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Patel K, Pirie D, Heazell AEP, Morgan B, Woolner A. Subsequent pregnancy outcomes after second trimester miscarriage or termination for medical/fetal reason: A systematic review and meta-analysis of observational studies. Acta Obstet Gynecol Scand 2024; 103:413-422. [PMID: 38037500 PMCID: PMC10867354 DOI: 10.1111/aogs.14731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Women with a prior stillbirth or a history of recurrent first trimester miscarriages are at increased risk of adverse pregnancy outcomes. However, little is known about the impact of a second trimester pregnancy loss on subsequent pregnancy outcome. This review investigated if second trimester miscarriage or termination for medical reason or fetal anomaly (TFMR/TOPFA) is associated with future adverse pregnancy outcomes. MATERIAL AND METHODS A systematic review of observational studies was conducted. Eligible studies included women with a history of a second trimester miscarriage or termination for medical reasons and their pregnancy outcomes in the subsequent pregnancy. Where comparative studies were identified, studies which compared subsequent pregnancy outcomes for women with and without a history of second trimester loss or TFMR/TOPFA were included. The primary outcome was livebirth, and secondary outcomes included: miscarriage (first and second trimester), termination of pregnancy, fetal growth restriction, cesarean section, preterm birth, pre-eclampsia, antepartum hemorrhage, stillbirth and neonatal death. Studies were excluded if exposure was nonmedical termination or if related to twins or higher multiple pregnancies. Electronic searches were conducted using the online databases (MEDLINE, Embase, PubMed and The Cochrane Library) and searches were last updated on June 16, 2023. Risk of bias was assessed using the Newcastle-Ottawa scale. Where possible, meta-analysis was undertaken. PROSPERO registration: CRD42023375033. RESULTS Ten studies were included, reporting on 12 004 subsequent pregnancies after a second trimester pregnancy miscarriage. No studies were found on outcomes after second trimester TFMR/TOPFA. Overall, available data were of "very low quality" using GRADE assessment. Meta-analysis of cohort studies generated estimated outcome frequencies for women with a previous second trimester loss as follows: live birth 81% (95% CI: 64-94), miscarriage 15% (95% CI: 4-30, preterm birth 13% [95% CI: 6-23]).The pooled odds ratio for preterm birth in subsequent pregnancy after second trimester loss in case-control studies was OR 4.52 (95% CI: 3.03-6.74). CONCLUSIONS Very low certainty evidence suggests there may be an increased risk of preterm birth in a subsequent pregnancy after a late miscarriage. However, evidence is limited. Larger, higher quality cohort studies are needed to investigate this potential association.
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Affiliation(s)
- Keya Patel
- Maternal and Fetal Health Research Center, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Department of ObstetricsManchester University NHS Foundation TrustManchesterUK
| | - Danielle Pirie
- Aberdeen Center for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & NutritionUniversity of AberdeenAberdeenUK
- NHS Grampian, Aberdeen Maternity HospitalAberdeenUK
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Center, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Department of ObstetricsManchester University NHS Foundation TrustManchesterUK
| | - Bethan Morgan
- Library ServicesManchester University NHS Foundation TrustManchesterUK
| | - Andrea Woolner
- Aberdeen Center for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & NutritionUniversity of AberdeenAberdeenUK
- NHS Grampian, Aberdeen Maternity HospitalAberdeenUK
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Cheung KW, Seto MTY, Wang W, Mok YK, Cheung VYT. Clinical presentation, investigation, underlying causes, and subsequent pregnancy outcomes among different phenotypes of second trimester miscarriage. J Obstet Gynaecol Res 2023; 49:539-547. [PMID: 36455921 DOI: 10.1111/jog.15514] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
AIM To evaluate the causes of miscarriage and subsequent pregnancy outcomes among different phenotypes of second trimester miscarriage. METHODS Retrospective analysis of 170 consecutive second trimester miscarriages between 14 + 0 and 23 + 6 weeks recorded in the Clinical Data Analysis and Reporting System from 2012 to 2021. Cases were excluded if miscarriages occurred before 14 + 0 weeks of gestation, data were incomplete, or passage of the fetus happened before the clinical assessment. Cases were classified with a stepwise approach into three phenotypic groups including silent miscarriages (ST-SM), rupture of membranes (ST-ROM), and inevitable miscarriages (ST-IM) depending on the fetal heart pulsation and leakage of liquor at presentation. Clinical investigation of the underlying causes and the outcome of the subsequent pregnancy was then reviewed. RESULTS There were 97 cases of ST-SM, 21 cases of ST-ROM, and 52 cases of ST-IM. Placental histology and karyotype examination were more likely to yield significant results in the cases of ST-ROM and ST-SM (p < 0.05). The phenotypic examination identified different underlying causes including fetal anomaly, suspected cervical insufficiency, diabetes mellitus, and unknown causes (p < 0.001). Sixty-four cases achieved a subsequent pregnancy. Although women with history of ST-ROM and ST-IM received more cervical length monitoring and cervical cerclage than those with ST-SM (66.7% vs. 44.4% vs. 7.5%, p = 0.0002; and 16.7% vs. 22.2% vs. 2.5%, p = 0.031, respectively), the risk of recurrent second trimester miscarriage was higher in ST-ROM and ST-IM than in ST-SM (16.7% vs. 0%, p = 0.018). CONCLUSION The classification can differentiate different second trimester miscarriage phenotypes, which offers essential information to guide investigation panels of the underlying cause of miscarriages, and the prognosis and management of subsequent pregnancy. Future researches focused on second trimester miscarriage should report their findings according to different phenotypes.
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Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Mimi Tin Yan Seto
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Weilan Wang
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Yin Kwan Mok
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Vincent Y T Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Ruan H, Dai Z, Yan J, Long X, Chen Y, Yang Y, Yang Q, Zhu J, Zheng M, Zhang X. ZBTB24 (Zinc Finger and BTB Domain Containing 24) prevents recurrent spontaneous abortion by promoting trophoblast proliferation, differentiation and migration. Bioengineered 2022; 13:2777-2790. [PMID: 35038951 PMCID: PMC8973579 DOI: 10.1080/21655979.2021.2019655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is a common complication during early gestation, which is associated with aberrant DNA methylation. Zinc Finger and BTB Domain Containing 24 (ZBTB24) plays a critical role in facilitating DNA methylation and cell proliferation. However, the regulatory role of ZBTB24 on trophoblast development in RSA remains unclear. In this study, ZBTB24 expression was compared between decidua tissues of RSA patients and induced abortion controls from a published dataset, which was further validated in placental villi tissues by RT-qPCR and Western blot. The roles of ZBTB24 in trophoblast proliferation, differentiation, and migration were investigated by functional assays after ZBTB24 knockdown or overexpression in HTR-8/SVneo cells. Our results showed that ZBTB24 expression was significantly decreased in RSA patients, and ZBTB24 expression level positively regulated cell viability, differentiation, and migration in HTR-8/SVneo cells. We further demonstrated that ZBTB24 modulated the expression of E-cadherin by altering the DNA methylation at the promoter region. Overall, the downregulation of ZBTB24 is implicated in RSA by inhibiting trophoblast proliferation, differentiation, and migration. Therefore, ZBTB24 may serve as a promising therapeutic target and diagnostic marker for RSA.
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Affiliation(s)
- Haibo Ruan
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Zhenzhen Dai
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Jinyu Yan
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Xiaoxi Long
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Yi Chen
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Youlin Yang
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Qian Yang
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Jun Zhu
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Meiyun Zheng
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Xiahui Zhang
- Department of Obstetrics and Gynecology, The First People's Hospital of Wenling, Wenling, Zhejiang, China
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Long Non-Coding RNA ZEB2-AS1 Augments Activity of Trophoblast Cells and Prevents the Development of Recurrent Spontaneous Abortion in Mice Through EZH2-Mediated CST3 Inhibition. Reprod Sci 2022; 29:963-974. [PMID: 35075612 DOI: 10.1007/s43032-022-00857-7] [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: 09/17/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
Recurrent spontaneous abortion (RSA) is the most common complication of pregnancy where reduced invasion of trophoblasts plays a major role. This work aimed to explore the effect of abnormally expressed long non-coding RNA (lncRNA) ZEB2-AS1 on the occurrence of RSA. Differentially expressed lncRNAs in trophoblast cells between healthy controls and patients with RSA were screened using the GEO database. Female CBA/J mice were allowed to mate with male DBA/2 mice to establish inbred mice with RSA. ZEB2-AS1 was poorly expressed in placental tissues and trophoblast cells in the condition of RSA. ZEB2-AS1 upregulation augmented proliferation, migration, and invasion of trophoblast cells in vitro. ZEB2-AS1 negatively regulated cystatin C (CST3) expression. Further overexpression of CST3 blocked the activity of trophoblast cells. ZEB2-AS1 recruited enhancer of EZH2 to the promoter region of CST3, which increased H3K27me3 modification to suppress CST3 expression. In vivo, overexpression of ZEB2-AS1 reduced embryo resorption rate and increased the weights of fetuses and placentas in mice with RSA. However, the protective roles of ZEB2-AS1 were blocked upon artificial silencing of EZH2 or upregulation of CST3. Taken together, this study demonstrates that ZEB2-AS1 enhances activity of trophoblast cells and prevents RSA development through reducing CST3 expression in an EZH2-dependent manner.
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Zhu X, Liu H, Zhang Z, Wei R, Zhou X, Wang Z, Zhao L, Guo Q, Zhang Y, Chu C, Wang L, Li X. MiR-103 protects from recurrent spontaneous abortion via inhibiting STAT1 mediated M1 macrophage polarization. Int J Biol Sci 2020; 16:2248-2264. [PMID: 32549769 PMCID: PMC7294935 DOI: 10.7150/ijbs.46144] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/16/2020] [Indexed: 12/12/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is a common complication of early pregnancy. Excessive M1 macrophage was found to be involved in RSA, but the underlying mechanisms remains unclear. MicroRNAs play critical roles in RSA as well as the polarization of macrophages; however, the regulatory effect of miRNAs on M1 differentiation in RSA has not been fully investigated. In this study, miRNA microarray assay revealed that miR-103 was significantly decreased in RAW264.7-derived M1 macrophages upon IFNγ and LPS stimulation. Quantitative real-time polymerase chain reaction (qRT-PCR) analysis showed that in RSA patients, miR-103 expression was decreased substantially, and negatively correlated with that of STAT1. Moreover, down-regulation of miR-103 could sensitively discriminate RSA patients from normal pregnancies (NP) subjects. Experiments in vitro showed that overexpression of miR-103 suppressed M1 polarization by inhibiting STAT1/IRF1 signaling pathway and vice versa. miR-103 regulated STAT1 expression by direct binding to its 3'-UTR. Moreover, our in vivo study demonstrated that overexpressed miR-103 could reduce mice embryo resorption and M1 polarization effectively. Overall, the results suggested that decreased miR-103 was involved in RSA by increasing M1 macrophage polarization via promoting STAT1/IRF1 signaling pathway. miR-103 may be explored as a promising diagnostic marker and therapeutic target for RSA.
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Affiliation(s)
- Xiaoxiao Zhu
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Haiping Liu
- Reproductive Medicine Center, The 960th Hospital of the PLA Joint Logistics Support Force, 25 Wuyingshan Road, Jinan 250031, Shandong, China
| | - Zhen Zhang
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Ran Wei
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Xianbin Zhou
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Zhaoxia Wang
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Lin Zhao
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Qiang Guo
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Yunhong Zhang
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Chu Chu
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, 18877 Jingshi Road, Jinan 250062, Shandong, China
| | - Li Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, 16766 Jingshi Road, Jinan 250014, Shandong, China
| | - Xia Li
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 18877 Jingshi Road, Jinan 250062, Shandong, China
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Pinar MH, Gibbins K, He M, Kostadinov S, Silver R. Early Pregnancy Losses: Review of Nomenclature, Histopathology, and Possible Etiologies. Fetal Pediatr Pathol 2018; 37:191-209. [PMID: 29737906 DOI: 10.1080/15513815.2018.1455775] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Miscarriage is a frequent complication of human pregnancy: ∼50% to 70% of spontaneous conceptions are lost prior to the second trimester. Etiology of miscarriage includes genetic abnormalities, infections, immunological and implantation disorders, uterine and endocrine abnormalities, and lifestyle factors. Given such variability, knowledge regarding causes, pathophysiological mechanisms, and morphologies of primary early pregnancy loss has significant gaps; often, pregnancy losses remain unexplained. Pathologic evaluation of miscarriage tissue is an untapped source of knowledge. Although miscarriage specimens comprise a significant part of pathologists' workload, information reported from these specimens is typically of minimal clinical utility for delineating etiology or predicting recurrence risk. Standardized terminology is available, though not universally used. We reintroduce the terminology and review new information about early pregnancy losses and their morphologies. Current clinical terminology is inconsistent, hampering research progress. This review is a resource for diagnostic pathologists studying this complex problem.
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Affiliation(s)
- M Halit Pinar
- a Perinatal and Pediatric Pathology , Warren Alpert Medical School, Brown University , Providence , Rhode Island , USA
| | - Karen Gibbins
- b Division of Maternal and Fetal Medicine , University of Utah Hospital, Obstetrics and Gynecology , Salt Lake City , Utah , USA
| | - Mai He
- c Pathology and Laboratory Medicine, Division of Pediatric Pathology , Washington University in Saint Louis School of Medicine , Saint Louis , Missouri , USA
| | - Stefan Kostadinov
- d Pathology and Laboratory Medicine, Division of Perinatal and Pediatric Pathology, Women and Infants Hospital , Brown University Warren Alpert Medical School , Providence , Rhode Island , USA
| | - Robert Silver
- e Division of Maternal Fetal Medicine , University of Utah Hospital, Obstetrics and Gynecology , Salt Lake City , Utah , USA
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Sneider K, Christiansen OB, Sundtoft IB, Langhoff-Roos J. Recurrence of second trimester miscarriage and extreme preterm delivery at 16-27 weeks of gestation with a focus on cervical insufficiency and prophylactic cerclage. Acta Obstet Gynecol Scand 2017; 95:1383-1390. [PMID: 27663202 DOI: 10.1111/aogs.13027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 09/19/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this study was to describe recurrence rates of second trimester miscarriage and extreme preterm delivery by phenotype and use of prophylactic cerclage in a register-based cohort. MATERIAL AND METHODS We included women with a first second trimester miscarriage or extreme preterm delivery (16+0 to 27+6 gestational weeks) in Denmark in 1997-2012 (n = 9602) by combined use of the Danish Medical Birth Register and the Danish National Patient Register. Eight phenotypes were identified by ICD-10 codes in a hierarchy with the following sequence: major fetal anomaly, multiple gestation, uterine anomaly, placental insufficiency, antepartum bleeding, cervical insufficiency, preterm premature rupture of membranes, and intrauterine fetal death. Recurrence rate after a second trimester miscarriage/spontaneous delivery in the period was calculated based on the register data. In cervical insufficiency outcome was stratified by prophylactic cerclage applied <16 weeks of gestation. RESULTS Overall recurrence rate was 7.3% (n = 452), a rate that differed by phenotype from <5% (fetal anomaly, multiple gestations, intrauterine fetal death) to 21% (cervical insufficiency). In women with cervical insufficiency the recurrence rate was 28% without cerclage; vaginal cerclage was associated with a significant reduction [adjusted odds ratio (OR) 0.47; 95% CI 0.29-0.76] and abdominal cerclage with an even greater reduction (adjusted OR 0.14; 95% CI 0.03-0.61). CONCLUSIONS The overall recurrence rate of second trimester miscarriage or extreme preterm delivery was 7%, but it differed significantly by phenotype. The highest rate, 28%, was found in cervical insufficiency, and prophylactic cerclage was associated with a significant reduction in recurrence.
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Affiliation(s)
- Kirstine Sneider
- Department of Clinical Research, Vendsyssel Hospital, Hjørring, Denmark
| | - Ole B Christiansen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,The Fertility Clinic, University Hospital Copenhagen, Copenhagen, Denmark
| | - Iben B Sundtoft
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Langhoff-Roos
- Department of Obstetrics, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
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Sneider K, Langhoff-Roos J, Sundtoft IB, Christiansen OB. Validation of second trimester miscarriages and spontaneous deliveries. Clin Epidemiol 2015; 7:517-27. [PMID: 26715859 PMCID: PMC4686223 DOI: 10.2147/clep.s85107] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To validate the diagnosis of second trimester miscarriages/deliveries (16+0 weeks to 27+6 weeks of gestation) recorded as miscarriages in the Danish National Patient Registry or spontaneous deliveries in the Danish Medical Birth Registry, and asses the validity of risk factors, pregnancy complications, and cerclage by review of medical records. Materials and methods In a cohort of 2,358 women with a second trimester miscarriage/delivery in first pregnancy and a subsequent delivery during 1997–2012, we reviewed a representative sample of 682 medical records. We searched for clinically important information and calculated positive predictive values of the registry diagnoses stratified by type of registry, as well as sensitivity, specificity, positive predictive value, and kappa coefficients of risk factors, pregnancy complications, and cerclage. Results Miscarriage/spontaneous delivery in the second trimester was confirmed in 621/682 patients (91.1%). Pregnancy complications in second trimester miscarriages were underreported, resulting in low sensitivities and poor to moderate agreements between records and registries. There was a good agreement (kappa >0.6) between medical records and the registries regarding risk factors and cerclage. The diagnosis of cervical insufficiency had “moderate” kappa values for both miscarriages and deliveries (0.55 and 0.57). Conclusion Spontaneous second trimester deliveries and miscarriages recorded in the registers were confirmed by medical records in 91%, but register-based information on pregnancy complications need to be improved. We recommend that all pregnancies ending spontaneously beyond the first trimester are included in the national birth registry and described by appropriate variables.
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Affiliation(s)
- Kirstine Sneider
- Department of Clinical Research, Vendsyssel Hospital, Hjørring, Denmark
| | - Jens Langhoff-Roos
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Ole Bjarne Christiansen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark ; The Fertility Clinic, University Hospital, Copenhagen, Denmark
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Swenson E, Schema L, McPherson E. Radiographic evaluation of stillbirth: what does it contribute? Am J Med Genet A 2014; 164A:2270-5. [PMID: 25044692 DOI: 10.1002/ajmg.a.36650] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/22/2014] [Indexed: 11/09/2022]
Abstract
Despite advances in perinatal care, stillbirth is relatively common (1/160 births) and frequently remains unexplained. Most recent protocols for etiologic evaluation of stillbirth either omit radiography or reserve it for infants with obvious skeletal disproportion. Over the past 30 years, the Wisconsin Stillbirth Service Program has collected radiographic images from 2,032 stillbirths and second trimester losses, of which about 25% (517) showed abnormalities. Review of these images by a medical geneticist showed that radiographs yielded a diagnosis in 45% of the infants with abnormalities (11.5% of all radiographs obtained) and were critical, yielding a diagnosis that would otherwise have been missed or incomplete in 1.5% of the total infants. The probability of a diagnosis was not significantly different between miscarriages <20 weeks and stillbirths. Diagnoses were mainly fetal, most commonly sporadic birth defects, idiopathic hydrops, chromosome abnormalities, and skeletal dysplasias, but chorioamnionitis with fetal sepsis, complications of twinning, and cord accidents were also diagnosed radiographically. Radiographs may help direct the use of newer technologies such as chromosomal microarray or gene sequencing. Limiting radiographs to infants with obvious skeletal disproportion would have resulted in many of these diagnoses, including 4/24 skeletal dysplasias, being overlooked. We recommend at least an anterior/posterior babygram film as part of the permanent record of all second trimester losses and stillbirths.
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Affiliation(s)
- Erica Swenson
- University of Wisconsin-Madison, Madison, Wisconsin; Department of Medical Genetics Services, Marshfield Clinic, Marshfield, Wisconsin
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Jorgensen M, McPherson E, Zaleski C, Shivaram P, Cold C. Stillbirth: the heart of the matter. Am J Med Genet A 2014; 164A:691-9. [PMID: 24459042 DOI: 10.1002/ajmg.a.36366] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 10/28/2013] [Indexed: 11/06/2022]
Abstract
We evaluated 2,083 cases within the Wisconsin Stillbirth Service Program (WiSSP) that had autopsy reports or ultrasound data relevant to the heart. Of these, 167/1,782 (9.4%) stillbirths after 20 weeks and 11/301 (3.7%) miscarriages <20 weeks had congenital heart disease (CHD). Cases were classified by type of heart defect and whether it related to cause of death. Among cardiac anomalies that contributed significantly to fetal death, 125/151 (83%) were associated with underlying conditions or syndromes, nearly half of which were chromosomal. The most common forms of CHD in stillborns were severe cyanotic lesions (3%), then ventricular (2.6%) and atrial (1.9%) septal defects. Compared to livebirths, this represents a shift toward more severe cardiac lesions, although all comparable categories, including non-lethal conditions such as atrial septal defect, are more common in stillbirths. Clinical cardiomyopathy was identified as cause of death in 1.2% of stillborns. Cardiomegaly, occurring in 26.7% of all cases and 76.7% of infants born to diabetic mothers, may represent undiagnosed cardiomyopathy and/or may decrease fetal tolerance of hypoxia. In contrast, 78.5% of Turner syndrome infants, all <32 weeks, had small hearts. More attention to cardiac findings can lead to increased understanding of stillbirth causes. Based on our findings, we recommend chromosome studies on all stillbirths and close attention to the heart during second trimester ultrasounds, with chromosome studies offered if CHD is found. Consideration of heart size can result in prenatal identification of infants at risk for stillbirth, particularly large hearts in fetuses of diabetic mothers in the third trimester, which may identify fetal cardiomyopathy before it becomes life-threatening.
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Affiliation(s)
- Michael Jorgensen
- Department of Medical Genetics Services, Marshfield Clinic, Marshfield, Wisconsin
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Abstract
Mid-trimester pregnancy loss (MTL) occurs between 12 and 24 weeks' gestation. The true incidence of this pregnancy complication is unknown, because research into MTL in isolation is scarce, although the estimated incidence has been noted to be 2% to 3% of pregnancies. A comprehensive preconceptual screening protocol is recommended, because the cause for an MTL may be present in isolation or combined (dual pathology), and is often heterogeneous. Patients with a history of MTL are at an increased risk of future miscarriage and preterm delivery. This risk is increased further depending on the number of associative factors diagnosed.
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Affiliation(s)
- Kelly M McNamee
- Department of Obstetrics, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK.
| | - Feroza Dawood
- Department of Obstetrics, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Roy G Farquharson
- Department of Gynaecology, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
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12
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Current Concepts and New Trends in the Diagnosis and Management of Recurrent Miscarriage. Obstet Gynecol Surv 2013; 68:445-66. [DOI: 10.1097/ogx.0b013e31828aca19] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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14
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Burmeister B, Zaleski C, Cold C, McPherson E. Wisconsin Stillbirth Service Program: Analysis of large for gestational age cases. Am J Med Genet A 2012; 158A:2493-8. [DOI: 10.1002/ajmg.a.35578] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 06/25/2012] [Indexed: 11/05/2022]
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Derrick M, Englof I, Drobyshevsky A, Luo K, Yu L, Tan S. Intrauterine fetal demise can be remote from the inciting insult in an animal model of hypoxia-ischemia. Pediatr Res 2012; 72:154-60. [PMID: 22580720 PMCID: PMC6109451 DOI: 10.1038/pr.2012.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fetal hypoxia-ischemia (H-I) results in significant morbidity and mortality. Little is known about the timing of death in human stillbirths. The vulnerability of the fetus varies with age at the time of insult, but it is unknown what happens to the timing of fetal death in relation to a fetal insult. We asked the question of whether the timing of fetal death was influenced by the age at which the insult occurred. METHODS Fetal H-I was achieved at three ages by sustained uterine ischemia in rabbits, mimicking the acute placental insufficiency of placental abruption. RESULTS H-I at 22 d gestation (E22) resulted in fewer perinatal deaths than at E25 and E29. Fetal deaths were grouped into early and late perinatal deaths. Early perinatal death mostly occurred immediately after H-I and these fetuses delivered before term. Late perinatal death occurred between the insult and delivery at term gestation. Early perinatal death occurred more often in the E25 hypoxic-ischemic group as compared with those of the E22 hypoxic-ischemic group. CONCLUSION There is an increasing vulnerability to hypoxia with increasing gestational age. Perinatal deaths may occur long after the episode of H-I. The timing of an intrauterine hypoxic-ischemic event cannot be inferred from the detection of fetal death.
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Affiliation(s)
- Matthew Derrick
- Department of Pediatrics, University of Chicago and Northshore University HealthSystem, Evanston, Illinois, USA.
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VanderWielen B, Zaleski C, Cold C, McPherson E. Wisconsin stillbirth services program: a multifocal approach to stillbirth analysis. Am J Med Genet A 2011; 155A:1073-80. [PMID: 21480484 DOI: 10.1002/ajmg.a.34016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 03/01/2011] [Indexed: 11/09/2022]
Abstract
Stillbirth accounts for about 26,000 deaths annually in the US. In most previous studies, discrete causes are identified in less than half of all stillbirths. In order to identify causes and non-causal but potentially contributing abnormalities, we analyzed 416 of the most recent (2004-2010) Wisconsin Stillbirth Service Program (WiSSP) cases from a multifocal approach. In 70% of cases a cause sufficient to independently explain the demise was identified including 40% placental, 21.5% fetal, and 12.7% maternal. Results for stillbirths and second trimester miscarriages did not differ significantly. In 95% of cases at least one cause or non-causal abnormality was recognizable, and in two-thirds of cases, more than one cause or non-causal abnormality was identified. In cases with maternal cause, the placenta was virtually always abnormal. Both placentas (59%) and fetuses (38%) were frequently smaller than expected for gestational age. Previous miscarriage and/or stillbirth were risk factors for second and third trimester losses, with 35% of previous pregnancies ending in fetal demise. Recommendations include complete evaluation of all second and third trimester losses with special attention to placental pathology and thorough investigation for multiple causes or abnormalities whether or not a primary cause is initially recognized. Improved understanding of the causes of late miscarriage and stillbirth may contribute to recognition and management of pregnancies at risk and eventually to prevention of stillbirth.
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Affiliation(s)
- Beth VanderWielen
- Department of Medical Genetics Services, Marshfield Clinic, Wisconsin, USA
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