatment options and pregnancy outcome in women with idiopathic recurrent miscarriage: a randomized placebo-controlled study. Arch Gynecol Obstet 2007; 278:33-8. [PMID: 18071727 DOI: 10.1007/s00404-007-0527-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Accepted: 11/20/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare the use of enoxaparin alone with combination therapy of prednisone, aspirin and progesterone in the treatment of women with idiopathic recurrent miscarriage (IRM) in terms of live births and pregnancy outcome. METHODS A prospective, randomized, single-blinded, placebo-controlled trial was conducted at a tertiary referral obstetric hospital. The participants were 170 women with a diagnosis of IRM. Women were recruited after full investigative screening. Women with > or =3 fetal losses and after exclusion of all known causes of recurrent miscarriage were randomly allocated to receive either enoxaparin alone, combination treatment consisting of prednisone, aspirin, and progesterone or placebo. Rates of live births, antenatal complications, delivery and neonatal outcomes were recorded prospectively. Data were statistically analyzed as appropriate. RESULTS Ten patients were dropped out after random assignment. Eighty-one percent of the enoxaparin (46/57) group and 85% of the combination-treated group (45/53) were delivered of live infants compared to 48% (24/50) of the placebo (P < 0.05). Women who were treated with combination therapy had a 4.2% higher live birth rate than enoxaparin group. This difference was not significant. Miscarriage rates were significantly lower in the treated groups compared with placebo (P < 0.05). There were no significant differences in late obstetric complications or neonatal mortality between groups. CONCLUSIONS A combination treatment consisting of high-dose, low-duration prednisone, progesterone and aspirin might be an effective treatment as enoxaparin alone. Both regimens were associated with a good pregnancy outcome.
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