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Suker A, Li Y, Robson D, Marren A. Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I. Aust N Z J Obstet Gynaecol 2024. [PMID: 38934264 DOI: 10.1111/ajo.13821] [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: 09/21/2023] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.
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Affiliation(s)
- Adriana Suker
- Department of Obstetrics & Gynaecology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ying Li
- Department of Reproductive Endocrinology & Infertility, Royal Prince Alfred Hospital, Women & Babies, Sydney, New South Wales, Australia
| | - Danielle Robson
- Department of Reproductive Endocrinology & Infertility, Royal Prince Alfred Hospital, Women & Babies, Sydney, New South Wales, Australia
| | - Anthony Marren
- Department of Reproductive Endocrinology & Infertility, Royal Prince Alfred Hospital, Women & Babies, Sydney, New South Wales, Australia
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Suker A, Li Y, Robson D, Marren A. Australasian recurrent pregnancy loss clinical management guideline 2024, part II. Aust N Z J Obstet Gynaecol 2024. [PMID: 38934293 DOI: 10.1111/ajo.13820] [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: 09/28/2023] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
Part II of the Australasian guideline for the investigation and management of recurrent pregnancy loss (RPL) provides evidence-based guidance on the management of RPL provided. The implications of inherited and acquired thrombophilia with respect to RPL and suggestions for clinical management are provided. Autoimmune factors, including human leukocyte antigen, cytokines, antinuclear antibodies and coeliac antibodies, and guidance for management are discussed. Infective, inflammatory and endometrial causes of RPL are discussed in detail. Environmental and lifestyle factors, male factor and unexplained causes are outlined. Levels of evidence and grades of consensus are provided for all evidence-based statements.
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Affiliation(s)
- Adriana Suker
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ying Li
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Danielle Robson
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Anthony Marren
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Conklin MB, Wells BM, Doe EM, Strother AM, Tarasiewicz MEB, Via ER, Conrad LB, Farias-Eisner R. Understanding Health Disparities in Preeclampsia: A Literature Review. Am J Perinatol 2024; 41:e1291-e1300. [PMID: 36603833 DOI: 10.1055/a-2008-7167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Preeclampsia is a multifactorial pathology with negative outcomes in affected patients in both the peripartum and postpartum period. Black patients in the United States, when compared to their White and Hispanic counterparts, have higher rates of preeclampsia. This article aims to review the current literature to investigate how race, social determinants of health, and genetic profiles influence the prevalence and outcomes of patients with preeclampsia. Published studies utilized in this review were identified through PubMed using authors' topic knowledge and a focused search through a Medline search strategy. These articles were thoroughly reviewed to explore the contributing biosocial factors, genes/biomarkers, as well as negative outcomes associated with disparate rates of preeclampsia. Increased rates of contributing comorbidities, including hypertension and obesity, which are largely associated with low access to care in Black patient populations lead to disparate rates of preeclampsia in this population. Limited research shows an association between increased rate of preeclampsia in Black patients and specific APOL1, HLA-G, and PP13 gene polymorphisms as well as factor V Leiden mutations. Further research is required to understand the use of certain biomarkers in predicting preeclampsia within racial populations. Understanding contributing biosocial factors and identifying genes that may predispose high-risk populations may help to address the disparate rates of preeclampsia in Black patients as described in this review. Further research is required to understand if serum, placental, or urine biomarkers may be used to predict individuals at risk of developing preeclampsia in pregnancy. KEY POINTS: · Prevalence of preeclampsia in the U.S. is higher in Black patients compared to other racial groups.. · Patients with preeclampsia are at risk for poorer health outcomes both during and after delivery.. · Limited research suggests specific biomarkers or gene polymorphisms contribute to this difference; however, explanations for this disparity are multifactorial and further investigation is necessary..
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Affiliation(s)
- Mary B Conklin
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Emily M Doe
- School of Medicine, Creighton University, Omaha, Nebraska
| | | | | | - Emily R Via
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Lesley B Conrad
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
| | - Robin Farias-Eisner
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
- College of Osteopathic Medicine of the Pacific Northwest, Western University of Health Sciences, Pomona, California
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, the University of California at Los Angeles, Los Angeles, California
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Fan BE. Concerns about the ALIFE2 trial. Lancet 2024; 403:245-246. [PMID: 38245241 DOI: 10.1016/s0140-6736(23)02337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/16/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Bingwen Eugene Fan
- Department of Haematology, Tan Tock Seng Hospital, Novena 308433, Singapore; Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Wysocka U, Sałacińska K, Pinkier I, Kępczyński Ł, Ałaszewski W, Dudarewicz L, Gach A. To Test or Not to Test: Routine Thrombophilia Diagnostic Screening of Women with Reproductive Failures. J Clin Med 2023; 12:7527. [PMID: 38137596 PMCID: PMC10743545 DOI: 10.3390/jcm12247527] [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: 10/01/2023] [Revised: 11/19/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Recurrent reproductive failure is a global health issue affecting a significant number of women. Thrombophilias have been implicated as a possible cause. Inherited thrombophilias include a single nucleotide variant on factor V Leiden and prothrombin. OBJECTIVE The aim of this study was to evaluate the association between the following single nucleotide variants: factor V Leiden (c.1601G>A), the prothrombin gene (c.*97G>A) and the reproductive failure in the Polish population. METHODS The study was conducted in a group of 545 patients with recurrent pregnancy loss, RPL (≥2 miscarriages), and in a group of 641 patients with infertility. The distribution of genotypes for the selected variants were determined by RFLP-PCR and by the real-time PCR method. RESULTS A variant of the F5 gene was found in 5.14% of patients with RPL and in 6.08% of infertile women. A variant of the F2 gene was identified in 0.73% of patients with RPL and in 2.03% of women with infertility. The frequency in the study groups did not differ from that in the general population. No association between the studied variants of the F5 gene or the F2 gene and the predisposition to reproductive wastage was found. CONCLUSIONS Recommendations for routine thrombophilia testing in women with recurrent miscarriages should be revisited. The decision regarding testing should be made individually depending on additional factors indicating an increased risk of venous thromboembolism.
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Affiliation(s)
- Urszula Wysocka
- Department of Genetics, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland; (K.S.); (I.P.); (Ł.K.); (W.A.); (L.D.)
| | | | | | | | | | | | - Agnieszka Gach
- Department of Genetics, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland; (K.S.); (I.P.); (Ł.K.); (W.A.); (L.D.)
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Tomkiewicz J, Darmochwał-Kolarz D. The Diagnostics and Treatment of Recurrent Pregnancy Loss. J Clin Med 2023; 12:4768. [PMID: 37510883 PMCID: PMC10380966 DOI: 10.3390/jcm12144768] [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: 06/01/2023] [Revised: 06/21/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Recurrent pregnancy loss is a common problem in the reproductive age population of women. It can be caused by many different conditions. This problem is addressed in international guidelines that take a slightly different approach to its diagnosis and treatment. The guidelines used in this review mainly use the guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), American Society of Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE). This review shows how much the approach to miscarriages has changed and how much more needs to be explored and refined. The review also addresses the topic of unexplained pregnancy loss, which continues to be a challenge for clinicians.
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Affiliation(s)
- Julia Tomkiewicz
- Fryderyk Chopin University Hospital No 1, 35-055 Rzeszow, Poland
| | - Dorota Darmochwał-Kolarz
- Department of Obstetrics & Gynecology, Medical College, University of Rzeszow, 35-959 Rzeszow, Poland
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Yousif TYE. Prevalence of Inherited Thrombophilia in Women with Recurrent Pregnancy Loss During the First Trimester of Pregnancy. J Blood Med 2023; 14:253-259. [PMID: 37041968 PMCID: PMC10083015 DOI: 10.2147/jbm.s401469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/31/2023] [Indexed: 04/13/2023] Open
Abstract
Purpose This study aims to investigate the prevalence of inherited thrombophilia in women with recurrent pregnancy loss during the first trimester of pregnancy. The study was assessed the potential role of inherited thrombophilia in recurrent miscarriages and evaluate the consequences of this condition on the reproductive outcomes of affected women. Material and Methods This study was an analytical descriptive carried out in Khartoum, Sudan. The research comprised 98 controls who had given birth twice or more without experiencing a miscarriage and 120 patients. Each patient had done more than two miscarriages especially when the pregnancy is at its beginning trimester. (APCR), and (PS) were investigated using the clotting approach. There was an assessment of biological activities of (ATIII), (PC), and (PS) for both groups using the chromogenic method. Results The average age of the patients was 34, which was higher than the average age of the controls (33.5). The patient group had a much higher rate of multiple miscarriages among the women.: 35 (29.17%), 45 (37.50%), and 40 (33.33%). The incidence of PC deficiencies was determined to be 1.02% (1/98), whereas neither ATIII nor PS deficiencies were seen in the control group (0/98). APCR was more prevalent in the control group (4.10% or 4/98). Conclusion Despite contradicting evidence to the contrary in the literature, our findings imply that most miscarriages occur when pregnancy is at the first trimester when a woman is pregnant and they are all caused by thrombophilia.
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Affiliation(s)
- Tagwa Yousif Elsayed Yousif
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Gizan, 45142, Saudi Arabia
- Department of Medical Laboratory Sciences, College of Medical Laboratory Sciences, Alneelian university, Khartoum, Sudan
- Correspondence: Tagwa Yousif Elsayed Yousif, Email
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Pablo-Moreno JAD, Serrano LJ, Revuelta L, Sánchez MJ, Liras A. The Vascular Endothelium and Coagulation: Homeostasis, Disease, and Treatment, with a Focus on the Von Willebrand Factor and Factors VIII and V. Int J Mol Sci 2022; 23:ijms23158283. [PMID: 35955419 PMCID: PMC9425441 DOI: 10.3390/ijms23158283] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
The vascular endothelium has several important functions, including hemostasis. The homeostasis of hemostasis is based on a fine balance between procoagulant and anticoagulant proteins and between fibrinolytic and antifibrinolytic ones. Coagulopathies are characterized by a mutation-induced alteration of the function of certain coagulation factors or by a disturbed balance between the mechanisms responsible for regulating coagulation. Homeostatic therapies consist in replacement and nonreplacement treatments or in the administration of antifibrinolytic agents. Rebalancing products reestablish hemostasis by inhibiting natural anticoagulant pathways. These agents include monoclonal antibodies, such as concizumab and marstacimab, which target the tissue factor pathway inhibitor; interfering RNA therapies, such as fitusiran, which targets antithrombin III; and protease inhibitors, such as serpinPC, which targets active protein C. In cases of thrombophilia (deficiency of protein C, protein S, or factor V Leiden), treatment may consist in direct oral anticoagulants, replacement therapy (plasma or recombinant ADAMTS13) in cases of a congenital deficiency of ADAMTS13, or immunomodulators (prednisone) if the thrombophilia is autoimmune. Monoclonal-antibody-based anti-vWF immunotherapy (caplacizumab) is used in the context of severe thrombophilia, regardless of the cause of the disorder. In cases of disseminated intravascular coagulation, the treatment of choice consists in administration of antifibrinolytics, all-trans-retinoic acid, and recombinant soluble human thrombomodulin.
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Affiliation(s)
- Juan A. De Pablo-Moreno
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Javier Serrano
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Revuelta
- Department of Physiology, School of Veterinary Medicine, Complutense University of Madrid, 28040 Madrid, Spain;
| | - María José Sánchez
- Centro Andaluz de Biología del Desarrollo (CABD), Consejo Superior de Investigaciones Científicas (CSIC), Junta de Andalucía, Pablo de Olavide University, 41013 Sevilla, Spain;
| | - Antonio Liras
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
- Correspondence:
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HOUJAGHANİ S, GHORBANİ A. The association of factor V Leiden mutation (G1691A) with pregnancy complications (miscarriage) in the Iran, East Azerbaijan. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2021. [DOI: 10.33808/clinexphealthsci.742378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Padda J, Khalid K, Mohan A, Pokhriyal S, Batra N, Hitawala G, Cooper AC, Jean-Charles G. Factor V Leiden G1691A and Prothrombin Gene G20210A Mutations on Pregnancy Outcome. Cureus 2021; 13:e17185. [PMID: 34540419 PMCID: PMC8439407 DOI: 10.7759/cureus.17185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 12/12/2022] Open
Abstract
Factor V Leiden (FVL) G1619A mutation and prothrombin gene (PTG) G20210A are the most common inherited thrombophilias. They have been associated with various obstetric complications such as venous thromboembolism, recurrent pregnancy loss, preeclampsia, abruptio placentae, and small for gestational age fetus. The prevalence of these two mutations is 3-15% in Caucasians and is assumed to be far less common in other ethnic populations. However, there have been several controversies regarding advising routine screening of these thrombophilias because of a widely variable strength of association between different ethnic groups, as well as contradictory conclusions by different studies in regards to the association. In this study, the literature was analyzed thoroughly for the effect of FVL G1619A and PTG G20210A mutations on various obstetric outcomes. A review of multiple case-control and prospective studies suggests that despite the availability of robust data on this subject the results remain inconclusive and insubstantial. Further superior quality research, preferably prospective studies, is warranted to conclusively establish this relationship and to enable practitioners to follow a definitive protocol in the screening of various populations for these mutations to achieve an improved pregnancy outcome.
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Affiliation(s)
- Jaskamal Padda
- Internal Medicine, JC Medical Center, Orlando, USA
- Internal Medicine, Avalon University School of Medicine, Willemstad, CUW
| | | | - Ayushi Mohan
- Internal Medicine, JC Medical Center, Orlando, USA
| | | | - Nitya Batra
- Internal Medicine, JC Medical Center, Orlando, USA
| | | | | | - Gutteridge Jean-Charles
- Internal Medicine, JC Medical Center, Orlando, USA
- Internal Medicine, Advent Health & Orlando Health Hospital, Orlando, USA
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 187] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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12
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Alecsandru D, Klimczak AM, Garcia Velasco JA, Pirtea P, Franasiak JM. Immunologic causes and thrombophilia in recurrent pregnancy loss. Fertil Steril 2021; 115:561-566. [PMID: 33610320 DOI: 10.1016/j.fertnstert.2021.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
Certain miscarriages result from immunologic factors, but there is no clear identification of the precise causes of recurrent pregnancy loss (RPL). Miscarriages and RPL can arise from a disruption of maternal-fetal immune homeostasis. Remodeling of the maternal uterine spiral arteries is one of the key steps for normal growth and development of the fetus. An adequate oxygen supply is necessary for correct placentation, and it is accomplished by proper vascular changes. The development of fetal tissues creates a potential immunologic problem since the fetus can express paternal antigens and, in some cases, antigens of a gamete donor. The maternal immune system actively responds to fetal antigens, and dysregulation of this crosstalk could partly explain pregnancy complications such as miscarriages and RPL. RPL resulting from thrombophilia is primarily due to acquired thrombophilia, and therefore screening and treatment should be focused on antiphospholipid antibody syndrome.
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Affiliation(s)
- Diana Alecsandru
- Department of Immunology, IVI RMA Madrid, Spain; Rey Juan Carlos University, Madrid, Spain
| | | | - Juan A Garcia Velasco
- Rey Juan Carlos University, Madrid, Spain; Department of Reproductive Endocrinology and Infertility, IVI RMA Madrid; IVI Foundation, Health Research Institute La Fe, Valencia, Spain
| | - Paul Pirtea
- Department of Obstetrics and Gynecology, Hospital Foch, Paris, France.
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Bohiltea RE, Cirstoiu MM, Turcan N, Stoian AP, Zugravu CA, Munteanu O, Arsene LV, Oana B, Neacsu A, Furtunescu F. Inherited thrombophilia is significantly associated with severe preeclampsia. Exp Ther Med 2021; 21:261. [PMID: 33603868 DOI: 10.3892/etm.2021.9691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/26/2020] [Indexed: 12/27/2022] Open
Abstract
Methods to prevent the development of pathologies due to placental dysfunctions, such as gestational hypertension and preeclampsia, are the main approaches for obtaining the best maternal and fetal antepartum and postpartum prognosis. During 5 years of study (January, 2015 to December, 2019), the cases of pregnancy and puerperium complicated with pathology due to placental dysfunction were analyzed. The main objective was to determine the magnitude of the impact of thrombophilia on the development of an entity of gestational hypertension disorder. We compared the impact of thrombophilia and its associated complications in patients with gestational hypertension with moderate and severe preeclampsia. Thus, we found obesity, thrombophilia, and underlying cardiac pathology to be significant risk factors for severe preeclampsia. Regarding the comparative analysis of the risk factors and complications associated with patients with mild preeclampsia compared with those with severe preeclampsia, the presence in severe preeclampsia of thrombophilia, endocrine, liver, and cardiac pathology was higher and, a higher rate of complications was observed; complications included fetal death, intrauterine growth restriction (IUGR), prematurity, fetal arrhythmia with acute fetal distress, HELLP syndrome, and placental abruption. Thrombophilia has a significant effect on the development of severe preeclampsia, and oligohydramnios as specific complication of mild preeclampsia. Factors indicating an increased risk of progression from mild preeclampsia to severe preeclampsia are in addition to inherited thrombophilia the underlying pathologies, namely cardiac, hepatic, and endocrine factors.
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Affiliation(s)
- Roxana Elena Bohiltea
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Monica Mihaela Cirstoiu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Natalia Turcan
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Doctoral School, 020021 Bucharest, Romania
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, 'Carol Davila' University of Medicine and Pharmacy, 020475 Bucharest, Romania
| | - Corina-Aurelia Zugravu
- Department of Food Hygiene and Nutrition, 'Carol Davila' University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Octavian Munteanu
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania.,Department of Anatomy, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Luciana Valentina Arsene
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, Doctoral School, 020021 Bucharest, Romania
| | - Bodean Oana
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Adrian Neacsu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Florentina Furtunescu
- Department of Public Health and Management, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 050463 Bucharest, Romania
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Preeclampsia Among African American Pregnant Women: An Update on Prevalence, Complications, Etiology, and Biomarkers. Obstet Gynecol Surv 2020; 75:111-120. [PMID: 32105335 DOI: 10.1097/ogx.0000000000000747] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Importance Preeclampsia is a devastating disease of pregnancy associated with increased risk of fetal and maternal complications. African American pregnant women have a high prevalence of preeclampsia, but there is a need of systemic analyses of this high-risk group regarding complications, etiology, and biomarkers. Objective The aim of this study was to provide a synopsis of current research of preeclampsia specifically related to African American women. Evidence Acquisition A comprehensive search was performed in the bibliographic database PubMed with keywords "preeclampsia" and "African American." Results African American women with preeclampsia were at an increased risk of preterm birth, which resulted in low-birth-weight infants. Intrauterine fetal death among African American preeclamptic patients occurs at twice the rate as in other races. On the maternal side, African American mothers with preeclampsia have more severe hypertension, antepartum hemorrhage, and increased mortality. Those who survive preeclampsia have a high risk of postpartum cardiometabolic disease. Preexisting conditions (eg, systemic lupus erythematosus) and genetic mutations (eg, sickle cell disease in the mother, FVL or APOL1 mutations in the fetus) may contribute to the higher prevalence and worse outcomes in African American women. Many blood factors, for example, the ratio of proteins sFlt/PlGF, hormones, and inflammatory factors, have been studied as potential biomarkers for preeclampsia, but their specificity needs further investigation. Conclusions Further studies of preeclampsia among African American women addressing underlying risk factors and etiologies, coupled with identification of preeclampsia-specific biomarkers allowing early detection and intervention, will significantly improve the clinical management of this devastating disease.
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Abstract
Inherited thrombophilias are associated with an increased risk of venous thromboembolism and have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The purpose of this document is to review common thrombophilias and their association with maternal venous thromboembolism risk and adverse pregnancy outcomes, indications for screening to detect these conditions, and management options in pregnancy. This Practice Bulletin has been revised to provide additional information on recommendations for candidates for thrombophilia evaluation, updated consensus guidelines regarding the need for prophylaxis in women with an inherited thrombophilia during pregnancy and the postpartum period, and discussion of new published consensus guidelines from the Society for Obstetric Anesthesia and Perinatology addressing thromboprophylaxis and neuraxial anesthetic considerations in the obstetric population.
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16
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Uterine Radial Artery Resistance Index Predicts Reproductive Outcome in Women with Recurrent Pregnancy Losses and Thrombophilia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8787010. [PMID: 31534965 PMCID: PMC6724444 DOI: 10.1155/2019/8787010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/30/2019] [Indexed: 11/18/2022]
Abstract
Uterine radial artery resistance index (URa-RI) by Doppler ultrasound may reflect the changes in the uteroplacental circulation and be associated with adverse events in early pregnancy. Recurrent pregnancy losses (RPL) are associated with thrombophilia, and anticoagulation treatment with low molecular weight heparin improves pregnancy outcome in women with RPL and thrombophilia. A retrospective cohort study was conducted in 139 pregnant women with 3 or more RPL and thrombophilia. The relationship between pregnancy outcome and dynamic changes of URa-RI was analyzed in 116 women who delivered a liveborn infant and 23 who miscarried the index pregnancy. Patients were on preconception low molecular weight heparin, low-dose aspirin (81mg per day), and prednisone treatment. URa-RI was measured during periovulation time, at the time of positive pregnancy test, and then repeated every two weeks until 32-week gestation or the time of miscarriage. The URa-RI at 8-week gestation was significantly higher in women who miscarried the index pregnancy than those who delivered alive born infant (0.51±0.08 vs. 0.42±0.03, P<0.001). Receiver operating characteristic curve analysis demonstrated that URa-RI of 8 wk gestation effectively distinguished women who miscarried from those who had a live birth with an area under the curve of 82.6% (95% CI 69.01-97.17). After adjusting for covariates including age, BMI, and number of miscarriages, multiple logistic regression models showed that each 0.1 unit increase of URa-RI of 8 wk gestation was associated with 18.70-point increase in the risk of miscarriage (OR19.70, 95%CI 4.26-91.1, P<0.001), and women with an URa-RI≥0.45 had an OR of 49.48 (95% CI 8.01-307.95; P<0.001) for miscarriage compared to those who had URa-RI<0.45. In women with RPL and inherited thrombophilia, increased URa-RI at 8-week gestation was associated with spontaneous abortion independent of other risk factors while they were on anticoagulation treatment.
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17
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Fernández Arias M, Mazarico E, Gonzalez A, Muniesa M, Molinet C, Almeida L, Gómez Roig MD. Genetic risk assessment of thrombophilia in patients with adverse obstetric outcomes. PLoS One 2019; 14:e0211114. [PMID: 30811416 PMCID: PMC6392221 DOI: 10.1371/journal.pone.0211114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 01/08/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To investigate the incidence of inherited thrombophilias in patients with adverse obstetric outcomes and to compare detection rates of thrombophilias between standard blood tests and a novel genetic test. METHODS This is a case-control prospective study performed in Hospital Sant Joan de Déu in Barcelona, Spain. Cases had a history of intrauterine growth restriction requiring delivery before 34 weeks gestation, placental abruption before 34 weeks gestation, or severe preeclampsia. Controls had at least two normal, spontaneously conceived pregnancies at term, without complications or no underlying medical disease. At least 3 months after delivery, all case and control women underwent blood collection for standard blood tests for thrombophilias and saliva collection for the genetic test, which enables the diagnosis of 12 hereditary thrombophilias by analyzing genetic variants affecting different points of the blood coagulation cascade. RESULTS The study included 33 cases and 41 controls. There were no statistically significant differences between cases and controls in the standard blood tests for thrombophilias in plasma or the TiC test for genetic variables. One clinical-genetic model was generated using variables with the lowest P values: ABO, body mass index, C_rs5985, C_rs6025, and protein S. This model exhibited good prediction capacity, with an area under the curve of almost 0.7 (P <0.05), sensitivity of almost 67%, and specificity of 70%. CONCLUSION Although some association may exist between hypercoagulability and pregnancy outcomes, no significant direct correlation was observed between adverse obstetric outcomes and inherited thrombophilias when analyzed using either standard blood tests or the genetic test. Future studies with a larger sample size are required to create a clinical-genetic model that better discriminates women with a history of adverse pregnancy outcomes and an increased risk of poor outcomes in subsequent pregnancies.
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Affiliation(s)
- M. Fernández Arias
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
| | - E. Mazarico
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
- Maternal and Child Health and Development Network II (SAMID II) funded by Instituto de Salud Carlos III (ISCIII)—Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), Madrid, Spain
- Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain
- * E-mail:
| | - A. Gonzalez
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
| | - M. Muniesa
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
| | - C. Molinet
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
| | - L. Almeida
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
- Maternal and Child Health and Development Network II (SAMID II) funded by Instituto de Salud Carlos III (ISCIII)—Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), Madrid, Spain
- Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain
| | - M. D. Gómez Roig
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Sant Joan de Deu and Hospital Clínic), Barcelona, Spain
- Maternal and Child Health and Development Network II (SAMID II) funded by Instituto de Salud Carlos III (ISCIII)—Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), Madrid, Spain
- Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain
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Akdemir Y, Ayvaci H, Uludogan M. Effect of multiple thrombophilic gene mutations on uterine artery blood flow in nonpregnant recurrent pregnancy loss patients: are we searching enough? J Matern Fetal Neonatal Med 2019; 33:2466-2472. [PMID: 30704356 DOI: 10.1080/14767058.2019.1569618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To investigate whether multiple thrombophilic mutations had a significant effect on uterine artery blood flow of nonpregnant recurrent pregnancy loss (RPL) patients.Materials and methods: Among 71 RPL patients, FV Leiden (FV), prothrombin G20210A (PTGM) and MTHFR mutations, deficiency of protein S, protein C and antithrombin III (AT3), association of Val34Leu polymorphism of the FXIII (FXIII), 4G/5G polymorphism of plasminogen activator inhibitor (PAI), -455-G/A polymorphism of β-fibrinogen (fibrinogen), and HPA-1 a/b L33P polymorphism of GPIIIa (GPIIIa) genes were investigated. Doppler flow measurements of RPL patients and healthy controls were performed at mid-luteal phase.Results: Twenty-two patients who had no thrombophilic gene mutations were grouped as unexplained RPL. Also, while 25 patients had multiple mutations, 24 patients had single mutation. In the multiple mutation RPL group, the most frequent mutations were PAI (22%), MTHFR C677T (20%), MTHFR A1298C (19%), and fibrinogen (11%). Only in the multiple mutation RPL group, mean PI and dominant PI values were significantly higher than the control group.Conclusions: Our data showed negative effects of multiple thrombophilic gene mutations on uterine artery blood flow and clarified the different effects of single and multiple thrombophilic factors on uterine artery vasculature. It is concluded that investigating more thrombophilic mutations could ameliorate prognostic factors of RPL and interactions to improve uterine artery blood flow could bring benefit to obstetric outcome.
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Affiliation(s)
- Yesim Akdemir
- Obstetrics and Gynecology Department, Bulent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Habibe Ayvaci
- Perinatology Department, Zeynep Kamil Women and Children's Training and Research Hospital, Istanbul, Turkey
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19
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Tran JP, Stribling SS, Ibezim UC, Omere C, McEnery KA, Pacheco LD, Hankins GD, Saade GR, Saad AF. Performance of Risk Assessment Models for Peripartum Thromboprophylaxis. Reprod Sci 2018; 26:1243-1248. [DOI: 10.1177/1933719118813197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period. Study Design: This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant. Results: A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini. Conclusion: The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.
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Affiliation(s)
- Jacquelynn P. Tran
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Shelby S. Stribling
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Uloma C. Ibezim
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Chasey Omere
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Kayla A. McEnery
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Luis D. Pacheco
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Anesthesia, The University of Texas Medical Branch, Galveston, TX, USA
| | - Gary D. Hankins
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA
| | - George R. Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Antonio F. Saad
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Anesthesia, The University of Texas Medical Branch, Galveston, TX, USA
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20
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Homer HA. Modern management of recurrent miscarriage. Aust N Z J Obstet Gynaecol 2018; 59:36-44. [DOI: 10.1111/ajo.12920] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Hayden Anthony Homer
- Christopher Chen Oocyte Biology Research Laboratory, UQ Centre for Clinical Research; The University of Queensland; Brisbane Queensland Australia
- Reproductive Endocrinology & Infertility Clinic; Royal Brisbane & Women's Hospital; Brisbane Queensland Australia
- Queensland Fertility Group and Eve Health; Brisbane Queensland Australia
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21
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Workalemahu T, Enquobahrie DA, Gelaye B, Sanchez SE, Garcia PJ, Tekola-Ayele F, Hajat A, Thornton TA, Ananth CV, Williams MA. Genetic variations and risk of placental abruption: A genome-wide association study and meta-analysis of genome-wide association studies. Placenta 2018; 66:8-16. [PMID: 29884306 PMCID: PMC5995331 DOI: 10.1016/j.placenta.2018.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Accumulating epidemiological evidence points to strong genetic susceptibility to placental abruption (PA). However, characterization of genes associated with PA remains incomplete. We conducted a genome-wide association study (GWAS) of PA and a meta-analysis of GWAS. METHODS Participants of the Placental Abruption Genetic Epidemiology (PAGE) study, a population based case-control study of PA conducted in Lima, Peru, were genotyped using the Illumina HumanCore-24 BeadChip platform. Genotypes were imputed using the 1000 genomes reference panel, and >4.9 million SNPs that passed quality control were analyzed. We performed a GWAS in PAGE participants (507 PA cases and 1090 controls) and a GWAS meta-analysis in 2512 participants (959 PA cases and 1553 controls) that included PAGE and the previously reported Peruvian Abruptio Placentae Epidemiology (PAPE) study. We fitted population stratification-adjusted logistic regression models and fixed-effects meta-analyses using inverse-variance weighting. RESULTS Independent loci (linkage-disequilibrium<0.80) suggestively associated with PA (P-value<5e-5) included rs4148646 and rs2074311 in ABCC8, rs7249210, rs7250184, rs7249100 and rs10401828 in ZNF28, rs11133659 in CTNND2, and rs2074314 and rs35271178 near KCNJ11 in the PAGE GWAS. Similarly, independent loci suggestively associated with PA in the GWAS meta-analysis included rs76258369 near IRX1, and rs7094759 and rs12264492 in ADAM12. Functional analyses of these genes showed trophoblast-like cell interaction, as well as networks involved in endocrine system disorders, cardiovascular diseases, and cellular function. CONCLUSIONS We identified several genetic loci and related functions that may play a role in PA risk. Understanding genetic factors underlying pathophysiological mechanisms of PA may facilitate prevention and early diagnostic efforts.
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Affiliation(s)
- Tsegaselassie Workalemahu
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA; Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA; Center for Perinatal Studies, Swedish Medical Center, Seattle, WA, USA
| | - Bizu Gelaye
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sixto E Sanchez
- Facultad de Medicina Humana, Universidad San Martín de Porres, Lima, Peru; Asociación Civil PROESA, Lima, Peru; Instituto Nacional Materno Perinatal, Lima, Peru
| | | | - Fasil Tekola-Ayele
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Anjum Hajat
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | | | - Cande V Ananth
- Department of Obstetrics and Gynecology, Roy and Diana Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
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Dłuski D, Mierzyński R, Poniedziałek-Czajkowska E, Leszczyńska-Gorzelak B. Adverse pregnancy outcomes and inherited thrombophilia. J Perinat Med 2018; 46:411-417. [PMID: 28792912 DOI: 10.1515/jpm-2017-0059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/30/2017] [Indexed: 11/15/2022]
Abstract
AIM (1) To evaluate the prevalence of inherited thrombophilia in pregnant women with adverse pregnancy outcomes: intrauterine growth retardation (IUGR), preeclampsia (PE) and placental abruption. (2) To assess the impact of inherited thrombophilia on the nature of obstetric complications. (3) To assess levels of protein S, protein C, antithrombin III and homocysteine in pregnant women with adverse pregnancy outcomes. SUBJECTS AND METHODS The study comprised 162 pregnant women. The patients were divided into three test groups and one control group. In all 162 patients the following tests were completed: activated protein C resistance (APC-R), the level of free protein S, activity of protein C, antithrombin III and the level of homocysteine. The data were statistically analyzed via χ2 of independence or homogeneity test. RESULTS In 32 of 162 patients participating in clinical research thrombophilia was diagnosed (10 patients with APC-R, 21 patients with protein S deficiency, one patient with hyperhomocysteinemia): seven patients belonged to the control group and 25 patients had diagnosed adverse pregnancy outcomes (P=0.04). In 32 patients with diagnosed thrombophilia, level of protein S was decreased (P=0.04). Protein S deficiency was diagnosed, when level of protein S was lower than 30% in the second trimester and lower than 24% in the third trimester. The incidence of activated protein C resistance caused by the mutation of factor V Leiden was in six patients (5.9%) with adverse pregnancy outcomes, and in four patients (6.6%) from the control group. Results were not statistically significant. No protein C deficiency was diagnosed (diagnosis: level<60%), but in 50% of patients with thrombophilia level of protein C was over the norm (P=0.02). The level of antithrombin III was often decreased in patients with preeclampsia - (32.4%), then in the other patients - (17.2%) (P=0.04), but no patient was diagnosed with antithrombin III deficiency (diagnosis: level<60%). CONCLUSIONS Tests for thrombophilia should be carried out in women with adverse pregnancy outcomes in their history, who are planning pregnancy, to start anticoagulant prophylaxis. Our study supports the thesis that tests for thrombophilia should be carried out in women with a history of adverse pregnancy outcomes and who are planning a pregnancy to start anticoagulant prophylaxis.
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Affiliation(s)
- Dominik Dłuski
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Street: Jaczewskiego 8, 20-954 Lublin, Poland
| | - Radzisław Mierzyński
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Lublin, Poland
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Kardi MT, Yousefian E, Allahveisi A, Alaee S. Association of Factor V Leiden and Prothrombin G20210A Polymorphisms in Women with Recurrent Pregnancy Loss in Isfahan Province, Iran. Int J Prev Med 2018. [PMID: 29541428 PMCID: PMC5843958 DOI: 10.4103/ijpvm.ijpvm_240_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Maternal thrombophilia has been identified as a risk factor for recurrent pregnancy loss (RPL). The aim of this study was to investigate the association between prothrombin G20210A and factor V Leiden (FVL) polymorphisms in women with RPL and a control group of parous women in Isfahan province of Iran. Methods: We studied 250 women with idiopathic RPL and 116 control cases. Prothrombin and FVL different genotypes were determined using polymerase chain reaction and reverse hybridization technique. Results: The frequencies of heterozygous mutation prothrombin G20210A were 6% and 0.9%, respectively (P = 0.025), in cases compared to the control group. The frequencies of homozygous mutation prothrombin G20210A were 0.4% and 0%, respectively, in cases compared to controls (P = 0.02). The prothrombin mutation was significantly higher in cases compared to the control group (odds ratio 8.81; 95% confidence interval: 1.16–66.62). There was no significant difference between the FVL mutation and pregnancy loss. Conclusions: The results indicated a significant higher frequency of prothrombin G20210A in women with RPL in comparison with controls. Our data suggest that the prothrombin G20210A mutation, but not the FVL mutation, may be an unrecognized cause of RPL in our population.
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Affiliation(s)
- Mohammad Taghi Kardi
- Department of Biology, Faculty of Sciences, University of Isfahan, Isfahan, Iran
| | - Elham Yousefian
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azra Allahveisi
- Department of Anatomy, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Sanaz Alaee
- Department of Reproductive Biology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
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Hemsworth EM, O'Reilly AM, Allen VM, Kuhle S, Brock JAK. Association Between Factor V Leiden Mutation, Small for Gestational Age, and Preterm Birth: A Systematic Review and Meta-Analysis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 38:897-908. [PMID: 27720088 DOI: 10.1016/j.jogc.2016.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/24/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the association of a maternal factor V Leiden (FVL) mutation with SGA and preterm birth. DATA SOURCES We performed a search of PubMed, Embase, Scopus, CINAHL, and the Cochrane Library from inception to April 2016 for cohort and case-control studies of women with FVL mutation and associated outcomes of SGA and preterm birth that included a reference group without FVL mutation. Additional studies were identified from reference lists of relevant research and review articles. STUDY SELECTION Two authors (JKB, AMO) independently examined the abstracts of the potentially eligible studies, and full texts of eligible studies were retrieved for further evaluation. Disagreements were resolved by consensus. We identified 42 studies suitable for inclusion in the meta-analysis. DATA EXTRACTION Thirty-two studies evaluated SGA, and 18 studies assessed preterm birth. Study quality was assessed using the Newcastle Ottawa Scale. A random effects model with inverse variance weighting was used to calculate pooled ORs and 95% CIs. Subgroup analyses were performed by study design. DATA SYNTHESIS The overall OR associating FVL mutation with SGA was significant (OR 1.40, 95% CI 1.18 to 1.67). Analysis of 13 cohort studies resulted in an OR of 1.20 (95% CI 1.03 to 1.41), and data from 19 case-control studies yielded an OR of 1.86 (95% CI 1.35 to 2.56). There was no significant association between FVL mutation and preterm birth (OR 1.17, 95% CI 1.00 to 1.37) when all groups were studied, but the association was significant for case-control studies alone (OR 1.40, 95% CI 1.05 to 1.86). CONCLUSION There is an increased risk for SGA in pregnancies complicated by FVL mutation in both cohort and case-control study designs. The risk of preterm birth with FVL mutation is less clear, although there is conflicting evidence from cohort and case-control studies regarding the risk of preterm birth associated with FVL mutation.
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Affiliation(s)
- Erin M Hemsworth
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax NS
| | - Amanda M O'Reilly
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax NS
| | - Victoria M Allen
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax NS
| | - Stefan Kuhle
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax NS; Department of Pediatrics, Dalhousie University, Halifax NS
| | - Jo-Ann K Brock
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax NS
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Baptista FS, Bortolotto MRDFL, Bianchini FRM, Krebs VLJ, Zugaib M, Francisco RPV. Can thrombophilia worsen maternal and perinatal outcomes in cases of severe preeclampsia? Pregnancy Hypertens 2018. [DOI: 10.1016/j.preghy.2017.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Croles FN, Nasserinejad K, Duvekot JJ, Kruip MJ, Meijer K, Leebeek FW. Pregnancy, thrombophilia, and the risk of a first venous thrombosis: systematic review and bayesian meta-analysis. BMJ 2017; 359:j4452. [PMID: 29074563 PMCID: PMC5657463 DOI: 10.1136/bmj.j4452] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To provide evidence to support updated guidelines for the management of pregnant women with hereditary thrombophilia in order to reduce the risk of a first venous thromboembolism (VTE) in pregnancy.Design Systematic review and bayesian meta-analysis.Data sources Embase, Medline, Web of Science, Cochrane Library, and Google Scholar from inception through 14 November 2016.Review methods Observational studies that reported on pregnancies without the use of anticoagulants and the outcome of first VTE for women with thrombophilia were eligible for inclusion. VTE was considered established if it was confirmed by objective means, or when the patient had received a full course of a full dose anticoagulant treatment without objective testing. Results 36 studies were included in the meta-analysis. All thrombophilias increased the risk for pregnancy associated VTE (probabilities ≥91%). Regarding absolute risks of pregnancy associated VTE, high risk thrombophilias were antithrombin deficiency (antepartum: 7.3%, 95% credible interval 1.8% to 15.6%; post partum: 11.1%, 3.7% to 21.0%), protein C deficiency (antepartum: 3.2%, 0.6% to 8.2%; post partum: 5.4%, 0.9% to 13.8%), protein S deficiency (antepartum: 0.9%, 0.0% to 3.7%; post partum: 4.2%; 0.7% to 9.4%), and homozygous factor V Leiden (antepartum: 2.8%, 0.0% to 8.6%; post partum: 2.8%, 0.0% to 8.8%). Absolute combined antepartum and postpartum risks for women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutations, or compound heterozygous factor V Leiden and prothrombin G20210A mutations were all below 3%. Conclusions Women with antithrombin, protein C, or protein S deficiency or with homozygous factor V Leiden should be considered for antepartum or postpartum thrombosis prophylaxis, or both. Women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation, or compound heterozygous factor V Leiden and prothrombin G20210A mutation should generally not be prescribed thrombosis prophylaxis on the basis of thrombophilia and family history alone. These data should be considered in future guidelines on pregnancy associated VTE risk.
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Affiliation(s)
- F Nanne Croles
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Marieke Jha Kruip
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Centre, University of Groningen, Groningen, Netherlands
| | - Frank Wg Leebeek
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
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El Hachem H, Crepaux V, May-Panloup P, Descamps P, Legendre G, Bouet PE. Recurrent pregnancy loss: current perspectives. Int J Womens Health 2017; 9:331-345. [PMID: 28553146 PMCID: PMC5440030 DOI: 10.2147/ijwh.s100817] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.
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Affiliation(s)
- Hady El Hachem
- Department of Reproductive Medicine, Ovo Clinic, Montréal, QC, Canada.,Department of Obstetrics and Gynecology, University of Montreal, Montréal, QC, Canada
| | - Vincent Crepaux
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Biology, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
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Frequency of Thrombophilic Gene Mutations in Patients with Deep Vein Thrombosis and in Women with Recurrent Pregnancy Loss. Open Life Sci 2017. [DOI: 10.1515/biol-2017-0019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractThrombophilia may be anticipated by single or combined hereditary defects in encoding genes factor V, Prothrombin, and MTHFR. The aim of this study was to determine the prevalence and associated risks of V Leiden (G1691A), Prothrombin (G20210A), and MTHFR (C677T) mutations in Saudi women with Deep Vein Thrombosis (DVT) and women with recurrent pregnancy loss (RPL). Protein C and protein S activity were measured to determine combined effects, if any. We examined 60 women with a history of DVT and 60 with RPL, extracted DNA from EDTA blood and determined three mutations by using multiplex PCR reactions followed by Strip Assay KIT. Pro C Global assay was used to determine the cutoff value [PCATNR = 0.80]. Protein C/S chromogenic assay was used to estimate protein C and S percentages. Frequency of Factor V Leiden G/A genotype in patients with DVT 7 (11.6%) had a significant association for DVT χ2 (OR = 5.1, P = 0.03). In women with RPL the three mutations did not show any significant association, levels of Protein C, protein S and PCAT-NR in patient groups not different from controls (P > 0.05). In conclusion, we recommend expanding on these data to provide larger-scale studies.
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Mendez-Figueroa H, Truong VTT, Pedroza C, Khan AM, Chauhan SP. Small-for-gestational-age infants among uncomplicated pregnancies at term: a secondary analysis of 9 Maternal-Fetal Medicine Units Network studies. Am J Obstet Gynecol 2016; 215:628.e1-628.e7. [PMID: 27372269 DOI: 10.1016/j.ajog.2016.06.043] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most small (birthweight <10%) for-gestational-age cases occur at term, in uncomplicated pregnancies, and are not identified during prenatal visits as having fetal growth restriction. Hence, they do not benefit from antepartum surveillance and timed delivery. There is dismissive and disquieting opinion that small for gestational age among uncomplicated pregnancies is not associated with increased morbidities and, therefore, does not warrant improved detection. Our hypothesis was that among uncomplicated pregnancies at term, small for gestational age have significantly higher morbidity and mortality than appropriate (birthweight 10-89%) for gestational age. OBJECTIVE We sought to compare composite neonatal morbidity among uncomplicated term singleton pregnancies with small vs appropriate for gestational age. STUDY DESIGN We culled collected data from 9 completed Maternal-Fetal Medicine Units studies conducted from 1989 through 2004. All data were collected prospectively by trained staff. We excluded women who delivered <37 weeks and those with hypertension or diabetes, multiple gestation, known anomalies, and birthweight of ≥90% for gestational age. Using multivariable analysis, we compared composite neonatal morbidity, which included stillbirth and neonatal mortality between small and appropriate for gestational age. Random effect logistic regressions were used to account for study heterogeneity, with adjustment for potential confounders. We calculated adjusted odds ratios and 95% confidence intervals. RESULTS Of the >91,000 women enrolled in the studies, 60% (n = 50,011) met the inclusion criteria. Among the uncomplicated pregnancies, 10.8% (n = 5416) were small for gestational age. The rate of composite neonatal morbidity of 16% in small for gestational age and 10% in appropriate for gestational age persisted (adjusted odds ratio, 1.75; 95% confidence interval, 1.71-1.78). After adjustment for confounders, the following neonatal morbidities were significantly more common among term small than appropriate for gestational age: Apgar <4 at 5 minutes, respiratory distress syndrome, mechanical ventilation, necrotizing enterocolitis grade 2 or 3, and neonatal sepsis. Lastly, rate of stillbirths (3.5 vs 0.9/1000 births; adjusted odds ratio, 3.49; 95% confidence interval, 1.83-6.67) and neonatal mortality (1.1 vs 0.4/1000 births; adjusted odds ratio, 2.56; 95% confidence interval, 1.83-3.57) were significantly more common with small than appropriate for gestational age. In secondary analyses the composite neonatal morbidity among newborns at <5% and at 5-9% was significantly higher than appropriate for gestational age. Lastly, in subgroup analyses of women who delivered at 37.0-38.6 weeks or at ≥39.0 weeks, the increased rate of composite neonatal morbidity, stillbirth, and neonatal mortality among small for gestational age persisted. CONCLUSION Among uncomplicated pregnancies at term, small- compared to appropriate-for-gestational-age newborns have a significantly higher likelihood of composite neonatal morbidity, stillbirth, and neonatal mortality. A large multicenter trial is warranted to determine if improved detection of small for gestational age among uncomplicated pregnancies can mitigate morbidities and mortality, without disproportionate interventions and iatrogenic complications.
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Sibai BM, Rouse DJ. Pharmacologic Thromboprophylaxis in Obstetrics: Broader Use Demands Better Data. Obstet Gynecol 2016; 128:681-4. [PMID: 27607853 PMCID: PMC5035205 DOI: 10.1097/aog.0000000000001656] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Baha M. Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences UT Health- University of Texas Medical School at Houston
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Silver RM, Saade GR, Thorsten V, Parker CB, Reddy UM, Drews-Botsch C, Conway D, Coustan D, Dudley DJ, Bukowski R, Rowland Hogue CJ, Pinar H, Varner MW, Goldenberg R, Willinger M. Factor V Leiden, prothrombin G20210A, and methylene tetrahydrofolate reductase mutations and stillbirth: the Stillbirth Collaborative Research Network. Am J Obstet Gynecol 2016; 215:468.e1-468.e17. [PMID: 27131585 DOI: 10.1016/j.ajog.2016.04.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND An evaluation for heritable thrombophilias is recommended in the evaluation of stillbirth. However, the association between thrombophilias and stillbirth remains uncertain. OBJECTIVE We sought to assess the association between maternal and fetal/placental heritable thrombophilias and stillbirth in a population-based, case-control study in a geographically, racially, and ethnically diverse population. STUDY DESIGN We conducted secondary analysis of data from the Stillbirth Collaborative Research Network, a population-based case-control study of stillbirth. Testing for factor V Leiden, prothrombin G20210A, methylene tetrahydrofolate reductase C677T and A1298C, and plasminogen activating inhibitor (PAI)-1 4G/5G mutations was done on maternal and fetal (or placental) DNA from singleton pregnancies. Data analyses were weighted for oversampling and other aspects of the design. Odds ratios (OR) were generated from univariate models regressing stillbirth/live birth status on each thrombophilia marker. RESULTS Results were available for ≥1 marker in 488 stillbirths and 1342 live birth mothers and 405 stillbirths and 990 live birth fetuses. There was an increased odds of stillbirth for maternal homozygous factor V Leiden mutation (2/488; 0.4% vs 1/1380; 0.0046%; OR, 87.44; 95% confidence interval, 7.88-970.92). However, there were no significant differences in the odds of stillbirth for any other maternal thrombophilia, even after stratified analyses. Fetal 4G/4G PAI-1 (OR, 0.63; 95% confidence interval, 0.43-0.91) was associated with decreased odds of stillbirth. Other fetal thrombophilias were similar among groups. CONCLUSION Most maternal and fetal thrombophilias were not associated with stillbirth. Maternal factor V Leiden was weakly associated with stillbirth, and the fetal PAI-1 4G/4G polymorphism was associated with live birth. Our data do not support routine testing for heritable thrombophilias as part of an evaluation for possible causes of stillbirth.
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Dixon SG, Bruce CT, Glueck CJ, Sisk RA, Hutchins RK, Jetty V, Wang P. Retinal vascular occlusion: a window to diagnosis of familial and acquired thrombophilia and hypofibrinolysis, with important ramifications for pregnancy outcomes. Clin Ophthalmol 2016; 10:1479-86. [PMID: 27563233 PMCID: PMC4984829 DOI: 10.2147/opth.s106969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim Our specific aim was to document the pathoetiologic importance of thrombophilia among females presenting with severe ischemic retinal vein (RVO) or retinal artery (RAO) occlusion, without typical risk factors, and to emphasize that the ophthalmologists’ diagnosis of thrombophilia has important diagnostic and therapeutic downstream ramifications for nonocular thrombosis, including reproductive outcomes. Methods We evaluated familial and acquired thrombophilia in 60 females with RVO (central RVO, n=52; branch RVO, n=8) and 16 with RAO (central RAO, n=11; branch RAO, n=5). They were referred by retinologists, without typical risk factors for RVO/RAO and/or severe ocular ischemic presentation. We focused on extraocular thrombotic events, particularly pregnancy complications, including unexplained spontaneous abortion, pre-eclampsia–eclampsia. Thrombophilia measurements in the 76 females were compared with 62 healthy normal females without ocular vascular occlusions (OVOs). Results The 76 females with OVO were more likely than 62 normal female controls to have high homocysteine (24% vs 0%, P<0.0001), high anticardiolipin antibody (immunoglobulin M, 17% vs 3%, P=0.012), high (>150%) factor VIII (42% vs 11%, P<0.0001), and high (>150%) factor XI (22% vs 4%, P=0.004). Of the 76 females, 26 (34%) had ≥1 spontaneous abortion; 17 (22%) had ≥2 spontaneous abortions and/or pre-eclampsia–eclampsia. Compared to 62 healthy female controls, these 17 females with pregnancy complications had high homocysteine (29% vs 0%, P=0.0003), high anticardiolipin antibody immunoglobulin M (24% vs 3%, P=0.02), high factor VIII (38% vs 11%, P=0.02), and were marginally more likely to be heterozygous for the factor V Leiden mutation (19% vs 3%, P=0.058). Conclusion In females lacking typical risk factors for retinal vascular occlusion or severely ischemic presentation, by diagnosing thrombophilia as an etiology for OVO, the ophthalmologist opens a window to family screening and preventive therapy, with particular relevance to pregnancy outcomes and venous thromboembolism.
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Affiliation(s)
- Stephan G Dixon
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Carl T Bruce
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Robert A Sisk
- Cincinnati Eye Institute; Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert K Hutchins
- Cincinnati Eye Institute; Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vybhav Jetty
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
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Leaf RK, Connors JM. The Role of Anticoagulants in the Prevention of Pregnancy Complications. Clin Appl Thromb Hemost 2016; 23:116-123. [DOI: 10.1177/1076029615615972] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The role of anticoagulants in the prevention of pregnancy complications, including recurrent miscarriage, late fetal loss, and preeclampsia, continues to be an area of active research and debate. Although prophylactic anticoagulation with heparin and aspirin is considered the standard of care in some conditions, such as obstetric antiphospholipid antibody syndrome, the optimal management of pregnant women with factor V Leiden mutation, prothrombin G20210A mutation, and other inherited thrombophilias without a history of thrombosis remains unknown. Some studies suggest a benefit of heparins in preventing late-term losses but not earlier miscarriages in the inherited thrombophilias. In the following review, we will discuss the recent literature regarding anticoagulation and pregnancy complications and conclude with our suggested approach to the management of these challenging patients.
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Affiliation(s)
- Rebecca Karp Leaf
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA, USA
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Perez Botero J, Ormsby WD, Ashrani AA, McBane RD, Wysokinski WE, Patnaik MM, Lewis BR, Grill DE, Pruthi RK, Heit JA. Do incident and recurrent venous thromboembolism risks truly differ between heterozygous and homozygous Factor V Leiden carriers? A retrospective cohort study. Eur J Intern Med 2016; 30:77-81. [PMID: 26970916 DOI: 10.1016/j.ejim.2016.02.023] [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] [Received: 01/06/2016] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION While Factor V Leiden (F5 rs6025 A allele) is a known venous thromboembolism (VTE) risk factor, VTE risk among heterozygous vs. homozygous carriers is uncertain. MATERIALS AND METHODS In a retrospective cohort study of Mayo Clinic patients referred for genotyping between 1996 and 2013, we tested Factor V Leiden genotype as a risk factor for incident and recurrent VTE. RESULTS Among heterozygous (n=268) and homozygous (n=111) carriers, the prevalence of VTE was 54% and 68%, respectively (p=0.016). While mean patient age at first VTE event (43.9 vs. 42.9years; p=0.70) did not differ significantly, median VTE-free survival was modestly shorter for homozygous carriers (56.8 vs 59.5 years; p=0.04). Sixty-nine (48%) and 31 (42%) heterozygous and homozygous carriers had ≥1 VTE recurrence (p=0.42). In a multivariable model, idiopathic incident VTE and a second thrombophilia were associated with increased and anticoagulation duration >6months with reduced hazards of VTE recurrence; Factor V Leiden genotype was not an independent predictor of recurrence. CONCLUSIONS Aside from a higher VTE prevalence and modestly reduced VTE-free survival, VTE penetrance and phenotype severity did not differ significantly among homozygous vs. heterozygous carriers, suggesting that VTE prophylaxis and management should not differ by Factor V Leiden genotype.
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Affiliation(s)
- J Perez Botero
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA.
| | - W D Ormsby
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA
| | - A A Ashrani
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA
| | - R D McBane
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - W E Wysokinski
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - M M Patnaik
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA
| | - B R Lewis
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - D E Grill
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - R K Pruthi
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA
| | - J A Heit
- Division of Hematology, Department of Medicine Mayo Clinic, Rochester, MN, USA; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Brookfield KF, O’Malley K, El-Sayed YY, Blumenfeld YJ, Butwick AJ. Does Time of Delivery Influence the Risk of Neonatal Morbidity? Am J Perinatol 2016; 33:502-9. [PMID: 26595143 PMCID: PMC4821785 DOI: 10.1055/s-0035-1567891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine whether time of delivery influences the risk of neonatal morbidity among women with singleton pregnancies. STUDY DESIGN Secondary analysis of data from the Maternal Fetal Medicine Units Network Factor V Leiden Mutation study. We categorized time of delivery as day (07:00-16:59), evening (17:00-23:59), and overnight (midnight-06:59). Severe neonatal morbidity was defined by at least one of the following: respiratory distress syndrome, transient tachypnea of the newborn, sepsis, seizures, neonatal intensive care admission, or a 5-minute APGAR ≤3. We calculated frequencies of severe neonatal morbidity by time of delivery. Multivariate analysis was performed to determine whether time of delivery was independently associated with severe neonatal morbidity. RESULTS Among 4,087 women, 1,917 (46.9%) delivered during the day, 1,140 (27.9%) delivered in the evening, and 1,030 (25.2%) delivered overnight. We observed no significant differences in the rates of neonatal morbidity between delivery time periods (day: 12.3%; evening: 12.8%; overnight: 12.6%; p = 0.9). No significant association was observed between time of delivery and neonatal morbidity after adjustment for maternal, obstetric, and peripartum factors. CONCLUSION Our findings suggest that time of delivery is not associated with severe neonatal morbidity.
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Affiliation(s)
- Kathleen F. Brookfield
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Katharine O’Malley
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Yasser Y. El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Yair J. Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Alexander J. Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Abstract
Recurrent pregnancy loss (RPL) is a multifactorial condition. Approximately half of patients with RPL will have no explanation for their miscarriages. De novo chromosome abnormalities are common in sporadic and recurrent pregnancy loss. Testing for embryonic abnormalities can provide an explanation for the miscarriage in many cases and prognostic information. Regardless of the cause of RPL, patients should be reassured that the prognosis for live birth with an evidence-based approach is excellent for most patients. The authors review current evidence for the evaluation and treatment of RPL and explore the proposed use of newer technology for patients with RPL.
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Toth B, Würfel W, Bohlmann MK, Gillessen-Kaesbach G, Nawroth F, Rogenhofer N, Tempfer C, Wischmann T, von Wolff M. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG (S1-Level, AWMF Registry No. 015/050, December 2013). Geburtshilfe Frauenheilkd 2015; 75:1117-1129. [PMID: 26997666 DOI: 10.1055/s-0035-1558299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Purpose: Official guideline coordinated and published by the German Society of Gynecology and Obstetrics (DGGG). Aim of the guideline was to standardize the diagnosis and treatment of patients with recurrent miscarriage (RM). Recommendations were proposed, based on the current national and international literature and the experience of the involved physicians. Consistent definitions, objective assessments and standardized therapy were applied. Methods: Members of the different involved societies developed a consensus in an informal process based on the current literature. The consensus was subsequently approved by the heads of the scientific societies. Recommendations: Recommendations for the diagnosis and treatment of patients with RM were compiled which took the importance of established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders into consideration.
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Affiliation(s)
- B Toth
- Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Universitätsfrauenklinik Heidelberg, Heidelberg
| | - W Würfel
- Kinderwunsch Centrum München-Pasing, München
| | - M K Bohlmann
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Mannheim, Mannheim
| | | | - F Nawroth
- Facharzt-Zentrum für Kinderwunsch, Pränatale Medizin, Endokrinologie und Osteologie, Hamburg
| | - N Rogenhofer
- Hormon und Kinderwunschzentrum der Ludwig-Maximilians-Universität München, München
| | - C Tempfer
- Universitätsfrauenklinik der Ruhr-Universität Bochum, Marienhospital Herne, Herne
| | - T Wischmann
- Institut für Medizinische Psychologie im Zentrum für Psychosoziale Medizin des Universitätsklinikums Heidelberg, Heidelberg
| | - M von Wolff
- Inselspital, Universitätsfrauenklinik, Abteilung Gynäkologische Endokrinologie und Reproduktionsmedizin, Bern, Switzerland
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Aberrant maternal inflammation as a cause of pregnancy complications: A potential therapeutic target? Placenta 2015; 36:960-6. [DOI: 10.1016/j.placenta.2015.05.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/12/2015] [Accepted: 05/25/2015] [Indexed: 12/17/2022]
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Abstract
Human reproduction is remarkably inefficient; nearly 70% of human conceptions do not survive to live birth. Spontaneous fetal aneuploidy is the most common cause for spontaneous loss, particularly in the first trimester of pregnancy. Although losses owing to de novo fetal aneuploidy occur at similar frequencies among women with sporadic and recurrent losses, some couples with recurrent pregnancy loss have additional associated genetic factors and some have nongenetic etiologies. Genetic testing of the products of conception from couples experiencing two or more losses may aid in defining the underlying etiology and in counseling patients about prognosis in a subsequent pregnancy. Parental karyotyping of couples who have experienced recurrent pregnancy loss (RPL) will detect some couples with an increased likelihood of recurrent fetal aneuploidy; this may direct interventions. The utility of preimplantation genetic analysis in couples with RPL is unproven, but new approaches to this testing show great promise.
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Affiliation(s)
- Kassie J Hyde
- University of Missouri School of Medicine, Columbia, Missouri 65201
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri School of Medicine, Columbia, Missouri 65201
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Denis M, Enquobahrie DA, Tadesse MG, Gelaye B, Sanchez SE, Salazar M, Ananth CV, Williams MA. Placental genome and maternal-placental genetic interactions: a genome-wide and candidate gene association study of placental abruption. PLoS One 2014; 9:e116346. [PMID: 25549360 PMCID: PMC4280220 DOI: 10.1371/journal.pone.0116346] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/08/2014] [Indexed: 01/02/2023] Open
Abstract
While available evidence supports the role of genetics in the pathogenesis of placental abruption (PA), PA-related placental genome variations and maternal-placental genetic interactions have not been investigated. Maternal blood and placental samples collected from participants in the Peruvian Abruptio Placentae Epidemiology study were genotyped using Illumina's Cardio-Metabochip platform. We examined 118,782 genome-wide SNPs and 333 SNPs in 32 candidate genes from mitochondrial biogenesis and oxidative phosphorylation pathways in placental DNA from 280 PA cases and 244 controls. We assessed maternal-placental interactions in the candidate gene SNPS and two imprinted regions (IGF2/H19 and C19MC). Univariate and penalized logistic regression models were fit to estimate odds ratios. We examined the combined effect of multiple SNPs on PA risk using weighted genetic risk scores (WGRS) with repeated ten-fold cross-validations. A multinomial model was used to investigate maternal-placental genetic interactions. In placental genome-wide and candidate gene analyses, no SNP was significant after false discovery rate correction. The top genome-wide association study (GWAS) hits were rs544201, rs1484464 (CTNNA2), rs4149570 (TNFRSF1A) and rs13055470 (ZNRF3) (p-values: 1.11e-05 to 3.54e-05). The top 200 SNPs of the GWAS overrepresented genes involved in cell cycle, growth and proliferation. The top candidate gene hits were rs16949118 (COX10) and rs7609948 (THRB) (p-values: 6.00e-03 and 8.19e-03). Participants in the highest quartile of WGRS based on cross-validations using SNPs selected from the GWAS and candidate gene analyses had a 8.40-fold (95% CI: 5.8-12.56) and a 4.46-fold (95% CI: 2.94-6.72) higher odds of PA compared to participants in the lowest quartile. We found maternal-placental genetic interactions on PA risk for two SNPs in PPARG (chr3:12313450 and chr3:12412978) and maternal imprinting effects for multiple SNPs in the C19MC and IGF2/H19 regions. Variations in the placental genome and interactions between maternal-placental genetic variations may contribute to PA risk. Larger studies may help advance our understanding of PA pathogenesis.
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Affiliation(s)
- Marie Denis
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America; UMR AGAP (Amélioration Génétique et Adaptation des Plantes méditerranéennes et tropicales), CIRAD, Montpellier, France
| | - Daniel A Enquobahrie
- Center for Perinatal Studies, Swedish Medical Center, Seattle, Washington, United States of America; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Mahlet G Tadesse
- Department of Mathematics and Statistics, Georgetown University, Washington, D.C., United States of America
| | - Bizu Gelaye
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Sixto E Sanchez
- Sección de Post Grado, Facultad de Medicina Humana, Universidad San Martín de Porres, Lima, Peru; A.C. PROESA, Lima, Peru
| | - Manuel Salazar
- Department of Obstetrics and Gynecology, San Marcos University, Lima, Peru
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, United States of America; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Michelle A Williams
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
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Mazzucconi MG, De Sanctis V, Alfò M, Amendolea MA, Conti L, Santoro C, Baldacci E, Peraino M, Masala C. Maternal thrombophilia and adverse pregnancy outcome: a case-control study. Acta Haematol 2014; 133:242-8. [PMID: 25401392 DOI: 10.1159/000363048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 04/18/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the risk of adverse pregnancy outcomes in patients with acquired and/or congenital thrombophilia factors. PATIENTS AND METHODS A cohort of 130 women with a history of pregnancy loss and no successful gestation were investigated for the presence of congenital and acquired thrombophilia factors, and then compared with a control group of 130 healthy women who had had at least one successful gestation and no pregnancy loss, and were screened for congenital and acquired thrombophilia factors. RESULTS Acquired and congenital thrombophilia factors were found in 30 (23%) patients and in 14 (10.8%) controls (p < 0.015). The presence of ≥1 congenital thrombophilia factor was associated with pregnancy loss with an odds ratio of 2.46 (p = 0.040). Moreover, women who had had >1 early fetal loss had a 2.85-fold risk of being carriers of congenital thrombophilia factors, compared to the controls. CONCLUSION Our study showed the increased risk of miscarriage in patients with congenital thrombophilia factors and >1 early fetal loss.
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Jeve YB, Davies W. Evidence-based management of recurrent miscarriages. J Hum Reprod Sci 2014; 7:159-69. [PMID: 25395740 PMCID: PMC4229790 DOI: 10.4103/0974-1208.142475] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 07/03/2014] [Accepted: 08/05/2014] [Indexed: 11/15/2022] Open
Abstract
Recurrent miscarriages are postimplantation failures in natural conception; they are also termed as habitual abortions or recurrent pregnancy losses. Recurrent pregnancy loss is disheartening to the couple and to the treating clinician. There has been a wide range of research from aetiology to management of recurrent pregnancy loss. It is one of the most debated topic among clinicians and academics. The ideal management is unanswered. This review is aimed to produce an evidence-based guidance on clinical management of recurrent miscarriage. The review is structured to be clinically relevant. We have searched electronic databases (PubMed and Embase) using different key words. We have combined the searches and arranged them with the hierarchy of evidences. We have critically appraised the evidence to produce a concise answer for clinical practice. We have graded the evidence from level I to V on which these recommendations are based.
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Affiliation(s)
- Yadava B Jeve
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester LE1 5WW, Northampton, UK
| | - William Davies
- Department of Obstetrics and Gynaecology, Northampton General Hospital, Northampton, UK
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Shetty S, Ghosh K. Paternal factor V Leiden and recurrent pregnancy loss: a new concept behind fetal genetics? Comment. J Thromb Haemost 2014; 12:1758-9. [PMID: 24894632 DOI: 10.1111/jth.12621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 11/26/2022]
Affiliation(s)
- S Shetty
- National Institute of Immunohaematology (ICMR), KEM Hospital, Mumbai, India
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Ghidini A. Overview of low molecular weight heparin for preventative treatment of adverse obstetric outcomes related to abnormal placentation. Prenat Diagn 2014; 34:649-54. [PMID: 24752745 DOI: 10.1002/pd.4385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 11/10/2022]
Abstract
Different proportions of cases of preterm and severe preeclampsia, placental abruption, fetal growth restriction, and fetal death share a common causal pathway of abnormal placental implantation. Documentation of an association between the risk of such adverse pregnancy outcomes (APOs) and inherited thrombophilias prompted initial studies to evaluate the benefit of anticoagulants for the prevention of recurrences both in patients with and without inherited thrombophilias. Prenatal administration of low molecular weight heparin (LMWH) has been evaluated in case control, cohort and randomized clinical trials. The evidence suggests a benefit of LMWH in the reduction of recurrences of APOs, with a number needed to treat of 6 (95% confidence interval: 4-10) to prevent one case of recurrent APOs. Such benefit is independent of the presence of inherited thrombophilias or the administration of low dose aspirin. Further studies are needed to establish the optimal duration for the prophylaxis, to better delineate the mechanism of action of LMWH and to explore the role, if any, of maternal serum markers and uterine artery Doppler findings in the modulation of the LMWH prophylaxis.
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Affiliation(s)
- Alessandro Ghidini
- Perinatal Diagnostic Center, Inova Alexandria Hospital, Alexandria, VA, USA
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Sakashita T, Higashi Y, Soga J, Miyoshi H, Kudo Y. Circulating endothelial progenitor cells and placental abruption in women with preeclampsia. Pregnancy Hypertens 2014; 4:203-8. [PMID: 26104606 DOI: 10.1016/j.preghy.2014.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/21/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Abnormalities in circulating angiogenic factors and endothelial progenitor cells (EPCs) have been reported in patients with preeclampsia and placental abruption. The objective of this study was to determine whether the number of EPCs is altered in patients with placental abruption. DESIGN A case control study. SETTING Hiroshima University Hospital in Japan. SAMPLE Pregnant Japanese women with preeclampsia (n=27) and those without any complications (n=15). METHOD The EPC (CD45(low)CD34(+)CD133(+) cells) counts were examined using flow cytometry in peripheral blood collected from 27 women with preeclampsia and 15 normal pregnant women. Among the 27 women with preeclampsia, five subsequently developed placental abruption. All subjects were divided into three groups: normal pregnancy (NP, n=15), preeclampsia without placenta abruption (PE, n=22) and preeclampsia with placental abruption (PA, n=5). MAIN OUTCOME MEASURES The EPC counts were measured in pregnant women with preeclampsia who subsequently developed placental abruption. RESULTS The EPC count in the PE group significantly decreased in comparison to that observed in the NP group (620cells/ml versus 1918 cells/ml, P<0.01). In the PA group, the EPC count was found to markedly decrease in comparison to that observed in the PE group (221cells/ml, P<0.05). CONCLUSIONS The number of EPCs was found to significantly decrease in preeclamptic women who subsequently developed placental abruption.
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Affiliation(s)
- Tomohisa Sakashita
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yukihito Higashi
- Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Junko Soga
- Department of Cardiovascular Physiology and Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Miyoshi
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshiki Kudo
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Neki R, Miyata T, Fujita T, Kokame K, Fujita D, Isaka S, Ikeda T, Yoshimatsu J. Nonsynonymous mutations in three anticoagulant genes in Japanese patients with adverse pregnancy outcomes. Thromb Res 2014; 133:914-8. [DOI: 10.1016/j.thromres.2014.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/14/2014] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
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Dutra CG, Fraga LR, Nácul AP, Passos EP, Gonçalves RO, Nunes OL, Godoy BAD, Leistner-Segal S, Vianna FSL, Schüler-Faccini L, Sanseverino MTV. Lack of association between thrombophilic gene variants and recurrent pregnancy loss. HUM FERTIL 2014; 17:99-105. [DOI: 10.3109/14647273.2014.882022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abu-Heija A. Thrombophilia and Recurrent Pregnancy Loss: Is heparin still the drug of choice? Sultan Qaboos Univ Med J 2014; 14:e26-36. [PMID: 24516750 DOI: 10.12816/0003333] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/24/2013] [Accepted: 10/23/2013] [Indexed: 12/11/2022] Open
Abstract
The association between thrombophilia and recurrent pregnancy loss (RPL) has become an undisputed fact. Thorombophilia creates a hypercoaguable state which leads to arterial and/or venous thrombosis at the site of implantation or in the placental blood vessels. Anticoagulants are an effective treatment against RPL in women with acquired thrombophilia due to antiphospholipid syndrome. The results of the use of anticoagulants for treating RPL in women with inherited thrombophilia (IT) are encouraging, but recently four major multicentre studies have shown that fetal outcomes (determined by live birth rates) may not be as favourable as previously suggested. Although the reported side-effects for anticoagulants are rare and usually reversible, the current recommendation is not to use anticoagulants in women with RPL and IT, or for those with unexplained losses. This review examines the strength of the association between thrombophilia and RPL and whether the use of anticoagulants can improve fetal outcomes.
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Affiliation(s)
- Adel Abu-Heija
- Department of Obstetrics & Gynecology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman, E-mail:
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