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Chen J, Huai J, Yang H. Low-molecular-weight heparin for the prevention of preeclampsia in high-risk pregnancies without thrombophilia: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:68. [PMID: 38233773 PMCID: PMC10792962 DOI: 10.1186/s12884-023-06218-9] [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: 03/14/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES To systematically evaluate the efficacy of low molecular weight heparin (LMWH) to prevent preeclampsia in high risk pregnant women without thrombophilia. SEARCH STRATEGY PubMed, Embase and the Cochrane library were searched for articles published before 1st August 2022 using the combination keywords "preeclampsia", "Low Molecular Weight Heparin", "LMWH", "Heparin, Low Molecular Weight", "Dalteparin", "Nadroparin", and "Tinzaparin". SELECTION CRITERIA Randomized controlled trials evaluating the use of LMWH in pregnant women at high risk of preeclampsia without thrombophilia. DATA COLLECTION AND ANALYSIS Ten studies were included in the meta-analysis (1758 patients in total). Outcomes were expressed as relative risk (RR) with 95% confidence intervals (CI). RESULTS LMWH reduced the incidence of PE (RR = 0.67; 95% CI = 0.50-0.90; P = 0.009) in high risk pregnant women without thrombophilia. Subgroup analysis found that the prophylactic effect of LMWH was only significant in studies using low-dose aspirin (LDA) as the primary intervention. The combination of LMWH and LDA was also effective for the prevention of preterm birth and fetal growth restriction, but had no effect on the incidence of placenta abruption. CONCLUSION For women at high risk of developing preeclampsia without thrombophilia, the combination of LMWH and low-dose aspirin is effective for the prevention of preeclampsia, preterm birth and fetal growth restriction and is superior to LDA alone.
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Affiliation(s)
- Jiahui Chen
- Department of Obstetrics and Gynecology, Peking University First Hospital, No. 1 Xi 'an Men Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Jing Huai
- Department of Obstetrics and Gynecology, Peking University First Hospital, No. 1 Xi 'an Men Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, No. 1 Xi 'an Men Street, Xicheng District, Beijing, 100034, China.
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China.
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Flagstad H, Abdalla TE, Sultan Y, Mastrodomenico P, Wood EG. A Successful Pregnancy Outcome After Continued Surveillance of Lupus Anticoagulant Antibodies in a Patient With Recurrent Pregnancy Loss: A Case Report and Literature Review. Cureus 2023; 15:e46029. [PMID: 37900394 PMCID: PMC10603598 DOI: 10.7759/cureus.46029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Recurrent pregnancy loss (RPL) can be a devastating experience for individuals trying to have children. Various potential causes contribute to the multifactorial pathogenesis of RPL, including chromosomal anomalies, endocrine conditions, autoimmunity, thrombophilias, and infectious agents. Antinuclear antibodies (ANAs) offer an unspecific clue to the underlying autoimmune pathogenic etiology of RPL. This case details a 40-year-old female with a history of RPL, fibromyalgia, and ANA positivity, who spontaneously developed lupus anticoagulant antibodies during her second trimester of pregnancy. Although the recommended American Society of Reproductive Medicine (ASRM) diagnostic criteria for initiating a thrombophilia evaluation was not formally met, the patient's maintenance of low-molecular-weight heparin (LMWH) throughout her pregnancy may have contributed to the success of the pregnancy. When treating a patient with RPL, consideration of the comprehensive clinical picture should precede the need to strictly adhere to published criteria for using non-proven clinical interventions. A risk-benefit analysis ought to be considered when offering patients additional medications that may come with some risks but could significantly improve the chances of a successful clinical outcome, such as live birth. We aim to provide evidence to promote greater flexibility in guidelines so that a patient's unique autoimmune etiologies of RPL are not overlooked.
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Affiliation(s)
- Hannah Flagstad
- Obstetrics and Gynecology, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, USA
| | - Tori E Abdalla
- Medicine, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Yasmina Sultan
- Biomedical Sciences Program, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | | | - Ellen G Wood
- Reproductive Endocrinology and Infertility, IVFMD South Florida Institute for Reproductive Medicine, Cooper City, USA
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Lian X, Pan Z, Xia F, Mao C, Zhou W, Zhong Y, Zhou Y. Analysis of the guidance and predictive value of uterine artery flow parameters in patients with recurrent spontaneous abortion. J Obstet Gynaecol Res 2023; 49:803-811. [PMID: 36577510 DOI: 10.1111/jog.15523] [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: 06/13/2022] [Accepted: 12/01/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the uterine artery blood flow parameters of patients with recurrent spontaneous abortion (RSA) at different gestational ages and to investigate the effects of aspirin and low molecular weight heparin (LMWH) on uterine artery blood flow parameters and pregnancy outcomes. METHODS This was a retrospective cohort study involving analysis of clinical data for 140 patients: 47 in an aspirin group, 49 in a combination group, and 44 in a control group. The uterine artery blood flow parameters of the three groups in the middle luteal period and 10th, 12th, 16th, and 20th gestational weeks were compared. Trends in uterine artery flow parameters were predicted by function fitting, and the uterine artery flow parameters and pregnancy outcomes between different drug administration regimens were compared. RESULTS With increasing gestational age, the uterine artery blood flow parameters of the three groups gradually decreased. In the middle luteal phase, the uterine artery blood flow parameters (mRI, mPI, mS/D) of the recurrent spontaneous abortion group, that is, the aspirin and combination groups, were significantly higher than those of the control group. Uterine artery blood flow parameters from 10 to 20 weeks of gestation were as follows: combined group < aspirin group < normal pregnancy group. The mean resistance index (mRI) in the combination group decreased most rapidly compared with the aspirin group between 10 and 20 weeks of gestation. The live birth rate was higher in the combination group than in the aspirin group. CONCLUSIONS Both aspirin and aspirin combined with LMWH can reduce uterine artery blood flow parameters, and combination therapy is superior to aspirin alone. In the RSA group, the rate of mRI decline may predict pregnancy outcome to some extent. Combination therapy can improve the live birth rate and reduce the miscarriage rate.
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Affiliation(s)
- Xiaolu Lian
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhansheng Pan
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fei Xia
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Caiping Mao
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Weiqin Zhou
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yanyu Zhong
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ying Zhou
- Reproductive Medicine Centre, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Mohammad-Akbari A, Mohazzab A, Tavakoli M, Karimi A, Zafardoust S, Zolghadri Z, Shahali S, Tokhmechi R, Ansaripour S. The effect of low-molecular-weight heparin on live birth rate of patients with unexplained early recurrent pregnancy loss: A two-arm randomized clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2022; 27:78. [PMID: 36438075 PMCID: PMC9693726 DOI: 10.4103/jrms.jrms_81_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/26/2022] [Accepted: 05/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The effect of anticoagulant medication in unexplained early recurrent pregnancy loss (RPL) patients is controversial. This clinical trial evaluated the effect of low-molecular-weight heparin (LMWH) on pregnancy outcomes in these patients. MATERIALS AND METHODS The study was performed as a single-blind randomized clinical trial between 2016 and 2018. Samples were selected from patients who were referred to Avicenna RPL clinic with a history of at least two previously happened early unexplained miscarriages. The eligibility was defined strictly to select unexplained RPL patients homogenously. One hundred and seventy-three patients who got pregnant recently were allocated randomly into two groups LMWH plus low-dose aspirin treatment (Group A = 85) and low-dose aspirin treatment only (Group B = 88)) and were followed up till their pregnancy termination (delivery/abortion). A per-protocol analysis was carried out and all statistical tests were two-sided with a P < 0.05 significance level. RESULTS The live birth rates (LBRs) in Groups A and B were 78% and 77.1%, respectively, which did not show any statistically significant difference between the two groups, neither in rates nor in time of abortion. In subgroup analysis for polycystic ovary syndrome (PCOS) patients, the odds ratio for study outcome (intervention/control) was 2.25 (95% confidence interval: 0.65-7.73). There was no major adverse event whereas minor bleeding was observed in 18% of patients in Group A. CONCLUSION LMWH does not improve the LBR in unexplained RPL patients, however, it is recommended to evaluate its effect separately in PCOS patients.
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Affiliation(s)
- Azam Mohammad-Akbari
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Arash Mohazzab
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Tavakoli
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran
| | - Atousa Karimi
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Simin Zafardoust
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Zhaleh Zolghadri
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Shadab Shahali
- Department of Reproductive Health and Midwifery, Tarbiat Modares University, Tehran, Iran
| | | | - Soheila Ansaripour
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran,Address for correspondence: Prof. Soheila Ansaripour, Avicenna Research Institute, Evin, Daneshjoo Blvd, Chamran Exp.Way, Tehran 1936773493, Iran. E-mail:
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Dai YF, Lin LZ, Lin N, He DQ, Guo DH, Xue HL, Li Y, Xie X, Xu LP, He SQ. APA scoring system: a novel predictive model based on risk factors of pregnancy loss for recurrent spontaneous abortion patients. J OBSTET GYNAECOL 2022; 42:2069-2074. [PMID: 35048758 DOI: 10.1080/01443615.2021.2021507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yi-Fang Dai
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Li-Zhen Lin
- Department of Gynecology and Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Na Lin
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - De-Qin He
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Dan-Hua Guo
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Hui-Li Xue
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Ying Li
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Xi Xie
- Department of Gynecology and Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Liang-Pu Xu
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
| | - Shu-Qiong He
- Center of Prenatal Diagnosis, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory for Prenatal diagnosis and Birth Defect, Fuzhou, China
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6
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Yan X, Wang D, Yan P, Li H. Low molecular weight heparin or LMWH plus aspirin in the treatment of unexplained recurrent miscarriage with negative antiphospholipid antibodies: A meta-analysis of randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2021; 268:22-30. [PMID: 34794071 DOI: 10.1016/j.ejogrb.2021.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Unexplained recurrent miscarriage (uRM) has caused serious distress to women of childbearing age, and effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of low molecular weight heparin (LMWH) and LMWH combined with aspirin for uRM. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported the LMWH or LMWH combined with aspirin for women with uRM and negative antiphospholipid antibodies (aPL). The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data, and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS A total of 7 studies involving 1849 patients were included. The meta-analysis results showed that compared with the control group, both LMWH and LMWH + aspirin interventions showed no substantial influence on miscarriage rate (LMWH: RR = 0.69, 95%CI: 0.34-1.39, P = 0.293, LMWH + aspirin: RR = 0.62, 95%CI: 0.30-1.27, P = 0.19) and the occurrence of pre-eclampsia (LMWH: RR = 1.1, 95%CI: 0.53-2.31, P = 0.792; LMWH + aspirin: RR = 1.49, 95%CI: 0.25-8.79, P = 0.662). LMWH therapy had no influence on the live births (RR = 0.99, 95%CI: 0.92-1.06, P = 0.72). Subgroup analysis showed that enoxaparin is not effective in women with uRM and negative aPL (miscarriage rate: RR = 0.82, 95%CI: 0.31-2.19, P = 0.695; pre-eclampsia: RR = 1.03, 95%CI: 0.46-2.33, P = 0.936). CONCLUSIONS LMWH and LMWH combined with aspirin therapy cannot improve the pregnancy outcome of women with uRM and negative aPL. However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
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Affiliation(s)
- Xiaoli Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan Wang
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ping Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongyu Li
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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7
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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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Zhang K, Wang E, Li Y, Xu H, Zhang J, Wang X, Shu J. Role of low-molecular-weight heparin in altering uterine artery blood flow in recurrent spontaneous abortion: a prospective study. J Int Med Res 2021; 48:300060520945558. [PMID: 32780610 PMCID: PMC7557691 DOI: 10.1177/0300060520945558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study aimed to determine the role of uterine artery blood flow (UABF) in recurrent spontaneous abortion (RSA) and to determine a viable option to promote the outcome of pregnancy. METHODS A total of 421 women were prospectively recruited for this research. UABF indices, including the systolic/diastolic ratio, pulsatility index and resistance index, during the midluteal phase were compared between patients with RSA and women without RSA (controls). After low-molecular-weight heparin (LMWH) was administered to patients with RSA, indices at 7, 10, and 12 weeks of gestation were compared between the two groups. RESULTS UABF indices during the midluteal phase were significantly higher in the RSA group than in the control group. After LMWH was administered to the RSA group, UABF indices in the first trimester were similar to those in the control group. The rate of spontaneous miscarriage was also similar between the groups after LMWH treatment. CONCLUSIONS Our study shows that sufficient uterine perfusion is crucial for a successful pregnancy. LMWH reduces the rate of spontaneous miscarriage in patients with RSA to a similar rate in women without RSA. LMWH might play a role in decreasing UABF resistance and increasing uterine perfusion.
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Affiliation(s)
- Kemei Zhang
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
| | - Ensheng Wang
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
| | - Yang Li
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
| | - Haiyan Xu
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
| | - Jiaou Zhang
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
| | - Xuhong Wang
- Ultrosonic Department, Ningbo First Hospital, Zhejiang, China
| | - Jing Shu
- Reproductive Medicine Centre, Ningbo First Hospital, Zhejiang, China
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Bettiol A, Avagliano L, Lombardi N, Crescioli G, Emmi G, Urban ML, Virgili G, Ravaldi C, Vannacci A. Pharmacological Interventions for the Prevention of Fetal Growth Restriction: A Systematic Review and Network Meta-Analysis. Clin Pharmacol Ther 2021; 110:189-199. [PMID: 33423282 DOI: 10.1002/cpt.2164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/08/2022]
Abstract
The prevention of fetal growth restriction (FGR) is challenging in clinical practice. To date, no meta-analysis summarized evidence on the relative benefits and harms of pharmacological interventions for FGR prevention. We performed a systematic review and network meta-analysis (NetMA), searching PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception until November 2019. We included clinical trials and observational studies on singleton gestating women evaluating antiplatelet, anticoagulant, or other treatments, compared between each other or with controls (placebo or no treatment), and considering the pregnancy outcome FGR (primary outcome of the NetMA). Secondary efficacy outcomes included preterm birth, placental abruption, and fetal or neonatal death. Safety outcomes included bleeding and thrombocytopenia. Network meta-analyses using a frequentist framework were conducted to derive odds ratios (ORs) and 95% confidence intervals (CIs). Of 18,780 citations, we included 30 studies on 4,326 patients. Low molecular weight heparin (LMWH), alone or associated with low-dose aspirin (LDA), appeared more efficacious than controls in preventing FGR (OR 2.00, 95% CI 1.27-3.16 and OR 2.67, 95% CI 1.21-5.89 for controls vs. LMWH and LDA + LMWH, respectively). No difference between active treatments emerged in terms of FGR prevention, but estimates for treatments other than LMWH +/- LDA were imprecise. Only the confidence in the evidence regarding LMWH vs. controls was judged as moderate, according to the Confidence in Network Meta-Analysis framework. No treatment was associated with an increased risk of bleeding, although estimates were precise enough only for LMWH. These results should inform clinicians on the benefits of active pharmacological prophylaxis for FGR prevention.
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Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Laura Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milan, Milan, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Claudia Ravaldi
- PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
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10
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Dias ATB, Modesto TB, Oliveira SAD. Effectiveness of the use of Low Molecular Heparin in patients with repetition abortion history: Systematic review and meta-analysis. JBRA Assist Reprod 2021; 25:10-27. [PMID: 32598832 PMCID: PMC7863102 DOI: 10.5935/1518-0557.20200042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of using low molecular weight heparin (LMWH) in women with a history of recurrent abortion without an identified cause. Methods: To develop a systematic review to select the studies. Total found 437 papers. Seven studies were completed or requested. The following variables were analyzed: clinical pregnancy, implantation rate, live births, abortion, premature birth, pregnancy, continuous pregnancy, beyond the 20th gestational week, congenital abnormality, hemorrhage, preeclampsia, placental premature detachment. Results: The LMWH group had a higher incidence of continuous pregnancy after the 20th week of gestation and there was no significant difference between the LMWH group and the expectant management group in the analysis of other variables. Conclusions: There was no data showing risk and/or less use of LMWH compared to expectant management; on the contrary, LMWH use increased the incidence of evolutionary pregnancy after the 20th gestational week. LMWH has some influence on prophylactic treatment of repeat abortion for unknown cause.
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Affiliation(s)
| | - Tauane Bahia Modesto
- State University of Bahia (UNEB) - Life Sciences Department. Salvador - Bahia - Brazil
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11
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The role of low molecular weight heparin on recurrent pregnancy loss: A systematic review and meta-analysis. Taiwan J Obstet Gynecol 2021; 60:1-8. [PMID: 33494980 DOI: 10.1016/j.tjog.2020.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
To assess the roles of the low molecular weight heparin (LMWH) on recurrent pregnancy loss (RPL). The relevant studies of all randomized controlled trials (RCTs) were retrieved, and the systematic evaluation was conducted. PubMed, Embase, and Cochrane library databases were searched by using keywords, including low-molecular-weight heparin or LMWH, and recurrent miscarriage or recurrent pregnancy loss in pregnant women from their earliest data to February 2020. Two investigators independently evaluated eligibility. Risk ratios (RRs) and their corresponding 95% confidence interval (CI) were determined. To pool the results, this meta-analysis was performed using random-effect model due to the high heterogeneity among these eight studies. A total of eight RCTs involving 1854 participants were included in the meta-analysis involving 963 patients with RPL who were prescribed LMWH (enoxaparin, tinzaparin, or dalteparin) alone and 891 patients who were treated with no LMWH interventions (placebo, folic acid or non-treatment) were compared. Pooled data from the remaining eight RCTs showed the differences between intervention groups and control groups. Compared with control groups, LMWH had significantly improved live births (RR,1.19; 95%CI, 1.03 to 1.38; P = 0.02), and reduced miscarriage rates (RR, 0.62; 95%CI, 0.43 to 0.91; P = 0.01). The study suggested that LMWH could improve the live births and reduce the miscarriage rates of RPL. Therefore, LMWH might be a good treatment choice for women with unexplained PRL.
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Awolumate OJ, Kang A, Khokale R, Cancarevic I. Role of Low Molecular Weight Heparin in the Management of Unexplained Recurrent Pregnancy Loss: A Review of Literature. Cureus 2020; 12:e10956. [PMID: 33083161 PMCID: PMC7567305 DOI: 10.7759/cureus.10956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Recurrent pregnancy loss remains a significant challenge in gynecological practice, accounting for about 2%-4% of pregnancies. In some patients, the etiology is unknown. Unexplained recurrent pregnancy loss (URPL) refers to the spontaneous loss of three or more consecutive pregnancies without an identifiable risk factor, accounting for about 40%-50% of pregnancy losses. The review aims to understand the role of low molecular weight heparin (LMWH) in the treatment of URPL. Articles for this review have been found in the PubMed database, and studies published more than ten years before the review excluded. The articles were reviewed to determine the effect of LMWH on live birth rates, reduced late pregnancy complications, and adverse drug reactions following its use. Many studies show improved live birth rates in women treated with LMWH compared to the control, while some studies show no improvement. There was no statistically significant difference in reducing late pregnancy complications, such as preeclampsia, intrauterine growth restriction, preterm labor, and low birth weight, in either study and control groups. Adverse drug reaction was rare among women treated with LMWH and, if present, was mild and self-limiting, thus making it a safe therapy. More studies, preferably large multicenter randomized controlled trials, need to be conducted on the use of LMWH to establish a consensus guideline on the treatment of URPL.
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Affiliation(s)
- Oluwatayo J Awolumate
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ayesha Kang
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rhutuja Khokale
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Hold your needles in women with recurrent pregnancy losses with or without hereditary thrombophilia: Meta-analysis and review of the literature. J Gynecol Obstet Hum Reprod 2020; 50:101935. [PMID: 33035720 DOI: 10.1016/j.jogoh.2020.101935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The use of antithrombotic prophylaxis in women with recurrent pregnancy losses (RPL) remains controversial. METHODS We performed meta-analysis of randomized controlled trials (RCTs) comparing low molecular weight heparin (LMWH) versus No LMWH in women with or without hereditary thrombophilia and RPL. Twelve RCTs met our inclusion criteria and 2298 women were included in this meta-analysis. Our primary end point was live birth and odds ratio (OR) for live birth are reported. RESULTS In women with thrombophilia the benefit of LMWH on live birth is not significant but heterogeneity of the studies is significant (OR, 2.09; 95 % CI, 0.58-7.57; p = 0.26; I2 = 86 %, p = 0.0001). Considering women without thrombophilia there is no benefit of LMWH in OR of live birth and data from studies have low heterogeneity (OR, 1.25; 95 % CI, 0.88-1.78; p = 0 0.21; I2 = 44 %, p = 0.07). CONCLUSIONS Hold your needles in women with RPL. Probably in some hereditary thrombophilic defects LMWH has a positive effect on OR for live birth.
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Nascimento S, Rodrigues M, Gonçalves Henriques M, Paixão Duarte F, Barra A, Matos T. Pregnancy with anti-PP1Pk antibody managed with prednisolone and low-molecular-weight heparin - A case report and literature review. Case Rep Womens Health 2020; 27:e00238. [PMID: 32642450 PMCID: PMC7334791 DOI: 10.1016/j.crwh.2020.e00238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022] Open
Abstract
The anti-PP1Pk is a rare antibody associated with recurrent miscarriages, mainly in the first half of pregnancy. There seems to be a direct correlation between the antibody titer and risk of miscarriage. As this is a rare entity, few case reports have been published. The most frequently proposed therapeutic approaches are double-filtration plasmapheresis and plasma exchange therapy. The rationale behind them is to remove the cytotoxic antibodies from maternal circulation. Here, we present the case of a 30-year-old woman with a history of two spontaneous miscarriages and a pre-conception anti-PP1Pk antibody titer of 1:4. As soon as she became pregnant, she was placed on prednisolone and low-molecular-weight heparin (LMWH). Biweekly antibody titers were performed throughout the entire gestation and remained below 1:16. As the titers were considered to be low, plasmapheresis was not performed. The pregnancy was uneventful and she delivered a healthy newborn child at 37 weeks of gestation, with no signs of anaemia.
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Affiliation(s)
- Sara Nascimento
- Corresponding author at: Hospital Prof. Doutor Fernando Fonseca, IC 19, 2760-276 Amadora, Portugal.
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15
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Li J, Gao YH, Xu L, Li ZY. Meta-analysis of heparin combined with aspirin versus aspirin alone for unexplained recurrent spontaneous abortion. Int J Gynaecol Obstet 2020; 151:23-32. [PMID: 32535924 DOI: 10.1002/ijgo.13266] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/23/2020] [Accepted: 06/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Unexplained recurrent spontaneous abortion (URSA) frustrates women of childbearing age profoundly, and effective therapies are particularly important. OBJECTIVE To compare the efficacy of heparin combined with aspirin and aspirin alone for URSA. SEARCH STRATEGY Electronic databases (PubMed, Medline, Web of Science, Clinical key and Cochrane Library) were searched for relevant studies from database inception to August 2019. SELECTION CRITERIA Studies of women of childbearing age with at least two consecutive abortions were included. DATA COLLECTION AND ANALYSIS Relevant items were extracted, tabulated, and subjected to STATA for data analysis. Study women were divided into group A (taking heparin plus aspirin) and group B (taking aspirin alone). The primary outcome was the rate of live birth. MAIN RESULTS Women from eight randomized controlled trials were included: 493 in group A and 501 in group B. The number of live births was significantly higher in group A (P=0.003). The result remained the same in subgroup analysis by presence of antiphospholipid antibodies. Among women who had a live birth, gestational age at delivery tended to be older in group B (P=0.054). No differences in birthweight or intrauterine growth restriction were observed. Adverse effects were sporadically reported. CONCLUSION Among women with URSA, heparin combined with aspirin increased the live birth rate as compared with aspirin alone. There was a beneficial tendency of taking aspirin-only to prolong gestation week.
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Affiliation(s)
- Jie Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Yue-Hua Gao
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Lin Xu
- Department of Gynecology and Obstetrics, Anyi People's hospital, Nanchang, PR China
| | - Zeng-Yan Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, PR China
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Rasmark Roepke E, Bruno V, Nedstrand E, Boij R, Strid CP, Piccione E, Berg G, Svensson-Arvelund J, Jenmalm MC, Rubér M, Ernerudh J. Low-molecular-weight-heparin increases Th1- and Th17-associated chemokine levels during pregnancy in women with unexplained recurrent pregnancy loss: a randomised controlled trial. Sci Rep 2019; 9:12314. [PMID: 31444404 PMCID: PMC6707182 DOI: 10.1038/s41598-019-48799-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/13/2019] [Indexed: 11/29/2022] Open
Abstract
Low-molecular-weight heparin (LMWH) is widely used to treat recurrent pregnancy loss (RPL) because of its anti-coagulant effects. Although in vitro studies have suggested additional immunological effects, these are debated. We therefore investigated whether LMWH could modulate immune responses in vivo during pregnancy of women with unexplained RPL. A Swedish open multi-centre randomised controlled trial included 45 women treated with tinzaparin and 42 untreated women. Longitudinally collected plasma samples were obtained at gestational weeks (gw) 6, 18, 28 and 34 and analysed by multiplex bead technology for levels of 11 cytokines and chemokines, chosen to represent inflammation and T-helper subset-associated immunity. Mixed linear models test on LMWH-treated and untreated women showed differences during pregnancy of the Th1-associated chemokines CXCL10 (p = 0.01), CXCL11 (p < 0.001) and the Th17-associated chemokine CCL20 (p = 0.04), while CCL2, CCL17, CCL22, CXCL1, CXCL8, CXCL12, CXCL13 and IL-6 did not differ. Subsequent Student's t-test showed significantly higher plasma levels of CXCL10 and CXCL11 in treated than untreated women at gw 28 and 34. The consistent increase in the two Th1-associated chemokines suggests a potential proinflammatory and unfavourable effect of LMWH treatment during later stages of pregnancy, when Th1 immunity is known to disrupt immunological tolerance.
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Affiliation(s)
- E Rasmark Roepke
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö and Lund University, Lund, Sweden.
| | - V Bruno
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Section of Gynecology and Obstetrics, Academic Department of Biomedicine and Prevention, and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - E Nedstrand
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - R Boij
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - C Petersson Strid
- Departmen of Obstetrics and Gynecology, Kalmar Hospital, Kalmar, Sweden
| | - E Piccione
- Section of Gynecology and Obstetrics, Academic Department of Biomedicine and Prevention, and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - G Berg
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - J Svensson-Arvelund
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - M C Jenmalm
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - M Rubér
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - J Ernerudh
- Department of Clinical Immunology and Transfusion Medicine, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Wojcieszek AM, Shepherd E, Middleton P, Lassi ZS, Wilson T, Murphy MM, Heazell AEP, Ellwood DA, Silver RM, Flenady V. Care prior to and during subsequent pregnancies following stillbirth for improving outcomes. Cochrane Database Syst Rev 2018; 12:CD012203. [PMID: 30556599 PMCID: PMC6516997 DOI: 10.1002/14651858.cd012203.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Stillbirth affects at least 2.6 million families worldwide every year and has enduring consequences for parents and health services. Parents entering a subsequent pregnancy following stillbirth face a risk of stillbirth recurrence, alongside increased risks of other adverse pregnancy outcomes and psychosocial challenges. These parents may benefit from a range of interventions to optimise their short- and longer-term medical health and psychosocial well-being. OBJECTIVES To assess the effects of different interventions or models of care prior to and during subsequent pregnancies following stillbirth on maternal, fetal, neonatal and family health outcomes, and health service utilisation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 June 2018), along with ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 June 2018). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs). Trials using a cluster-randomised design were eligible for inclusion, but we found no such reports. We included trials published as abstract only, provided sufficient information was available to allow assessment of trial eligibility and risk of bias. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and undertook data extraction and 'Risk of bias' assessments. We extracted data from published reports, or sourced data directly from trialists. We checked the data for accuracy and resolved discrepancies by discussion or correspondence with trialists, or both. We conducted an assessment of the quality of the evidence using the GRADE approach. MAIN RESULTS We included nine RCTs and one qRCT, and judged them to be at low to moderate risk of bias. Trials were carried out between the years 1964 and 2015 and took place predominantly in high-income countries in Europe. All trials assessed medical interventions; no trials assessed psychosocial interventions or incorporated psychosocial aspects of care. Trials evaluated the use of antiplatelet agents (low-dose aspirin (LDA) or low-molecular-weight heparin (LMWH), or both), third-party leukocyte immunisation, intravenous immunoglobulin, and progestogen. Trial participants were women who were either pregnant or attempting to conceive following a pregnancy loss, fetal death, or adverse outcome in a previous pregnancy.We extracted data for 222 women who had experienced a previous stillbirth of 20 weeks' gestation or more from the broader trial data sets, and included them in this review. Our GRADE assessments of the quality of evidence ranged from very low to low, due largely to serious imprecision in effect estimates as a result of small sample sizes, low numbers of events, and wide confidence intervals (CIs) crossing the line of no effect. Most of the analyses in this review were not sufficiently powered to detect differences in the outcomes assessed. The results presented are therefore largely uncertain.Main comparisonsLMWH versus no treatment/standard care (three RCTs, 123 women, depending on the outcome)It was uncertain whether LMWH reduced the risk of stillbirth (risk ratio (RR) 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), adverse perinatal outcome (RR 0.81, 95% CI 0.20 to 3.32; 2 trials; 77 participants; low-quality evidence), adverse maternal psychological effects (RR 1.00, 95% CI 0.07 to 14.90; 1 trial; 40 participants; very low-quality evidence), perinatal mortality (RR 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), or any preterm birth (< 37 weeks) (RR 1.01, 0.58 to 1.74; 3 trials; 114 participants; low-quality evidence). No neonatal deaths were reported in the trials assessed and no data were available for maternal-infant attachment. There was no clear evidence of a difference between the groups among the remaining secondary outcomes.LDA versus placebo (one RCT, 24 women)It was uncertain whether LDA reduced the risk of stillbirth (RR 0.85, 95% CI 0.06 to 12.01), neonatal death (RR 0.29, 95% CI 0.01 to 6.38), adverse perinatal outcome (RR 0.28, 95% CI 0.03 to 2.34), perinatal mortality, or any preterm birth (< 37 weeks) (both of the latter RR 0.42, 95% CI 0.04 to 4.06; all very low-quality evidence). No data were available for adverse maternal psychological effects or maternal-infant attachment. LDA appeared to be associated with an increase in birthweight (mean difference (MD) 790.00 g, 95% CI 295.03 to 1284.97 g) when compared to placebo, but this result was very unstable due to the extremely small sample size. Whether LDA has any effect on the remaining secondary outcomes was also uncertain.Other comparisonsLDA appeared to be associated with an increase in birthweight when compared to LDA + LMWH (MD -650.00 g, 95% CI -1210.33 to -89.67 g; 1 trial; 29 infants), as did third-party leukocyte immunisation when compared to placebo (MD 1195.00 g, 95% CI 273.35 to 2116.65 g; 1 trial, 4 infants), but these results were again very unstable due to extremely small sample sizes. The effects of the interventions on the remaining outcomes were also uncertain. AUTHORS' CONCLUSIONS There is insufficient evidence in this review to inform clinical practice about the effectiveness of interventions to improve care prior to and during subsequent pregnancies following a stillbirth. There is a clear and urgent need for well-designed trials addressing this research question. The evaluation of medical interventions such as LDA, in the specific context of stillbirth prevention (and recurrent stillbirth prevention), is warranted. However, appropriate methodologies to evaluate such therapies need to be determined, particularly where clinical equipoise may be lacking. Careful trial design and multicentre collaboration is necessary to carry out trials that would be sufficiently large to detect differences in statistically rare outcomes such as stillbirth and neonatal death. The evaluation of psychosocial interventions addressing maternal-fetal attachment and parental anxiety and depression is also an urgent priority. In a randomised-trial context, such trials may allocate parents to different forms of support, to determine which have the greatest benefit with the least financial cost. Importantly, consistency in nomenclature and in data collection across all future trials (randomised and non-randomised) may be facilitated by a core outcomes data set for stillbirth research. All future trials should assess short- and longer-term psychosocial outcomes for parents and families, alongside economic costs of interventions.
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Affiliation(s)
- Aleena M Wojcieszek
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
| | - Emily Shepherd
- The University of AdelaideRobinson Research Institute, Discipline of Obstetrics and Gynaecology, Adelaide Medical SchoolAdelaideSouth AustraliaAustralia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSAAustralia
| | - Zohra S Lassi
- The University of AdelaideThe Robinson Research InstituteAdelaideSouth AustraliaAustralia5005
| | - Trish Wilson
- Trish Wilson Counselling61A Brecon CrescentBuderimQLDAustralia4556
| | - Margaret M Murphy
- University College CorkSchool of Nursing and MidwiferyBrookfield Health Sciences ComplexCollege RoadCorkIrelandT12 AK54
| | - Alexander EP Heazell
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - David A Ellwood
- Griffith UniversitySchool of MedicineGold Coast CampusLevel 8, G40Gold CoastQueensland,Australia4216
| | - Robert M Silver
- University of UtahDivision of Maternal‐Fetal Medicine, Health Services Center30 North 1900 East SOM 2B200Salt Lake CityUtahUSA84132
| | - Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
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Lv S, Yu J, Xu X. A comparison of effectiveness among frequent treatments of recurrent spontaneous abortion: A Bayesian network meta-analysis. Am J Reprod Immunol 2018; 80:e12856. [PMID: 29709100 DOI: 10.1111/aji.12856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/21/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE A comprehensive network meta-analysis was designed to clarify contradictions and offer valuable clinical guidance in the treatment of recurrent spontaneous abortion (RSA). METHOD The included clinical trials were selected from the relevant medical journal databases and screened. Treatments were ranked by the surface under the cumulative ranking curve. Heat plots were constructed to analyze the inconsistency between direct data and network results, and adjusted funnel plots were constructed to assess publication bias. RESULTS Forty-nine randomized controlled trials involving a total of 8496 RSA patients were selected. With placebo as control, corticosteroid plus low dose aspirin (LDA) plus unfractionated heparin (UFH), granulocyte colony-stimulating factor (G-CSF) alone, and LDA plus low molecular weight heparin (LMWH) all demonstrated effectiveness in increasing successful live birth rates and reducing the incidences of miscarriage. However, no treatment was demonstrably superior to placebo in terms of pregnancy success. For all 3 endpoints (live birth, abortion and success pregnancy), the adjusted funnel plots were symmetric to zero and indicated no publication bias. In terms of live birth and abortion rates, no treatment outperformed placebo in patients with antiphospholipid syndrome. CONCLUSION In consideration of live birth and abortion rates, corticosteroid plus LDA plus UFH appeared to be the optimum treatment strategy; G-CSF was second, followed by LDA with LMWH, LDA plus LMWH plus intravenous immunoglobulin, corticosteroid with LDA and others. Subgroup analysis demonstrated no benefit of antithrombotic therapy in patients with antiphospholipid syndrome.
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Affiliation(s)
- Sha Lv
- Department of Gynaecology and Obstetrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jing Yu
- Department of Medical Imaging, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xiaoxiao Xu
- Department of Gynaecology and Obstetrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Rasmark Roepke E, Hellgren M, Hjertberg R, Blomqvist L, Matthiesen L, Henic E, Lalitkumar S, Strandell A. Treatment efficacy for idiopathic recurrent pregnancy loss - a systematic review and meta-analyses. Acta Obstet Gynecol Scand 2018; 97:921-941. [PMID: 29603135 DOI: 10.1111/aogs.13352] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/21/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Medical treatment of women with idiopathic recurrent pregnancy loss is controversial. The objective was to assess the effects of different treatments on live birth rates and complications in women with unexplained recurrent pregnancy loss. MATERIAL AND METHODS We searched MEDLINE, Embase and the Cochrane Library, and identified 1415 publications. This systematic review included 21 randomized controlled trials regarding acetylsalicylic acid, low-molecular-weight heparin, progesterone, intravenous immunoglobulin or leukocyte immune therapy in women with three or more consecutive miscarriages of unknown cause. The study quality was assessed and data was extracted independently by at least two authors. RESULTS No significant difference in live birth rate was found when acetylsalicylic acid was compared with low-molecular-weight heparin or with placebo. Meta-analyses of low-molecular-weight heparin vs. control found no significant differences in live birth rate [risk ratio (RR) 1.47, 95% CI 0.83-2.61]. Treatment with progesterone starting in the luteal phase seemed effective in increasing live birth rate (RR 1.18, 95% CI 1.09-1.27) but not when started after conception. Intravenous immunoglobulin showed no effect on live birth rate compared with placebo (RR 1.07, 95% CI 0.91-1.26). Paternal immunization compared with autologous immunization showed a significant difference in outcome (RR 1.8, 95% CI 1.34-2.41), although the studies were small and at high risk of bias. CONCLUSION The literature does not allow advice on any specific treatment for idiopathic recurrent pregnancy loss, with the exception of progesterone starting from ovulation. We suggest that any treatment for recurrent pregnancy loss should be used within the context of a randomized controlled trial.
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Affiliation(s)
- Emma Rasmark Roepke
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Lennart Blomqvist
- Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Leif Matthiesen
- Department of Obstetrics and Gynecology, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Emir Henic
- Reproductive Medicine Center, Skåne University Hospital, Malmö, Sweden
| | - Sujata Lalitkumar
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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