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Lin X, Yong J, Gan M, Tang S, Du J. Impact of low-dose aspirin exposure on obstetrical outcomes: a meta-analysis. J Psychosom Obstet Gynaecol 2024; 45:2344079. [PMID: 38712869 DOI: 10.1080/0167482x.2024.2344079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE To assess the impact of low-dose aspirin (LDA) on obstetrical outcomes through a meta-analysis of placebo-controlled randomized controlled trials (RCTs). METHODS A systematic search of the PubMed, Cochrane Library, Web of Science and Embase databases from inception to January 2024 was conducted to identify studies exploring the role of aspirin on pregnancy, reporting obstetrical-related outcomes, including preterm birth (PTB, gestational age <37 weeks), small for gestational age (SGA), low birth weight (LBW, birthweight < 2500g), perinatal death (PND), admission to the neonatal intensive care unit (NICU), 5-min Apgar score < 7 and placental abruption. Relative risks (RRs) were estimated for the combined outcomes. Subgroup analyses were performed by risk for preeclampsia (PE), LDA dosage (<100 mg vs. ≥100 mg) and timing of onset (≤20 weeks vs. >20 weeks). RESULTS Forty-seven studies involving 59,124 participants were included. Compared with placebo, LDA had a more significant effect on low-risk events such as SGA, PTB and LBW. Specifically, LDA significantly reduced the risk of SGA (RR = 0.91, 95% CI: 0.87-0.95), PTB (RR = 0.93, 95% CI: 0.89-0.97) and LBW (RR = 0.94, 95% CI: 0.89-0.99). For high-risk events, LDA significantly lowered the risk of NICU admission (RR = 0.93, 95% CI: 0.87-0.99). On the other hand, LDA can significantly increase the risk of placental abruption (RR = 1.72, 95% CI: 1.23-2.43). Subgroup analyses showed that LDA significantly reduced the risk of SGA (RR = 0.86, 95% CI: 0.77-0.97), PTB (RR = 0.93, 95% CI: 0.88-0.98) and PND (RR = 0.65, 95% CI: 0.48-0.88) in pregnant women at high risk of PE, whereas in healthy pregnant women LDA did not significantly improve obstetrical outcomes, but instead significantly increased the risk of placental abruption (RR = 5.56, 95% CI: 1.92-16.11). In pregnant women at high risk of PE, LDA administered at doses ≥100 mg significantly reduced the risk of SGA (RR = 0.77, 95% CI: 0.66-0.91) and PTB (RR = 0.56, 95% CI: 0.32-0.97), but did not have a statistically significant effect on reducing the risk of NICU, PND and LBW. LDA started at ≤20 weeks significantly reduced the risk of SGA (RR = 0.76, 95% CI: 0.65-0.89) and PTB (RR = 0.56, 95% CI: 0.32-0.97). CONCLUSIONS To sum up, LDA significantly improved neonatal outcomes in pregnant women at high risk of PE without elevating the risk of placental abruption. These findings support LDA's clinical application in pregnant women, although further research is needed to refine dosage and timing recommendations.
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Affiliation(s)
- Xiaoyan Lin
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Jingchao Yong
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Ming Gan
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China
| | - Shaowen Tang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China
- Department of Epidemiology, School of Public Health, Center for Global Health, Nanjing Medical University, Nanjing, China
- State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
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Baradwan S, Tawfiq A, Hakeem GF, Alkaff A, Hafedh B, Faden Y, Khadawardi K, Abdulghani SH, Althagafi H, Abu-Zaid A. The effects of low-dose aspirin on preterm birth: a systematic review and meta-analysis of randomized controlled trials. Arch Gynecol Obstet 2024; 309:1775-1786. [PMID: 38372754 DOI: 10.1007/s00404-024-07373-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 02/20/2024]
Abstract
AIM To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy of low-dose aspirin (LDA, ≤ 160 mg/day) on preventing preterm birth (PB). METHODS Five databases were screened from inception until June 25, 2023. The RCTs were assessed for quality according to Cochrane's risk of bias tool. The endpoints were summarized as risk ratio (RR) with 95% confidence interval (CI). RESULTS Overall, 40 RCTs were analyzed. LDA significantly decreased the risk of PB < 37 weeks (RR: 0.91, 95% CI 0.87, 0.96, p < 0.001, moderate certainty of evidence) with low between-study heterogeneity (I2 = 23.2%, p = 0.11), and PB < 34 weeks (RR: 0.78, 95% CI 0.61, 0.99, p = 0.04, low certainty of evidence) with high between-study heterogeneity (I2 = 58.3%, p = 0.01). There were no significant differences between both groups regarding the risk of spontaneous (RR: 0.94, 95% CI 0.83, 1.07, p = 0.37) and medically indicated (RR: 1.28, 95% CI 0.87, 1.88, p = 0.21) BP < 37 weeks. Sensitivity analysis revealed robustness for all outcomes, except for the risk of PB < 34 weeks. For PB < 37 weeks and PB < 34 weeks, publication bias was detected based on visual inspection of funnel plots for asymmetry and statistical significance for Egger's test (p = 0.009 and p = 0.0012, respectively). CONCLUSION LDA can significantly reduce the risk of PB < 37 and < 34 weeks. Nevertheless, further high-quality RCTs conducted in diverse populations, while accounting for potential confounding factors, are imperative to elucidate the optimal aspirin dosage, timing of initiation, and treatment duration for preventing preterm birth and to arrive at definitive conclusions.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afaf Tawfiq
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ghaidaa Farouk Hakeem
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Alya Alkaff
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bandr Hafedh
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Yaser Faden
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Sahar H Abdulghani
- Department of Obstetrics and Gynecology, Security Forces Hospital Program, Riyadh, Saudi Arabia
| | - Hanin Althagafi
- Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Abu-Zaid
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
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Horgan R, Hage Diab Y, Waller J, Abuhamad A, Saade G. Low-dose aspirin therapy for the prevention of preeclampsia: time to reconsider our recommendations? Am J Obstet Gynecol 2023; 229:410-418. [PMID: 37120049 DOI: 10.1016/j.ajog.2023.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
The American College of Obstetricians and Gynecologists recommends initiation of 81 mg of aspirin daily for women at risk of preeclampsia between 12 and 28 weeks' gestation, optimally before 16 weeks, with continuation until delivery. The World Health Organization recommends that 75 mg of aspirin should be initiated before 20 weeks of gestation for women at high risk of preeclampsia. Both the Royal College of Obstetricians and Gynaecologists and the National Institute of Health and Care Excellence quality statement on "Antenatal Assessment of Pre-eclampsia Risk" request that healthcare providers prescribe low-dose aspirin to pregnant women at increased risk of preeclampsia daily from 12 weeks of gestation. The Royal College of Obstetricians and Gynaecologists recommends 150 mg of aspirin daily, and the National Institute of Health and Care Excellence guidelines suggest risk stratification with a dosage of 75 mg for those at moderate risk of preeclampsia and 150 mg for those at high risk of preeclampsia. The International Federation of Gynecology and Obstetrics initiative on preeclampsia recommends 150 mg of aspirin to be initiated at 11 to 14+6 week's gestation and also proposes that 2 tablets of 81 mg is an acceptable alternative. Review of the available evidence suggests that both the dosage and timing of aspirin initiation is key to its effectiveness at reducing the risk of preeclampsia. Doses of >100 mg of aspirin daily initiated before 16 weeks' gestation seem to be most effective at reducing the risk of preeclampsia and thus dosages recommended by most major societies and organizations may not be effective. Randomized control trials examining 81 mg vs 162 mg of aspirin daily for the prevention of preeclampsia are required to assess the safety and efficacy of aspirin dosages available in the United States.
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Affiliation(s)
- Rebecca Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA.
| | - Yara Hage Diab
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Jerri Waller
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX
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Stubert J, Hinz B, Berger R. The Role of Acetylsalicylic Acid in the Prevention of Pre-Eclampsia, Fetal Growth Restriction, and Preterm Birth. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:617-626. [PMID: 37378599 PMCID: PMC10568740 DOI: 10.3238/arztebl.m2023.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Recent studies suggest that low-dose acetylsalicylic acid (ASA) can lower pregnancy-associated morbidity. METHODS This review is based on pertinent publications that were retrieved by a selective search in PubMed, with special attention to systematic reviews, metaanalyses, and randomized controlled trials. RESULTS Current meta-analyses document a reduction of the risk of the occurrence of pre-eclampsia (RR 0.85, NNT 50), as well as beneficial effects on the rates of preterm birth (RR 0.80, NNT 37), fetal growth restriction (RR 0.82, NNT 77), and perinatal death (RR 0.79, NNT 167). Moreover, there is evidence that ASA raises the rate of live births after a prior spontaneous abortion, while also lowering the rate of spontaneous preterm births (RR 0.89, NNT 67). The prerequisites for therapeutic success are an adequate ASA dose, early initiation of ASA, and the identification of women at risk of pregnancy-associated morbidity. Side effects of treatment with ASA in this patient group are rare and mainly involve bleeding in connection with the pregnancy (RR 0.87, NNH 200). CONCLUSION ASA use during pregnancy has benefits beyond reducing the risk of pre-eclampsia. The indications for taking ASA during pregnancy may be extended at some point in the future; at present, in view of the available evidence, it is still restricted to high-risk pregnancies.
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Affiliation(s)
- Johannes Stubert
- Department of Obstetrics and Gynecology, Klinikum Südstadt Rostock, Rostock University Hospital, Rostock, Germany
| | - Burkhard Hinz
- Department of Pharmacology and Toxicology, Rostock University Hospital, Rostock, Germany
| | - Richard Berger
- Department of Obstetrics and Gynecology, Marienhaus Klinikum St. Elisabeth Neuwied
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Blomqvist L, Nyström HF, Hellgren M, Strandell A. Preconceptual thyroid peroxidase antibody positivity in women with recurrent pregnancy losses may contribute to an increased risk for another miscarriage. Clin Endocrinol (Oxf) 2023; 98:259-269. [PMID: 36146941 DOI: 10.1111/cen.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 07/04/2022] [Accepted: 09/07/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate preconceptual thyroid peroxidase antibody (TPO-ab) positivity and/or thyroid stimulating hormone (TSH) levels in the upper range of normal as risk factors for recurrent unexplained first-trimester miscarriage. DESIGN A post-hoc study of a randomized trial, in which acetylsalicylic acid did not affect the risk of a new miscarriage. PATIENTS Women (n = 483) with at least three unexplained recurrent first-trimester miscarriages investigated at a Swedish secondary referral center. MEASUREMENTS The levels of TPO-ab and TSH were determined before pregnancy. The occurrence of a new first-trimester miscarriage was analyzed by logistic regression with adjustments when applicable, for age, number of previous miscarriages, obesity and the investigated covariates levels of TPO-ab and TSH. RESULTS Including all first trimester miscarriages, odds ratio (OR) according to presence of TPO-ab was 1.60 (95% confidence interval [CI]; 0.99-2.57), after adjustment 1.54 (95% CI; 0.94-2.53). Very early (biochemical) pregnancy losses occurred more often in women with than without preconceptual TPO-ab (6.8% vs. 2.0%), OR 3.51 (95% CI; 1.15-10.71), after adjustment 2.91 (95% CI; 0.91-9.29). There was no association between TSH in the upper range of normal and a new miscarriage, adjusted OR 0.76 (95% CI; 0.32-1.83). A prediction model for a new miscarriage included number of previous miscarriages, woman's age and presence of TPO-ab. CONCLUSION In women with at least three recurrent unexplained pregnancy losses, the presence of TPO-ab may contribute to an increased risk of a first-trimester miscarriage, possibly more pronounced in very early pregnancy. TSH levels 2.5-4.0 mU/L do not seem to increase the miscarriage risk.
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Affiliation(s)
- Lennart Blomqvist
- Department of Obstetrics and Gynaecologist, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and, gynaecologistsödra Älvsborg's Hospital, Borås, Sweden
| | - Helena F Nyström
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynaecologist, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynaecologist, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynaecologist, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynaecologist, Sahlgrenska University Hospital, Gothenburg, Sweden
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Genest G, Banjar S, Almasri W, Beauchamp C, Benoit J, Buckett W, Dzineku F, Gold P, Dahan MH, Jamal W, Jacques Kadoch I, Kadour-Peero E, Lapensée L, Miron P, Shaulov T, Sylvestre C, Tulandi T, Mazer BD, Laskin CA, Mahutte N. Immunomodulation for unexplained recurrent implantation failure: where are we now? Reproduction 2023; 165:R39-R60. [PMID: 36322478 DOI: 10.1530/rep-22-0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/02/2022] [Indexed: 11/05/2022]
Abstract
In brief Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies. Abstract Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.
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Affiliation(s)
- Geneviève Genest
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Shorooq Banjar
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Walaa Almasri
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Coralie Beauchamp
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Joanne Benoit
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - William Buckett
- McGill University Health Centre Reproductive Centre, Montreal, Quebec, Canada
| | | | - Phil Gold
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wael Jamal
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | | | - Einav Kadour-Peero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Louise Lapensée
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Pierre Miron
- Fertilys Reproductive Center, Laval, Quebec, Canada
| | - Talya Shaulov
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Sylvestre
- Division of Reproductive Endocrinology and Infertility, University of Montreal, Montreal, Quebec, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bruce D Mazer
- Department of Pediatrics, McGill University, Division of Allergy Immunology and Clinical Dermatology, Montreal Children's Hospital, McGill University, Montréal, Quebec, Canada
| | - Carl A Laskin
- Deptartments of Medicine and Obstetrics & Gynecology University of Toronto, Toronto, Ontario, Canada
| | - Neal Mahutte
- The Montreal Fertility Centre, Montreal, Quebec, Canada
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Ghesquiere L, Vachon-Marceau C, Kingdom JC, Ferreira E, Côté S, Guerby P, Maheux-Lacroix S, Bujold E. Short communication: Is there any benefit of initiating aspirin before the 11th week of gestation? Pregnancy Hypertens 2022; 30:189-191. [DOI: 10.1016/j.preghy.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/21/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
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Non-Criteria Obstetric Antiphospholipid Syndrome: How Different Is from Sidney Criteria? A Single-Center Study. Biomedicines 2022; 10:biomedicines10112938. [PMID: 36428506 PMCID: PMC9687766 DOI: 10.3390/biomedicines10112938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
This study aims to compare the demographic characteristics, clinical features, serology, and fetal-maternal outcomes between women with obstetric antiphospholipid syndrome (APS) and those with non-criteria (NC)-APS and seronegative (SN)-APS. Two-hundred and sixty-three women with APS obstetric morbidity ever pregnant were included. Of those, 66 met the APS classification criteria, 140 were NC-APS, and 57 were SN-APS. Patients with other autoimmune diseases were excluded. Adverse pregnancy outcomes (APO) included early pregnancy loss, fetal death, preeclampsia, abruptio placentae, and preterm birth. The mean age of the study group was 33.6 ± 5.3 years, and patients were followed up for 129.5 ± 81.9 months. In the NC-APS group, 31 (22.1%) did not fulfill clinical and serological criteria (Subgroup A), 49 (35%) did meet clinical but not serologic criteria (Subgroup B), and 60 (42.9%) fulfilled the serologic criteria but not the clinical ones (Subgroup C). The cardiovascular risk burden was higher in the APS group, due to a higher proportion of smoking. Patients with criteria APS received more intensive treatment than patients in the other study groups. The addition of standard of care (SoC) treatment significantly improved live birth and decreased APO in all groups. Significant clinical differences were observed between the study groups. However, when treated with SoC, fetal-maternal outcomes were similar, with a significant improvement in live births and a decrease in APO. Risk stratification in patients with obstetric morbidity associated with APS can help individualize their treatment.
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Effect of acetylsalicylic acid on uterine blood flow, gestation length, foal birth weight and placental weight in pregnant Thoroughbred mares - a clinical pilot study. J Equine Vet Sci 2022; 118:104107. [PMID: 36002117 DOI: 10.1016/j.jevs.2022.104107] [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: 06/21/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022]
Abstract
The aim of this double-blinded placebo-controlled study was to investigate the effect of acetylsalicylic acid (ASA) on uterine blood flow, gestation length, placental and foal weights in pregnant mares. Sixteen Thoroughbred mares of different age (13.3 ± 4.1) and parity (7.4 ± 3.1) were randomly assigned to three treatment groups. Mares in group C (n = 4) served as controls and received 5000 mg lactose orally once daily from D 120 (D 0 = day of ovulation) until parturition. Mares in group ASA1 (n = 7) received 5000 mg ASA orally once daily from D 120 until parturition. Mares in group ASA2 (n = 5) received the same dose ASA as group ASA1 from D 120 to D 285, but twice daily from D 285 until parturition. Mares were examined by ultrasonography on D 14, 28 and 60, and in 21-days intervals from D 120 until parturition. The cross-sectional area, time average maximum velocity (TAMV), and pulsatility index were measured in both uterine arteries and the blood flow volume was calculated for each uterine artery and then summarized. All 16 mares carried a normal pregnancy and delivered live foals. In group ASA2 TAMV in the ipsilateral artery was significantly higher (P = 0.03) and these mares showed a tendency of increased total blood flow volume (P = 0.07) during late pregnancy (D 305 to 346). Results indicate that oral administration of 5000 mg of ASA twice daily in pregnant mares causes a rise in uterine blood flow during late pregnancy.
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Kim JH, Kim SH, Yang N, Ko Y, Lee SR, Chae HD. Outcomes of Empirical Treatment With Intravenous Immunoglobulin G Combined With Low-Dose Aspirin in Women With Unexplained Recurrent Pregnancy Loss. J Korean Med Sci 2022; 37:e200. [PMID: 35762143 PMCID: PMC9239843 DOI: 10.3346/jkms.2022.37.e200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To assess the clinical efficacy of intravenous immunoglobulin G (IVIG) administration combined with low-dose aspirin in women with unexplained recurrent pregnancy loss (RPL). METHODS We retrospectively analyzed the medical records of patients who had been diagnosed with unexplained RPL and treated with IVIG and low-dose aspirin between January 2000 and March 2020 at Asan Medical Center. We analyzed pregnancy outcomes and their association with the percentage of natural killer (NK) cells. RESULTS The study analyzed a total of 93 patients and 113 natural and assisted reproductive technology pregnancy cycles. The live birth rate per cycle was 73.5% (83/113), and the term delivery rate was 86.7% (72/83). The live birth rate was high regardless of the type of RPL, method of pregnancy, timing of IVIG treatment, and presence or absence of autoantibodies. In addition, the live birth rate was significantly higher in patients who received IVIG more than once, compared with patients who received IVIG only once (77.8% vs. 42.9%, P = 0.006). There was no significant association between the NK cell counts and live birth rate (65.5% in the group with NK cell < 12%, and 69.7% in that with NK cell ≥ 12%, P = 0.725). Among all patients, 87.6% had no complications, and there were no congenital malformation among newborn babies. CONCLUSION IVIG combined with low-dose aspirin treatment showed favorable pregnancy outcomes regardless of the patient's NK cell counts (%).
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Affiliation(s)
- Ju Hee Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Nuri Yang
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yuri Ko
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sa Ra Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Dong Chae
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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11
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Wang N, Ge H, Zhou S. Cyclosporine A to Treat Unexplained Recurrent Spontaneous Abortions: A Prospective, Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Int J Womens Health 2021; 13:1243-1250. [PMID: 34916855 PMCID: PMC8670855 DOI: 10.2147/ijwh.s330921] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/18/2021] [Indexed: 12/27/2022] Open
Abstract
Background The World Health Organization (WHO) has defined Unexplained Recurrent Spontaneous Abortion (URSA) as three and more consecutive miscarriages before the 20th week of gestation. To date, empiric therapy for patients with unexplained recurrent pregnancy loss (URPL) is not precise. Studies have shown that URSAs are associated with Th1/Th2 and Th17/Treg immune imbalances at the maternal-fetal interface. The immunosuppressant cyclosporine A (CsA) is widely used in patients with organ transplantation or autoimmune diseases, and it has a good safety profile in pregnant women. However, high-quality evidence for CsA treatment of URSAs is lacking. Our purpose with this study is to evaluate the efficacy and safety of CsA for improving pregnancy outcomes in patients with URSAs and to explore the role of CsA in regulating the immune balance. Methods/Design We expect to officially initiate our study at the Taizhou People's Hospital in March 2022. We defined the live birth rate as the primary outcome, and the secondary outcomes include the rates of successful pregnancy, miscarriage, pregnancy complications, and adverse pregnancy outcomes, and newborn birth weights. Patients who meet URSA eligibility criteria will be randomized in a 1:1 ratio into either a study group receiving CsA 2 weeks after fertilization or a control group receiving placebo at 2 weeks after fertilization (the women in both groups will receive the relevant treatment for 6 months). In addition, we will collect peripheral blood samples of the participants before and after the treatments, and we will isolate mononuclear cells and measure cytokine levels (IFN-γ, TNF-α, IL-2, IL-10, IL-6, IL-4) and Th1/Th2, Th17/Treg ratios. Discussion This is the first randomized controlled trial to evaluate the clinical and immunomodulatory effects of CsA on the pregnancy outcomes of women with URSA and our results will provide evidence to evaluate the use of CsA as a treatment for women with URSAs.
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Affiliation(s)
- Nan Wang
- Department of Obstetrics and Gynecology, Taizhou People's Hospital, Taizhou, Jiangsu Province, People's Republic of China.,Department of Graduate College, Dalian Medical University, Dalian, Liaoning Province, People's Republic of China
| | - Hongshan Ge
- Department of Obstetrics and Gynecology, Taizhou People's Hospital, Taizhou, Jiangsu Province, People's Republic of China
| | - Shu Zhou
- Department of Obstetrics and Gynecology, Taizhou People's Hospital, Taizhou, Jiangsu Province, People's Republic of China
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Wang G, Zhang R, Li C, Chen A. Evaluation of the effect of low molecular weight heparin in unexplained recurrent pregnancy loss: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2021; 35:7601-7608. [PMID: 34311655 DOI: 10.1080/14767058.2021.1957819] [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] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The effectiveness of low molecular weight heparin (LMWH) in preventing miscarriage of unexplained recurrent pregnancy loss remains controversial. In order to explore the effect of LMWH therapy in unexplained recurrent pregnancy loss, we conducted this meta-analysis. METHODS We searched four databases PubMed, Cochrane Library, EMBASE, and Clinical Trials.gov (up to February 2020) for the randomized control trials (RCTs) evaluating the effectiveness of LMWH on the treatment of recurrent miscarriage. We used Stata software to perform a meta-analysis. Moreover, we performed analyses of sensitivity and predefined subgroups based on the definition of recurrent miscarriage (e.g. 2 or more miscarriages or 3 or more miscarriages) to search the source of heterogeneity. RESULTS 5 studies met the selection criteria, involving 1452 participants. LMWH reduce the risk of miscarriage of women suffering ≥3 miscarriages (RR = 0.46; 95% CI = 0.35-0.61, p = .00), but the risk of miscarriage of women suffering ≥2 miscarriages was not decreased by LMWH (RR = 0.70; 95% CI = 0.57-0.86, p = .26). No substantial influence was found on Live birth rate (RR = 1.19; 95% CI = 0.99-1.43), Preterm birth (RR = 0.95; 95% CI = 0.65-1.38), Preeclampsia (RR = 0.89, 95% CI = 0.45-1.76), Small for gestational age (RR = 0.89; 95% CI = 0.64-1.51). CONCLUSION LMWH treatment may decrease the miscarriage rate in women suffering a history of 3 or more miscarriages, but not reduce the incidence of miscarriage in women suffering a history of 2 or more miscarriages. We need more RCTs to provide robust and reliable results.
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Affiliation(s)
- Guangning Wang
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ran Zhang
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan Li
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aiping Chen
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
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Blomqvist LRF, Strandell AM, Jeppsson A, Hellgren MSE. Arachidonic acid-induced platelet aggregation and acetylsalicylic acid treatment during pregnancy in women with recurrent miscarriage, a post hoc study. Platelets 2021; 33:278-284. [PMID: 33646930 DOI: 10.1080/09537104.2021.1883573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In this post hoc study, arachidonic acid (AA)-induced platelet aggregation during pregnancy with and without acetylsalicylic acid (ASA) treatment was studied in 323 women with unexplained recurrent first-trimester miscarriage and in 59 healthy women with normal pregnancies. All women had normal AA-induced platelet aggregation in the non-pregnant state. Women with recurrent miscarriage were treated with 75 mg ASA or placebo daily. AA-induced platelet aggregation was measured with multiple electrode impedance aggregometry and presented in units (U), where 1 U = 10 aggregation units x minutes. There were no significant differences in platelet aggregation between placebo-treated women with recurrent miscarriage and healthy women. The mean differences were-0.7 (95%CI; -7.0; 5.6) U in the non-pregnant state, 3.8 (95%CI; -4.6; 12.2) U during the late first trimester and 1.7 (95%CI; -6.7; 10.3) U and 4.1 (95%CI; -3.9; 12.0) U during the early and late third trimester, respectively. ASA reduced platelet aggregation by median -84.0% (Q1; Q3; -89.8; -76.3), -79.9% (-84.7; -69.2) and -75.7% (-83.5; -49.5), respectively, during pregnancy. The degree of inhibition by ASA decreased during the third trimester (p < .0001). There were two (1.9%) complete non-responders to ASA and 32.1% with a partial response. The rate of subsequent miscarriage was not affected by ASA, which did not seem to influence the rate of early miscarriage if treatment was initiated when a viable pregnancy was detectable by ultrasound.
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Affiliation(s)
- Lennart R F Blomqvist
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, Borås, Sweden
| | - Annika M Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margareta S E Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Yu X, He L. Aspirin and heparin in the treatment of recurrent spontaneous abortion associated with antiphospholipid antibody syndrome: A systematic review and meta-analysis. Exp Ther Med 2021; 21:57. [PMID: 33365057 PMCID: PMC7716630 DOI: 10.3892/etm.2020.9489] [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] [Received: 06/24/2019] [Accepted: 03/17/2020] [Indexed: 12/19/2022] Open
Abstract
The present study aimed to review relevant, randomized, controlled trials in order to determine the effects of aspirin and heparin treatment on recurrent spontaneous abortion (RSA) in women with antiphospholipid syndrome (APS). Previous relevant studies were identified using PubMed, Cochrane, Embase, CNKI, VANFUN and VIP by retrieving appropriate key words. Additionally, key relevant sources in the literature were reviewed and articles published before May 2019 were included. The 22 selected studies included 1,515 patients in the treatment group and 1,531 patients in the control group. These previous studies showed that heparin and aspirin significantly improved live birth rate when compared with treatments using intravenous immunoglobulin, aspirin alone or aspirin combined with prednisone. Moreover, heparin and aspirin greatly increased the birth weight compared with placebo and improved vaginal delivery relative to intravenous immunoglobulin. The gestational age at birth was significantly higher in the heparin and aspirin group compared with the placebo group and the incidence of intrauterine growth restriction was lower in the heparin and aspirin group compared with the placebo group. Furthermore, heparin and aspirin markedly reduced the incidence of miscarriage compared with the aspirin group and the placebo group, and the incidence of pre-eclampsia was lower in the heparin and aspirin group than the placebo group. Thus, heparin and aspirin could be further examined for the treatment of RSA in women with APS.
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Affiliation(s)
- Xiaomei Yu
- Department of Obstetrics, Ward 1, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Li He
- Department of Women's Health Care, Chongqing Health Center for Women and Children, Yubei, Chongqing 401147, P.R. China
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Chaemsaithong P, Cuenca-Gomez D, Plana MN, Gil MM, Poon LC. Does low-dose aspirin initiated before 11 weeks' gestation reduce the rate of preeclampsia? Am J Obstet Gynecol 2020; 222:437-450. [PMID: 31494125 DOI: 10.1016/j.ajog.2019.08.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE DATA Preconception or early administration of low-dose aspirin might improve endometrial growth, placental vascularization, and organogenesis. Most studies have evaluated the potential benefit of preconception or early administration of low-dose aspirin in women with a history of recurrent pregnancy loss, women who have undergone in vitro fertilization, or women with thrombophilia or antiphospholipid syndrome. These women are at an increased risk of placenta-associated complications of pregnancy, including preeclampsia, preterm delivery, and fetal growth restriction. STUDY OUTCOMES We performed a systematic review and meta-analysis to evaluate the effect of low-dose aspirin initiated at <11 weeks' gestation on the risk of preeclampsia, gestational hypertension, or any hypertensive disorder of pregnancy. Secondary outcomes included preterm delivery at <37 weeks' gestation and fetal growth restriction. STUDY APPRAISAL AND SYNTHESIS METHODS We searched in MEDLINE via PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from 1985 to November 2018. Entry criteria were randomized controlled trials evaluating the effect of aspirin administered at <11 weeks' gestation in preventing preeclampsia and/or hypertensive disorders in pregnancy or improving pregnancy outcomes in women with recurrent miscarriage as compared with placebo or no treatment and outcome data available or provided by authors for >85% of the study population. Relative risks with 95% confidence intervals were calculated for each study and pooled for global analysis as the effect measure. We assessed statistical heterogeneity in each meta-analysis using the χ2 statistics, I2, and Tau2. Heterogeneity was considered substantial if an I2 was greater than 50% and either the Tau2 was greater than zero or there was a low P value (<0.10) in the χ2 test for heterogeneity. Random-effects meta-analysis, weighted by the size of the studies, was performed to produce an overall summary on aspirin effect for each outcome. Sensitivity analysis by sequential omission of each individual study and by fixed-effects model was performed. Publication bias was not assessed because of the small number of included studies. Statistical analysis was performed using Stata release 14.0 (StataCorp). RESULTS The entry criteria were fulfilled by 8 randomized controlled trials on a combined total of 1426 participants. Low-dose aspirin initiated at <11 weeks' gestation was associated with a nonsignificant reduction in the risk of preeclampsia (relative risk, 0.52; 95% confidence interval, 0.23-1.17, P = .115), gestational hypertension (relative risk, 0.49; 95% confidence interval, 0.20-1.21; P = .121), and any hypertensive disorder of pregnancy (relative risk, 0.59; 95% confidence interval, 0.33-1.04, P = .067). Early administration of low-dose aspirin reduced the risk of preterm delivery (relative risk, 0.52; 95% confidence interval, 0.27-0.97, P = .040) but had no impact on the risk of fetal growth restriction (relative risk, 1.10; 95% confidence interval, 0.58-2.07, P = .775). Except for preterm delivery and any hypertensive disorder of pregnancy, sensitivity analysis demonstrated similar observations, therefore confirming the robustness of the analysis. CONCLUSION The administration of low-dose aspirin at <11 weeks' gestation in women at high risk does not decrease the risk of preeclampsia, gestational hypertension, any hypertensive disorder of pregnancy, and fetal growth restriction. However, it might reduce the risk of preterm delivery. Larger randomized controlled trials will be required to substantiate the findings.
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Toth B, Zhu L, Karakizlis H, Weimer R, Morath C, Opelz G, Kuon RJ, Daniel V. NK cell subsets in idiopathic recurrent miscarriage and renal transplant patients. J Reprod Immunol 2020; 138:103098. [PMID: 32045760 DOI: 10.1016/j.jri.2020.103098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/25/2019] [Accepted: 01/29/2020] [Indexed: 12/14/2022]
Abstract
The present review article compares NK cell subsets and cytokine patterns determined in the peripheral blood as well as results of functional in-vitro assays using peripheral NK cells of idiopathic recurrent miscarriage (iRM) patients with corresponding results obtained in female healthy controls and female renal transplant recipients with good long-term graft function. Immune mechanisms, inducing transplant rejection in long-term transplant recipients might also be able to induce rejection of semi-allogeneic fetal cells in patients with iRM. Consequently, the immune status of transplant recipients with good stable long-term graft function should be different from the immune status of iRM patients. iRM patients show a strong persistent cytotoxic NK cell response in the periphery. Simultaneously, immunostimulatory Th1 as well as immunosuppressive Th2 type lymphocytes in the blood are strongly activated but plasma levels of immunosuppressive Th2 type cytokines are abnormally low. In-vitro, unstimulated NK cell cultures of iRM patients show a strong spontaneous TGF-ß1 release in the supernatant but lower TGF-ß1 levels after stimulation with tumor cell line K562, suggesting strong consumption of TGF-ß1 by pre-activated NK cells of iRM patients that might contribute to the low systemic Th2 type plasma levels. iRM patients do not show a systemic switch to a Th2 type cytokine pattern and one might hypothesize that low TGF-ß plasma levels indicate low TGF-ß levels in the micromilieu immediately before fetal rejection. Persistent TGF-ß deficiency implies a persistent unfavorable micromilieu for pregnancy resulting in failing tolerance induction due to lack of TGF-ß, a condition that might contribute to iRM.
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Affiliation(s)
- Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Li Zhu
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, 430030 Wuhan, China; Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
| | - Hristos Karakizlis
- Department of Internal Medicine, University of Giessen, Klinikstrasse 33, D-35385 Giessen, Germany.
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Klinikstrasse 33, D-35385 Giessen, Germany.
| | - Christian Morath
- Department of Nephrology, University of Heidelberg, Im NeuenheimerFeld 162, Heidelberg, Germany.
| | - Gerhard Opelz
- Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
| | - Ruben-Jeremias Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Im Neuenheimer Feld440, 69120 Heidelberg, Germany.
| | - Volker Daniel
- Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
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