1
|
Suker A, Li Y, Robson D, Marren A. Australasian recurrent pregnancy loss clinical management guideline 2024, part II. Aust N Z J Obstet Gynaecol 2024. [PMID: 38934293 DOI: 10.1111/ajo.13820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
Part II of the Australasian guideline for the investigation and management of recurrent pregnancy loss (RPL) provides evidence-based guidance on the management of RPL provided. The implications of inherited and acquired thrombophilia with respect to RPL and suggestions for clinical management are provided. Autoimmune factors, including human leukocyte antigen, cytokines, antinuclear antibodies and coeliac antibodies, and guidance for management are discussed. Infective, inflammatory and endometrial causes of RPL are discussed in detail. Environmental and lifestyle factors, male factor and unexplained causes are outlined. Levels of evidence and grades of consensus are provided for all evidence-based statements.
Collapse
Affiliation(s)
- Adriana Suker
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ying Li
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Danielle Robson
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Anthony Marren
- Department of Reproductive Endocrinology and Infertility, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Khattak H, Aleem Husain S, Baker D, Greer I. Use of anticoagulants to improve pregnancy outcomes in couples positive for M2 haplotype: A systematic review. Eur J Obstet Gynecol Reprod Biol 2024; 296:179-184. [PMID: 38452530 DOI: 10.1016/j.ejogrb.2024.02.039] [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: 06/16/2023] [Revised: 02/03/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Placental mediated pregnancy complications (PMPC) are common, often recurring, and pose a significant health risk to mother and fetus. Evidence suggests that the hypercoagulable state associated with many PMPC, could reflect reduced expression of Annexin 5 (ANXA5), a naturally occurring anticoagulant protein in placental tissue. The ANXA5 M2 haplotype is a genetic variant, which results in reduced expression of ANXA5 protein. M2 haplotype carrier couples may therefore be at increased risk of PMPC. Evidence regarding the effectiveness of anticoagulation to prevent PMPC is inconsistent. Furthermore, studies have not selected or stratified for M2 haplotype carriers, in whom there is a predisposition to hypercoagulability, to assess the effectiveness of anticoagulation, which may vary from those without the M2 haplotype. OBJECTIVES AND RATIONALE The aim of this study was to systematically review the current evidence to assess whether anticoagulant treatment improves pregnancy outcomes in couples positive for M2 haplotype. SEARCH METHODS The review was registered on PROSPERO (CRD42022343943). A comprehensive literature search was performed using MEDLINE, Embase and Cochrane collaboration databases from inception to January 2023. Two reviewers assessed the articles for eligibility and extracted the data simultaneously. Primary outcome was successful pregnancy and live birth. Secondary outcomes included PMPC (implantation failure, miscarriage, pre-eclampsia, preterm birth and fetal growth restriction). OUTCOMES From a pool of 410 references, 10 were selected for full text review, of which three studies (a post hoc analysis of a randomised controlled trial, cohort study and a case report) were included in this review. Included studies comprised of 223 individuals, 129 of whom who received anticoagulation treatment after testing positive for M2 haplotype. The studies collectively showed an improvement in pregnancy outcomes in M2 haplotype positive individuals however, given the heterogeneity of studies, it was not possible to conduct a meta-analysis and draw firm conclusions. WIDER IMPLICATIONS Current evidence is limited, such that the value of screening couples for the M2 haplotype to select or stratify for treatment with prophylactic anticoagulation remains unknown. Thus, further studies including well designed, large, multi-centre randomised controlled trials are required to assess whether anticoagulation treatment will be effective in improving pregnancy outcomes in M2 haplotype couples.
Collapse
Affiliation(s)
- Hajra Khattak
- WHO Collaborating Centre for Women's Health, Institute of Translational Medicine, University of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK; Elizabeth Garrett Anderson Institute for Women's Health, University College, London, UK.
| | - Syed Aleem Husain
- Sandwell and West Birmingham NHS Trust, Dudley Rd, Birmingham B18 7QH, UK
| | - Deborah Baker
- IHG Pharmaco Ltd, 20-22 Wenlock Road, London N17GU, UK
| | - Ian Greer
- Queen's University Belfast, University Road, Belfast BT7 1NN, Northern Ireland, UK
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Turesheva A, Aimagambetova G, Ukybassova T, Marat A, Kanabekova P, Kaldygulova L, Amanzholkyzy A, Ryzhkova S, Nogay A, Khamidullina Z, Ilmaliyeva A, Almawi WY, Atageldiyeva K. Recurrent Pregnancy Loss Etiology, Risk Factors, Diagnosis, and Management. Fresh Look into a Full Box. J Clin Med 2023; 12:4074. [PMID: 37373766 DOI: 10.3390/jcm12124074] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Recurrent pregnancy loss is a complex health challenge with no universally accepted definition. Inconsistency in definitions involves not only the number of spontaneous abortions (two or three) that are accepted for recurrent pregnancy loss but the types of pregnancy and gestational age at miscarriage. Due to the heterogeneity of definitions and criteria applied by international guidelines for recurrent pregnancy loss, the true incidence of recurrent miscarriage, which is reported to range from 1% to 5%, is difficult to estimate. Moreover, the exact etiology of recurrent pregnancy loss remains questionable; thus, it is considered a polyetiological and multifactorial condition with many modifiable and non-modifiable factors involved. Even after thoroughly evaluating recurrent pregnancy loss etiology and risk factors, up to 75% of cases remain unexplained. This review aimed to summarize and critically analyze accumulated knowledge on the etiology, risk factors, relevant diagnostic options, and management approach to recurrent pregnancy loss. The relevance of various factors and their proposed roles in recurrent pregnancy loss pathogenesis remains a matter of discussion. The diagnostic approach and the management largely depend on the etiology and risk factors taken into consideration by a healthcare professional as a cause of recurrent miscarriage for a particular woman or couple. Underestimation of social and health consequences of recurrent pregnancy loss leads to compromised reproductive health and psychological well-being of women after miscarriage. Studies on etiology and risk factors for recurrent pregnancy loss, especially idiopathic, should be continued. The existing international guidelines require updates to assist clinical practice.
Collapse
Affiliation(s)
- Akbayan Turesheva
- Department of Normal Physiology, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | | | - Talshyn Ukybassova
- Clinical Academic Department of Women's Health, CF "University Medical Center", Astana 010000, Kazakhstan
| | - Aizada Marat
- Department of Obstetrics and Gynecology #1, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Perizat Kanabekova
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
| | - Lyazzat Kaldygulova
- Department of Obstetrics and Gynecology #2, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Ainur Amanzholkyzy
- Department of Normal Physiology, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Svetlana Ryzhkova
- Department of Obstetrics and Gynecology #2, West-Kazakhstan Marat Ospanov Medical University, Aktobe 030000, Kazakhstan
| | - Anastassiya Nogay
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
| | - Zaituna Khamidullina
- Department of Obstetrics and Gynecology #1, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Aktoty Ilmaliyeva
- Department of Medicine #3, NJSC "Astana Medical University", Astana 010000, Kazakhstan
| | - Wassim Y Almawi
- Faculte' des Sciences de Tunis, Universite' de Tunis El Manar, Tunis 5000, Tunisia
| | - Kuralay Atageldiyeva
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
- Clinical Academic Department of Internal Medicine, CF "University Medical Center", Astana 010000, Kazakhstan
| |
Collapse
|
5
|
Brenner B, Papadakis E, Greer IA, Gris JC. Assessment-based management of placenta-mediated pregnancy complications: Pragmatism until a precision medicine approach evolves. Br J Haematol 2023. [PMID: 37169354 DOI: 10.1111/bjh.18856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 05/13/2023]
Abstract
The management of pregnant women with thrombophilia and a history of gestational vascular complications remains debatable. Treatment of the latter is often based on clinical outcome rather than disease mechanism. While the use of venous thromboembolism prophylaxis in pregnancy is recommended for those at increased risk, the ability of anticoagulant and/or antiplatelet agents to lower the risk of placenta-mediated complications in this clinical setting remains controversial. The available guidelines are inconsistent in some situations, which reflects the limited evidence base. This review critically discusses risk assessment models (RAMs) and management strategies of women with thrombophilia and pregnancy complications, using clinical vignettes. RAMs, taking into account obstetric and thrombotic history as well as thrombophilia status, could drive a precision medicine approach, based on disease mechanism, and guide individual therapeutic interventions in high-risk clinical settings.
Collapse
Affiliation(s)
- Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Emmanouil Papadakis
- Thrombosis & Hemostasis Clinic, Ob/Gyn Hematology, Genesis Hospital, Thessaloniki, Greece
| | | | - Jean-Christophe Gris
- Department of Haematology, CHU Nîmes, University of Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP-Montpellier University, Montpellier, France
- Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| |
Collapse
|
6
|
Giouleka S, Tsakiridis I, Arsenaki E, Kalogiannidis I, Mamopoulos A, Papanikolaou E, Athanasiadis A, Dagklis T. Investigation and Management of Recurrent Pregnancy Loss: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2023; 78:287-301. [PMID: 37263963 DOI: 10.1097/ogx.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Importance Recurrent pregnancy loss (RPL) is one of the most frustrating clinical entities in reproductive medicine requiring not only diagnostic investigation and therapeutic intervention, but also evaluation of the risk for recurrence. Objective The aim of this study was to review and compare the most recently published major guidelines on investigation and management of RPL. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, the American Society for Reproductive Medicine, the French College of Gynecologists and Obstetricians, and the German, Austrian, and Swiss Society of Gynecology and Obstetrics on RPL was carried out. Results There is consensus among the reviewed guidelines that the mainstays of RPL investigation are a detailed personal history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus. In contrast, inherited thrombophilias, vaginal infections, and immunological and male factors of infertility are not recommended as part of a routine RPL investigation. Several differences exist regarding the necessity of the cytogenetic analysis of the products of conception, parental peripheral blood karyotyping, ovarian reserve testing, screening for thyroid disorders, diabetes or hyperhomocysteinemia, measurement of prolactin levels, and performing endometrial biopsy. Regarding the management of RPL, low-dose aspirin plus heparin is indicated for the treatment of antiphospholipid syndrome and levothyroxine for overt hypothyroidism. Genetic counseling is required in case of abnormal parental karyotype. The Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, and the French College of Gynecologists and Obstetricians guidelines provide recommendations that are similar on the management of cervical insufficiency based on the previous reproductive history. However, there is no common pathway regarding the management of subclinical hypothyroidism and the surgical repair of congenital and acquired uterine anomalies. Use of heparin for inherited thrombophilias and immunotherapy and anticoagulants for unexplained RPL are not recommended, although progesterone supplementation is suggested by the American Society for Reproductive Medicine and the German, Austrian, and Swiss Society of Gynecology and Obstetrics. Conclusions Recurrent pregnancy loss is a devastating condition for couples. Thus, it seems of paramount importance to develop consistent international practice protocols for cost-effective investigation and management of this early pregnancy complication, with the aim to improve live birth rates.
Collapse
Affiliation(s)
| | - Ioannis Tsakiridis
- Consultant in Maternal-Fetal Medicine, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisavet Arsenaki
- Foundation Trainee Doctor, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Evangelos Papanikolaou
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Abbattista M, Capecchi M, Gianniello F, Artoni A, Bucciarelli P, Ciavarella A, Peyvandi F, Martinelli I. A retrospective study on the use of low-molecular-weight heparin for prevention of pregnancy-related recurrent venous thromboembolism and obstetrical complications. Blood Coagul Fibrinolysis 2023; 34:111-117. [PMID: 36598379 DOI: 10.1097/mbc.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is increased during pregnancy and it is further increased together with pregnancy complications in women with personal history of VTE and thrombophilia abnormalities. It is unclear how the use of low-molecular-weight heparin (LMWH) may prevent such complications. OBJECTIVE To evaluate the potential benefits and risks of the use of LMWH for prevention of pregnancy-related VTE and obstetrical complications in the first pregnancy after a previous VTE. METHODS This retrospective cohort study includes fertile women referred to the Thrombosis Center from January 2000 to September 2018 for a thrombophilia work-up, after having had at least one previous VTE and one pregnancy thereafter. Data on pregnancy-related recurrent VTE, pregnancy outcomes and the use of LMWH were collected. RESULTS Among 208 women, no thrombosis or major bleeding was recorded in 138 pregnancies conducted with LMWH, whereas 10 VTE (14%) were recorded in 70 pregnancies conducted without. Nine women (90%) with recurrent VTE had had a previous hormone-related event. The incidence of miscarriage was lower in pregnancies with LMWH than in those without (11% vs. 26%, relative risk 0.4, 95% confidence interval: 0.2-0.8), whereas late obstetrical complications and terminations were similar in the two groups. The prevalence of terminations was doubled in women with thrombophilia (12%) than in those without (6%). CONCLUSIONS LMWH prophylaxis during pregnancy appears to be effective and safe for the prevention of recurrent VTE and may reduce the incidence of miscarriage.
Collapse
Affiliation(s)
- Maria Abbattista
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
| | - Marco Capecchi
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
- Università degli Studi di Milano, Department of Biomedical Sciences for Health, Milan, Italy
| | - Francesca Gianniello
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
| | - Alessandro Ciavarella
- Università degli Studi di Milano, Department of Biomedical Sciences for Health, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Centro Emofilia e Trombosi Angelo Bianchi Bonomi
| |
Collapse
|
9
|
Treating unexplained recurrent pregnancy loss based on lessons learned from obstetric antiphospholipid syndrome and inherited thrombophilia: A propensity-score adjusted retrospective study. J Reprod Immunol 2022; 154:103760. [PMID: 36395545 DOI: 10.1016/j.jri.2022.103760] [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: 02/12/2022] [Revised: 09/14/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022]
Abstract
The efficacy of low molecular weight heparin (LMWH) is well-established in patients with obstetric antiphospholipid syndrome (O-APS). Their role in women with unexplained recurrent pregnancy loss (U-RPL) and late obstetrical complications (intrauterine growth restriction, IUGR and preeclampsia) is controversial. Here we compared rates of miscarriage and late obstetrical complications in RPL patients diagnosed with O-APS (n = 57) or hereditary thrombophilia (n = 25) (both assuming LMWH from the beginning of pregnancy) and in patients with a history of U-RPL (n = 118), assuming or not LMWH, followed at the 'Pregnancy at risk' and 'Recurrent pregnancy loss' outpatient clinics at the San Raffaele Hospital from April 2010 to April 2020. Patients with systemic autoimmune diseases other than primary O-APS were excluded. We tested for bivariate or multivariate associations among adverse pregnancy outcomes, the presence of thrombophilia and LMWH use by using chi-square test, Anova, propensity score adjusted univariate logistic regression and multivariate analysis as appropriate. U-RPL patients assuming LMWH from the beginning of pregnancy (group A) had a significantly lower rate of miscarriage compared to U-RPL patients who were not treated with LMWH (group B) (13 % vs. 41 % respectively, p 0.001) and similar pregnancy rates compared to both O-APS patients with a history of RPL taking LMWH (group C, 18 %) and RPL patients with thrombophilia and treated with LMWH (group D, 16 %). Our data highlight a protective effect of LMWH on miscarriage in patients with a history of U-RPL. In these patients, LMWH seems as effective as in O-APS and hereditary thrombophilia in reducing RPL.
Collapse
|
10
|
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.
Collapse
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:
| |
Collapse
|
11
|
Shehata H, Ali A, Silva-Edge M, Haroon S, Elfituri A, Viswanatha R, Jan H, Akolekar R. Thrombophilia screening in women with recurrent first trimester miscarriage: is it time to stop testing? - a cohort study and systematic review of the literature. BMJ Open 2022; 12:e059519. [PMID: 35831047 PMCID: PMC9280906 DOI: 10.1136/bmjopen-2021-059519] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE There are numerous studies reporting a disproportionally high prevalence of thrombophilia in women with a history of recurrent miscarriage (RM), which has led to overdiagnosis and treatment without an improvement in clinical outcomes. The objective of our study was to assess the prevalence of inherited and acquired thrombophilia in a large cohort of women with a history of early RM using internationally agreed diagnostic criteria and inclusion parameters and compare it to the meta-analysis results of existing literature. METHODS DESIGN: Retrospective cohort study and systematic review of literature. SETTING This is a retrospective cohort study set-up in two dedicated tertiary centres for women with RM in Southwest London and Surrey. We reviewed all the available literature related to causes of RMs. We ascertained the prevalence of thrombophilia in the study population and compared it with historical and published prevalence in the general population. PARTICIPANTS 1155 women between 2012 and 2017. All patients had three or more first trimester miscarriages and a full thrombophilia screen. RESULTS The overall prevalence of thrombophilia in our study population is 9.2% (106/1155) with 8.1% (94/1155) of cases positive for inherited thrombophilia, which is similar to the general population; Factor V Leiden (4.9%; 57/1155) and prothrombin gene mutation (2.9%; 34/1155) were the most common inherited thrombophilias, while only 1% (12/1155) tested positive for acquired thrombophilia. Persistent positive lupus anticoagulant (LA) was found in 0.5% (6/1155) and persistent positive anticardiolipin (ACL) antibodies with a value ≥40 U/mL was found in 0.5% (6/1155) of patients. Tests for LA/ACL were performed a minimum of 12 weeks apart thus meeting the revised Sapporo criteria for a diagnosis of antiphospholipid syndrome. CONCLUSION The findings of our study demonstrate that the prevalence of inherited thrombophilia is similar in women with RM to that in the general population. Similarly, the prevalence of acquired thrombophilia, using the revised Sapporo criteria, in the cohort of RMs is similar to that in the general population. Therefore, we do not recommend investigation or treatment of inherited or acquired thrombophilia in women with RM. PROSPERO REGISTRATION NUMBER CRD42020223554.
Collapse
Affiliation(s)
- Hassan Shehata
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Amanda Ali
- Women's Health, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | | | - Shahla Haroon
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Abdullatif Elfituri
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Radhika Viswanatha
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Haider Jan
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Ranjit Akolekar
- Women's Health, Medway Maritime Hospital, Gillingham, Kent, UK
| |
Collapse
|
12
|
Chen Y, Wang T, Liu X, Ye C, Xing D, Wu R, Li F, Chen L. Low molecular weight heparin and pregnancy outcomes in women with inherited thrombophilia: A systematic review and meta-analysis. J Obstet Gynaecol Res 2022; 48:2134-2150. [PMID: 35661489 DOI: 10.1111/jog.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/11/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
AIM To determine whether the use of low molecular weight heparin (LMWH) improves the pregnancy outcomes in women with inherited thrombophilia by conducting a meta-analysis of randomized controlled trials and observational studies. METHODS A systematic literature search of several databases was conducted through September 19, 2020 to identify relevant studies. The outcomes of interest included live birth and adverse pregnancy outcomes (APOs). The overall risk estimates were pooled using random-effects meta-analysis. RESULTS Ten randomized controlled trials and 12 cohort studies were included. In the meta-analyses of randomized controlled trials, the effectiveness of LMWH-treatment was found to be statistically significant in decreasing the risk of APOs (risk ratio [RR] = 0.76; 95% confidence interval [CI]: 0.61-0.95; p = 0.020), rather than in increasing the rate of live birth (RR = 1.12; 95% CI: 0.93-1.34; p = 0.230). In the meta-analyses of cohort studies, results showed that the use of LMWH was associated with a significantly higher proportion of live birth (RR = 1.86; 95% CI: 1.09-3.19; p = 0.020) as well as a significantly lower ratio of APOs (RR = 0.46; 95% CI: 0.31-0.69; p < 0.001) in women with inherited thrombophilia. CONCLUSIONS The use of LMWH may have a potentially beneficial effect on reducing the risk of APOs and even increasing the live birth rate in women with inherited thrombophilia. Further well-designed clinical trials with large samples are needed to address the role of LMWH in improving pregnancy outcomes among pregnant women with inherited thrombophilia.
Collapse
Affiliation(s)
- Yan Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China.,NHC Key Laboratory for Birth Defect for Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Hunan, China
| | - Xiaoling Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Changxiang Ye
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Dexiu Xing
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Rong Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Fang Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China.,Hunan Provincial Key Laboratory of clinical epidemiology, Changsha, Hunan, China
| |
Collapse
|
13
|
Stamou M, Intzes S, Symeonidou M, Bazntiara I, Bezirgiannidou Z, Pentidou A, Misidou C, Liapis K, Margaritis D, Kotsianidis I, Spanoudakis E. Reproductive Failure and Thrombophilia: Not Enough Evidence for a Tight Bond. Acta Haematol 2021; 145:170-175. [PMID: 34879375 DOI: 10.1159/000520439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The role of hereditary thrombophilia in reproductive failure (RF) is strongly debatable. In this retrospective single-center study, we analyzed pregnancy outcome in 175 women screened for thrombophilia after at least one event of RF. RESULTS The prevalence of thrombophilia in our cohort was 33.4%. Pregnancy survival curves were not different according to severity (log-rank, p = 0.302) or type of thrombophilia (log-rank, p = 0.532). In total, 81.7% of 175 subsequent pregnancies were proceeded with LMWH. Concomitant use of ASA was prescribed in 75 pregnancies according to physician choice. The primary endpoint was live birth rate (LBR) that succeeded in 152/175 next pregnancies (86.8%) and late obstetric complications (LOBC) which occurred in 17/175 next pregnancies (9.8%). In logistic regression analysis, neither the severity nor the type of thrombophilia was important for any pregnancy outcome (LBR or LOBC). Considering therapeutic interventions, the use of LMWH ± ASA was not related to LBR or LOBC. The only factor inversely related to LBR was age above the cutoff value of 35.5 years (p = 0.049). CONCLUSIONS Incidence of thrombophilia is increased among women with RF, but the severity or type of thrombophilia is not related to pregnancy outcome.
Collapse
Affiliation(s)
- Maria Stamou
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece,
| | - Stergios Intzes
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Marianthi Symeonidou
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioanna Bazntiara
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Aikaterini Pentidou
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christina Misidou
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Liapis
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Margaritis
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioannis Kotsianidis
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Emmanouil Spanoudakis
- Department of Hematology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| |
Collapse
|
14
|
Grandone E, Tiscia GL, Mastroianno M, Larciprete G, Kovac M, Tamborini Permunian E, Lojacono A, Barcellona D, Bitsadze V, Khizroeva J, Makatsarya A, Cacciola R, Martinelli I, Bucherini E, De Stefano V, Lodigiani C, Colaizzo D, De Laurenzo A, Piazza G, Margaglione M. Findings from a multicentre, observational study on reproductive outcomes in women with unexplained recurrent pregnancy loss: the OTTILIA registry. Hum Reprod 2021; 36:2083-2090. [PMID: 34195794 DOI: 10.1093/humrep/deab153] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/16/2021] [Indexed: 12/20/2022] Open
Abstract
STUDY QUESTION What evaluation and care is offered to women after unexplained recurrent pregnancy loss (RPL) or intra-uterine foetal death (IUFD) and what are the reproductive outcomes? SUMMARY ANSWER Women are assessed for thrombophilia and often treated with low-molecular weight heparin (LMWH) and/or low-dose aspirin (ASA). WHAT IS KNOWN ALREADY Randomized controlled trials (RCTs) on possible efficacy of heparins and/or aspirin have been inconclusive due to limited power to detect a difference and patient heterogeneity. STUDY DESIGN, SIZE, DURATION Prospective multicentre cohort study performed in 12 hospitals in three countries between 2012 and 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS All consecutive pregnant women with recurrent PL (≥3 losses or 2 losses in the presence of at least one euploid foetal karyotype) or at least one IUFD. Eligible women may have undergone thrombophilia testing before conception, at the discretion of local providers. The possible assignment of women to treatments (such as LMWH) was not decided a priori but was determined based on the responsible provider's current practice. Aims of the study were: (i) to evaluate factors associated with pregnancy outcome; (ii) to compare clinical management strategies in women with and without a subsequent successful pregnancy; and (iii) to evaluate characteristics of women who may benefit from antithrombotic therapy. A propensity score matching method was used to balance the differences in baseline characteristics. MAIN RESULTS AND THE ROLE OF CHANCE A matched sample of 265 pregnant women was analysed, with all undergoing thrombophilia screening; 103 out of 119 (86.6%) with and 98/146 (67.1%) without thrombophilia were prescribed with LMWH and/or ASA. Overall, live-births were recorded in 204 cases (77%), PL or IUFD in 61 (23%) pregnancies. Logistic regression showed a significant interaction between thrombophilia and treatment with LMWH (P = 0.03). Findings from sensitivity analysis showed odds ratio (OR) for pregnancy loss in women with inherited or acquired thrombophilia in absence of any treatment was 2.9 (95% CI, 1.4-6.1); the administration of LMWH (with or without ASA) was associated with higher odds of live-birth (OR, 10.6; 95% CI, 5.0-22.3). Furthermore, in women without thrombophilia, the odds of live-birth was significantly and independently associated with LMWH prophylaxis (alone or in association with ASA) (OR, 3.6; 95% CI, 1.7-7.9). LIMITATIONS, REASONS FOR CAUTION While the propensity score matching allows us to balance the differences in baseline characteristics, it does not eliminate all confounding. WIDER IMPLICATIONS OF THE FINDINGS Antithrombotic prophylaxis during pregnancy may be effective in women with otherwise unexplained PL or IUFD, and even more useful in those with thrombophilia. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by Italian Ministry of Health (Ricerca Corrente 2018-2020). Dr G.P. has received research grant support from Bristol Myers Squibb/Pfizer Alliance, Janssen, Boston Scientific Corporation, Bayer, and Portola and consultant fees from Amgen and Agile Therapeutics. Dr E.G. has received consultant fees from Italfarmaco and Sanofi. All other authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER NCT02385461.
Collapse
Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy.,Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Giovanni L Tiscia
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Mario Mastroianno
- Scientific Direction, Fondazione 'Casa Sollievo della Sofferenza', S. Giovanni Rotondo (Foggia), Italy
| | - Giovanni Larciprete
- Department of Obstetrics and Gynecology, Fatebenefratelli Isola Tiberina Hospital, Rome, Italy
| | - Mirjana Kovac
- Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | | | - Andrea Lojacono
- Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Doris Barcellona
- Dipartimento di Scienze Mediche Internistiche, University of Cagliari, Cagliari, Italy
| | - Victoria Bitsadze
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Jamilya Khizroeva
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Alexander Makatsarya
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Rossella Cacciola
- Haemostasis Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ida Martinelli
- Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Eugenio Bucherini
- Unit of Vascular Medicine and Angiology, Civic Hospital of Faenza, Faenza, Italy
| | | | - Corrado Lodigiani
- Thrombosis and Hemorrhagic Center, Humanitas Research Hospital and Humanitas University, Rozzano, Italy
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Antonio De Laurenzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Kobayashi T, Morishita E, Tsuda H, Neki R, Kojima T, Ohga S, Ochiai M, Adachi T, Miyata T. Clinical guidance for peripartum management of patients with hereditary thrombophilia. J Obstet Gynaecol Res 2021; 47:3008-3033. [PMID: 34169611 DOI: 10.1111/jog.14879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/13/2021] [Accepted: 05/29/2021] [Indexed: 12/24/2022]
Abstract
Hereditary thrombophilia is a condition in which individuals are susceptible to the formation of thrombi due to a hereditary deficiency in anticoagulant factors, antithrombin (AT), protein C (PC), or protein S (PS). Many Japanese thrombophilia patients have PS deficiency, especially PS p.K196E (also called as PS Tokushima), which is exclusive to the Japanese population, and thrombosis sometimes occurs during pregnancy. At present, no management guidelines for pregnancy and delivery in thrombophilia patients have been developed. The Study Group for Hereditary Thrombophilia, one of the research groups of blood coagulation abnormalities in the Research Program on Rare and Intractable Diseases supported with the Research Grants of the Ministry of Health, Labour and Welfare Science, has therefore developed this clinical guidance to provide healthcare workers with necessary information on safe pregnancy, parturition and neonatal management, adopting a format of responses to seven clinical questions (CQ). At the end of each answer, the corresponding Recommendation Level (A, B, C) is indicated.
Collapse
Affiliation(s)
- Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan.,The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan
| | - Eriko Morishita
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Department of Laboratory Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroko Tsuda
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Institute of Distribution Sciences, Nakamura Gakuen University, Fukuoka, Japan
| | - Reiko Neki
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Division of Counseling for Medical Genetics, Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsuhito Kojima
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Medical Division, Aichi Health Promotion Foundation, Nagoya, Japan
| | - Shouichi Ohga
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masayuki Ochiai
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoko Adachi
- Department of Obstetrics and Gynecology, Aiiku Maternal and Child Health Center, Aiiku Hospital, Tokyo, Japan
| | - Toshiyuki Miyata
- The Study Group for Hereditary Thrombophilia, Research on Blood Coagulation Abnormalities, Research Program on Rare and Intractable Diseases, The Ministry of Health, Labour and Welfare Science Research Grants, Tokyo, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
17
|
Grünewald M, Häge E, Lehnert S, Maier C, Schimke A, Bramlage P, Güth M. Prophylactic Anticoagulation With Intermediate-Dose Certoparin in Vascular-Risk Pregnancies-The PACER-VARP Registry. Clin Appl Thromb Hemost 2021; 27:10760296211016550. [PMID: 34027682 PMCID: PMC8150601 DOI: 10.1177/10760296211016550] [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: 12/03/2022] Open
Abstract
The management of pregnant women at increased risk of thromboembolic/other vascular events is still a matter of debate. In a single-center, retrospective, observational trial, we analyzed the safety and efficacy of prophylactic anticoagulation with certoparin in pregnant women at intermediate- or high-risk by EThIG criteria of thromboembolic/other vascular events. Subcutaneous certoparin 8,000 IU once daily was administered immediately after pregnancy confirmation and continued for 6 weeks postpartum. We investigated 74 pregnancies (49 women; mean age 31.8 years; weight 77.3 kg). Most prevalent risk factors were factor V Leiden mutation (40.5%), thrombogenic factor II mutation (12.2%) and protein S deficiency (8.1%). In 76 control pregnancies prior to registry inclusion/without anticoagulation there were 14 cases [18.4%] of venous thromboembolism (between week 7 gestation and week 8 postpartum); 63.2% pregnancies resulted in abortion (median week 8.6 gestation). With certoparin anticoagulation, thromboembolism was 1.4%, exclusively non-major bleeding was 4.1% and abortion was 10.8%. One case of pre-eclampsia necessitating obstetric intervention occurred. Prophylactic anticoagulation with intermediate-dose certoparin throughout pregnancies at increased venous vascular risk was safe and effective.
Collapse
Affiliation(s)
- Martin Grünewald
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
| | - Esther Häge
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
| | | | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Martina Güth
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
| |
Collapse
|
18
|
Vomstein K, Aulitzky A, Strobel L, Bohlmann M, Feil K, Rudnik-Schöneborn S, Zschocke J, Toth B. Recurrent Spontaneous Miscarriage: a Comparison of International Guidelines. Geburtshilfe Frauenheilkd 2021; 81:769-779. [PMID: 34276063 PMCID: PMC8277441 DOI: 10.1055/a-1380-3657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/01/2021] [Indexed: 01/11/2023] Open
Abstract
While roughly 30% of all women experience a spontaneous miscarriage in their lifetime, the incidence of recurrent (habitual) spontaneous miscarriage is 1 – 3% depending on the employed definition. The established risk factors include endocrine, anatomical, infection-related, genetic, haemostasis-related and immunological factors. Diagnosis is made more difficult by the sometimes diverging recommendations of the respective international specialist societies. The present study is therefore intended to provide a comparison of existing international guidelines and recommendations. The guidelines of the ESHRE, ASRM, the DGGG/OEGGG/SGGG and the recommendations of the RCOG were analysed. It was shown that investigation is indicated after 2 clinical pregnancies and the diagnosis should be made using a standardised timetable that includes the most frequent causes of spontaneous miscarriage. The guidelines concur that anatomical malformations, antiphospholipid syndrome and thyroid
dysfunction should be excluded. Moreover, the guidelines recommend carrying out pre-conception chromosomal analysis of both partners (or of the aborted material). Other risk factors have not been included in the recommendations by all specialist societies, on the one hand because of a lack of diagnostic criteria (luteal phase insufficiency) and on the other hand because of the different age of the guidelines (chronic endometritis). In addition, various economic and consensus aspects in producing the guidelines influence the individual recommendations. An understanding of the underlying decision-making process should lead in practice to the best individual diagnosis and resulting treatment being offered to each couple.
Collapse
Affiliation(s)
- Kilian Vomstein
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Anna Aulitzky
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Laura Strobel
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Michael Bohlmann
- Zentrum für Gynäkologie und Geburtshilfe, St Elisabethen-Krankenhaus Lörrach gGmbH, Lörrach, Germany
| | - Katharina Feil
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | | | - Johannes Zschocke
- Zentrum für medizinische Genetik, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Bettina Toth
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| |
Collapse
|
19
|
Low-molecular-weight heparin for prevention of unexplained recurrent miscarriage. Eur J Obstet Gynecol Reprod Biol 2021; 260:235-236. [PMID: 33773837 DOI: 10.1016/j.ejogrb.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/06/2021] [Indexed: 11/20/2022]
|
20
|
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.
Collapse
Affiliation(s)
| | - Tauane Bahia Modesto
- State University of Bahia (UNEB) - Life Sciences Department. Salvador - Bahia - Brazil
| | | |
Collapse
|
21
|
Han AR, Han JW, Lee SK. Inherited thrombophilia and anticoagulant therapy for women with reproductive failure. Am J Reprod Immunol 2020; 85:e13378. [DOI: 10.1111/aji.13378] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/09/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ae Ra Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Jae Won Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Sung Ki Lee
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| |
Collapse
|
22
|
Manning R, Iyer J, Bulmer JN, Maheshwari A, Choudhary M. Are we managing women with Recurrent Miscarriage appropriately? A snapshot survey of clinical practice within the United Kingdom. J OBSTET GYNAECOL 2020; 41:807-814. [DOI: 10.1080/01443615.2020.1803241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Rashmi Manning
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Janani Iyer
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Judith N Bulmer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Royal Hospitals NHS Trust, Aberdeen, UK
| | - Meenakshi Choudhary
- Newcastle Fertility Centre, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
23
|
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.
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Progress of the ALIFE2 study: A dynamic road towards more evidence. Thromb Res 2020; 190:39-44. [DOI: 10.1016/j.thromres.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/07/2020] [Accepted: 03/17/2020] [Indexed: 11/21/2022]
|
26
|
Jacobson B, Rambiritch V, Paek D, Sayre T, Naidoo P, Shan J, Leisegang R. Safety and Efficacy of Enoxaparin in Pregnancy: A Systematic Review and Meta-Analysis. Adv Ther 2020; 37:27-40. [PMID: 31673991 PMCID: PMC6979442 DOI: 10.1007/s12325-019-01124-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/19/2022]
Abstract
Introduction International guidelines support the use of low molecular weight heparins for the treatment of thromboembolism and thromboprophylaxis during pregnancy. However, evidence of the benefit and harm associated with specific low molecular weight heparins such as enoxaparin is dated. No current systematic review and meta-analysis describing the safety and efficacy of enoxaparin for thromboembolism and thromboprophylaxis during pregnancy exists. Methods PubMed, Embase, and Cochrane databases were searched on August 17, 2018 for clinical trials or observational studies in pregnant women receiving enoxaparin; patients with a prosthetic heart valve were excluded. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random effects model, and heterogeneity was measured using the I2 statistic. Results Of the 485 records identified in the search, 24 studies published clinical trials, and observational studies were found dating back to 2000. Only one observational cohort and one randomized control trial focused on the use of enoxaparin for thromboprophylaxis and therefore efficacy was not assessed; the other studies included women with recurrent pregnancy loss (15 studies), history of placental vascular complications (five studies), and recurrent in vitro fertilization failure (two studies) and were therefore analyzed in terms of safety only. Bleeding events were non-significantly more often reported for enoxaparin compared to untreated controls (RR 1.35 [0.88–2.07]) but less often reported for enoxaparin versus aspirin (RR 0.93 [0.62–1.39]); thromboembolic events, thrombocytopenia, and teratogenicity were rarely reported events; in patients with a history of recurrent pregnancy loss, encouragingly the rates of pregnancy loss were significantly lower for enoxaparin compared to untreated controls (RR 0.58 [0.34–0.96]) and enoxaparin + aspirin versus aspirin alone (RR 0.42 [0.32–0.56]) as well as observably lower for enoxaparin versus aspirin alone (RR 0.39 [0.15–1.01]), though significant heterogeneity was observed (I2 > 60). Conclusion Literature on the efficacy and safety of enoxaparin for thromboembolism and thromboprophylaxis remains scanty, and therefore efficacy was not assessed; in terms of safety, when including other indications for enoxaparin in pregnancy, we found that enoxaparin was associated with significantly lower complications than aspirin. Given differences in study design and study heterogeneity, pregnancy loss results should be interpreted with caution. Moreover, reports of thromboembolic events, thrombocytopenia, and congenital malformations were rare. Funding Sanofi. Electronic supplementary material The online version of this article (10.1007/s12325-019-01124-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Barry Jacobson
- Department of Haematology and Molecular Medicine, University of Witwatersrand, 1 Jan Smuts Ave, Johannesburg, South Africa
| | - Virendra Rambiritch
- Department of Pharmacology, University of KwaZulu-Natal, University Rd, Westville, South Africa
| | - Dara Paek
- Doctor Evidence, 301 Arizona Ave, Santa Monica, CA, USA
| | - Tobias Sayre
- Doctor Evidence, 301 Arizona Ave, Santa Monica, CA, USA
| | - Poobalan Naidoo
- Sanofi Affiliate, Medical, 2 Bond St, Grand Central, Midrand, South Africa
- Department of Health Informatics, School of Health Professions, Rutgers, State University of New Jersey, 57 US Highway 1, New Brunswick, NJ, USA
| | - Jenny Shan
- Sanofi Global, Medical, 54-56 Rue la Boétie, Paris, France
| | - Rory Leisegang
- Department of Pharmaceutical Biosciences, Uppsala University, 752 36, Uppsala, Sweden.
- FAMCRU, The Department of Paediatrics & Child Health, Stellenbosch University, Tygerberg, Cape Town, South Africa.
| |
Collapse
|
27
|
Tardy B, Chalayer E, Kamphuisen PW, Ni Ainle F, Verhamme P, Varlet MN, Chauleur C, Rodger M, Merah A, Buchmuller A, Bistervels I, De Sancho MT, Middeldorp S, Bertoletti L. Definition of bleeding events in studies evaluating prophylactic antithrombotic therapy in pregnant women: A systematic review and a proposal from the ISTH SSC. J Thromb Haemost 2019; 17:1979-1988. [PMID: 31402557 DOI: 10.1111/jth.14576] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Bernard Tardy
- Inserm CIC 1408, FCRIN-INNOVTE, CHU de Saint Etienne, Saint Etienne, France
| | - Emilie Chalayer
- Inserm CIC 1408, FCRIN-INNOVTE, CHU de Saint Etienne, Saint Etienne, France
| | | | - Fionnuala Ni Ainle
- Department of Haematology, Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - Marie Noelle Varlet
- Department of Gynecology and Obstetrics, University Hospital, Saint-Étienne, University Jean-Monnet, Saint-Étienne, France
| | - Celine Chauleur
- Department of Gynecology and Obstetrics, University Hospital, Saint-Étienne, University Jean-Monnet, Saint-Étienne, France
| | - Marc Rodger
- Department of Medicine, Division of Hematology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Adel Merah
- Inserm CIC 1408, FCRIN-INNOVTE, CHU de Saint Etienne, Saint Etienne, France
| | - Andrea Buchmuller
- Inserm CIC 1408, FCRIN-INNOVTE, CHU de Saint Etienne, Saint Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, St-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, St-Etienne, France
- FCRIN-INNOVTE, St-Etienne, France
| | - Ingrid Bistervels
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Maria T De Sancho
- Department of Medicine, Division of Hematology-Oncology, New York Presbyterian Hospital of Weill Cornell Medical College, New York, NY, USA
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Laurent Bertoletti
- Inserm CIC 1408, FCRIN-INNOVTE, CHU de Saint Etienne, Saint Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, St-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, St-Etienne, France
- FCRIN-INNOVTE, St-Etienne, France
| |
Collapse
|
28
|
Rogenhofer N, Bohlmann MK. Gerinnungsabklärung und Therapie bei habituellen Aborten und wiederholtem Implantationsversagen. GYNAKOLOGISCHE ENDOKRINOLOGIE 2019. [DOI: 10.1007/s10304-019-0261-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Villani M, Baldini D, Totaro P, Larciprete G, Kovac M, Carone D, Passamonti SM, Permunian ET, Bartolotti T, Lojacono A, Cacciola R, Pinto GL, Bucherini E, De Stefano V, Lodigiani C, Lavopa C, Cho YS, Pizzicaroli C, Colaizzo D, Grandone E. Rationale and design of two prospective, multicenter, observational studies on reproductive outcome in women with recurrent failures after spontaneous or assisted conception: OTTILIA and FIRST registries. BMC Pregnancy Childbirth 2019; 19:292. [PMID: 31409287 PMCID: PMC6693203 DOI: 10.1186/s12884-019-2444-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/31/2019] [Indexed: 12/03/2022] Open
Abstract
Background Spontaneous pregnancy loss and implantation failure after assisted reproductive technologies (ART) are very common occurrences. Although 50–60% of all cases remains unexplained, various predisposing factors, including thrombophilias, have been identified. Thus, the potential benefit of a prophylaxis with low-molecular-weight heparins in improving outcomes has been often investigated over the years. However, the majority of studies are observational and results from randomized clinical trials (RCTs) are inconclusive, probably due to heterogeneity and limited sample size. To cover these unmet needs and to have further data mainly based on the real-life clinical management, we designed these multicenter registries. Methods OTTILIA (Observational sTudy on antiThrombotic prevention in thrombophILIA and pregnancy loss) and FIRST (recurrent Failures in assIsted Reproductive Techniques) registries are two prospective, multicenter, observational studies to evaluate pregnancy or ART outcomes in consecutive women with previous reproductive failures after spontaneous or assisted conception, respectively. All enrolled women are observed from their first visit after positive pregnancy test (OTTILIA) or before commencing a new ART cycle (FIRST) until the end of pregnancy or ART procedure (negative pregnancy test/end of pregnancy, if successful cycle), respectively. Data are collected by means of questionnaires and recorded in a central database. Follow-up investigations are performed during hospital stay, routine clinical follow-up visits or telephone interviews. Primary outcome is live birth rate in the OTTILIA register and clinical pregnancy rate in the FIRST. Discussion Although RCTs are the ‘gold standard’ for evaluating treatment outcomes, we believe that our registries represent a valid alternative in improving knowledge on mechanisms involved in reproductive failures and supporting future clinical decisions. Trial registration NCT 02385461, retrospectively registered 5 March 2015 (OTTILIA); NCT 02685800, registered 10 February 2016 (FIRST).
Collapse
Affiliation(s)
- Michela Villani
- Thrombosis and Haemostasis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza" Poliambulatorio Giovanni Paolo II, Viale Padre Pio, San Giovanni Rotondo, Italy
| | - Domenico Baldini
- Centro di Fecondazione Medicalmente Assistita MoMò Fertilife, Bisceglie, Italy
| | | | - Giovanni Larciprete
- Department of Obstetrics and Gynecology, Fatebenefratelli Isola Tiberina Hospital, Rome, Italy
| | - Mirjana Kovac
- Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | | | - Serena Maria Passamonti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Andrea Lojacono
- Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Rossella Cacciola
- Haemostasis Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Eugenio Bucherini
- Unit of Vascular Medicine and Angiology, Civic Hospital of Faenza, Faenza, Italy
| | | | - Corrado Lodigiani
- Thrombosis and Hemorrhagic Center, Humanitas Research Hospital and Humanitas University, Rozzano, Italy
| | - Cristina Lavopa
- Centro di Fecondazione Medicalmente Assistita MoMò Fertilife, Bisceglie, Italy
| | | | - Caterina Pizzicaroli
- Department of Obstetrics and Gynecology, Fatebenefratelli Isola Tiberina Hospital, Rome, Italy
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza" Poliambulatorio Giovanni Paolo II, Viale Padre Pio, San Giovanni Rotondo, Italy
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza" Poliambulatorio Giovanni Paolo II, Viale Padre Pio, San Giovanni Rotondo, Italy. .,Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation.
| |
Collapse
|
31
|
Liu Y, Shan N, Yuan Y, Tan B, Che P, Qi H. The efficacy of enoxaparin for recurrent abortion: a meta-analysis of randomized controlled studies. J Matern Fetal Neonatal Med 2019; 34:473-478. [PMID: 30983451 DOI: 10.1080/14767058.2019.1608433] [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: 10/27/2022]
Abstract
Introduction: The efficacy of enoxaparin for recurrent abortion remains controversial. We conduct a systematic review and meta-analysis to explore the influence of enoxaparin versus placebo on recurrent abortion.Methods: We search PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through February 2019 for randomized controlled trials (RCTs) assessing the effect of enoxaparin versus placebo on recurrent abortion. This meta-analysis is performed using the fixed or random-effect model when appropriate.Results: Six RCTs involving 1034 patients are included in the meta-analysis. Overall, compared with control group for patients with recurrent abortion, enoxaparin has no obvious impact on live births (RR = 1.06; 95% CI = 0.97-1.16; p = .17), abortion rate (RR = 0.71; 95% CI = 0.45-1.10; p = .13), birth weight (std. MD = 0.38; 95% CI = -0.21-0.96; p = .21), preterm delivery (RR = 0.55; 95% CI = 0.30-1.00; p = .05), preeclampsia (RR = 1.52; 95% CI = 0.42-5.51; p = .52), and postpartum hemorrhage (RR = 1.17; 95% CI = 0.69-1.99; p = .55).Conclusions: Enoxaparin may provide no significant benefits to patients with recurrent abortion.
Collapse
Affiliation(s)
- Yangming Liu
- First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nan Shan
- First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yu Yuan
- First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Bin Tan
- First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ping Che
- Chongqing Hechuan Hospital, Chongqing, China
| | - Hongbo Qi
- First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| |
Collapse
|
32
|
|
33
|
Solt I, Ben David C, Carp H. Enoxaparin (or plus aspirin) for the prevention of recurrent miscarriage: a meta-analysis of randomized controlled studies. Eur J Obstet Gynecol Reprod Biol 2019; 239:67-68. [PMID: 31000143 DOI: 10.1016/j.ejogrb.2019.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/27/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Ido Solt
- Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel
| | - Chen Ben David
- Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel.
| | | |
Collapse
|
34
|
Pasquier E, de Saint-Martin L, Marhic G, Chauleur C, Bohec C, Bretelle F, Lejeune-Saada V, Hannigsberg J, Plu-Bureau G, Cogulet V, Merviel P, Mottier D. Hydroxychloroquine for prevention of recurrent miscarriage: study protocol for a multicentre randomised placebo-controlled trial BBQ study. BMJ Open 2019; 9:e025649. [PMID: 30898821 PMCID: PMC6527997 DOI: 10.1136/bmjopen-2018-025649] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Recurrent miscarriage (RM), defined by three or more consecutive losses during the first trimester of pregnancy, affects 1%-2% of fertile couples. Standard investigations fail to reveal any apparent cause in ~50% of couples. However, on the basis of animal models and clinical studies, several hypotheses have been put forward concerning underlying mechanisms of RM: altered ovarian reserve, progesterone defect, thrombotic and/or endothelial dysfunction and immunological disturbances. Nonetheless, no study has yet reached conclusive beneficial clinical evidence for a potential treatment in unexplained RM. Hydroxychloroquine (HCQ) is a molecule with extensive safety data during pregnancy. The pharmacological properties of HCQ (eg, antithrombotic, vascular protective, immunomodulatory, improved glucose tolerance, lipidlowering and anti-infectious) could be effective against some mechanisms of unexplained RM. Furthermore, eventhough clinical benefit of HCQ is suggested in prevention of thrombotic and late obstetric events in antiphospholipid (APL) syndrome, there are no data suggesting the benefit of HCQ in RM in the presence of APL antibodies. METHODS AND ANALYSIS Taken all together and given the low cost of HCQ, the aim of this multicentre, randomised, placebo-controlled, double-blind study is to investigate whether HCQ would improve the live birth rate in women with RM, irrespective of maternal thrombophilic status: (1) no known thrombophilia, (2) inherited thrombophilia or (3) APL antibodies. The primary end point is a live and viable birth. After confirming eligibility and obtaining consent, 300 non-pregnant women will be randomised into two parallel groups for a daily oral treatment (HCQ 400 mg or placebo), initiated before conception and stopped at 10 weeks' gestation. If pregnancy does not occur after 1 year, the treatment will be stopped. ETHICS AND DISSEMINATION Agreement from the French National Public Health and Drug Security Agency (160765A-22) and ethical approval from the Committee for the Protection of Persons of NORD-OUEST I (2016-001330-97) have been obtained. TRIAL REGISTRATION NUMBERS NCT0316513; Pre-results.
Collapse
Affiliation(s)
| | - Luc de Saint-Martin
- EA 3878 Groupe d’Etude de la Thrombose de Bretagne Occidentale, Brest, France
| | - Gisèle Marhic
- Centre d’Investigation Clinique-INSERM 1412, Brest, France
| | - Celine Chauleur
- Thrombosis Research Group, University Hospital Bellevue, Saint-Etienne, France
| | - Caroline Bohec
- Division of Gynaecology, Hôpital François Mitterand, Pau, France
| | - Florence Bretelle
- Division of Gynaecology, Université de la Méditerranée, Hôpital Nord, Marseille, France
| | | | | | | | - Virginie Cogulet
- Department of Pharmacy, Brest University Hospital, Brest, France
| | - Philippe Merviel
- Division of Gynecology, Brest University Hospital, Brest, France
| | | |
Collapse
|
35
|
Smith PP, Dhillon-Smith RK, O'Toole E, Cooper N, Coomarasamy A, Clark TJ. Outcomes in prevention and management of miscarriage trials: a systematic review. BJOG 2019; 126:176-189. [PMID: 30461160 DOI: 10.1111/1471-0528.15528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes. OBJECTIVE To review systematically, outcomes reported in existing miscarriage trials. SEARCH STRATEGY MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester. DATA COLLECTION AND ANALYSIS Data about the study characteristics, primary, and secondary outcomes were extracted. MAIN RESULTS We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation. CONCLUSIONS Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage. TWEETABLE ABSTRACT There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.
Collapse
Affiliation(s)
- P P Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - R K Dhillon-Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - E O'Toole
- Women's Voices Involvement Panel, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nam Cooper
- Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - T J Clark
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
36
|
Lin T, Chen Y, Cheng X, Li N, Sheng X. Enoxaparin (or plus aspirin) for the prevention of recurrent miscarriage: A meta-analysis of randomized controlled studies. Eur J Obstet Gynecol Reprod Biol 2019; 234:53-57. [DOI: 10.1016/j.ejogrb.2018.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/28/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
|
37
|
Akdemir Y, Ayvaci H, Uludogan M. Effect of multiple thrombophilic gene mutations on uterine artery blood flow in nonpregnant recurrent pregnancy loss patients: are we searching enough? J Matern Fetal Neonatal Med 2019; 33:2466-2472. [PMID: 30704356 DOI: 10.1080/14767058.2019.1569618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To investigate whether multiple thrombophilic mutations had a significant effect on uterine artery blood flow of nonpregnant recurrent pregnancy loss (RPL) patients.Materials and methods: Among 71 RPL patients, FV Leiden (FV), prothrombin G20210A (PTGM) and MTHFR mutations, deficiency of protein S, protein C and antithrombin III (AT3), association of Val34Leu polymorphism of the FXIII (FXIII), 4G/5G polymorphism of plasminogen activator inhibitor (PAI), -455-G/A polymorphism of β-fibrinogen (fibrinogen), and HPA-1 a/b L33P polymorphism of GPIIIa (GPIIIa) genes were investigated. Doppler flow measurements of RPL patients and healthy controls were performed at mid-luteal phase.Results: Twenty-two patients who had no thrombophilic gene mutations were grouped as unexplained RPL. Also, while 25 patients had multiple mutations, 24 patients had single mutation. In the multiple mutation RPL group, the most frequent mutations were PAI (22%), MTHFR C677T (20%), MTHFR A1298C (19%), and fibrinogen (11%). Only in the multiple mutation RPL group, mean PI and dominant PI values were significantly higher than the control group.Conclusions: Our data showed negative effects of multiple thrombophilic gene mutations on uterine artery blood flow and clarified the different effects of single and multiple thrombophilic factors on uterine artery vasculature. It is concluded that investigating more thrombophilic mutations could ameliorate prognostic factors of RPL and interactions to improve uterine artery blood flow could bring benefit to obstetric outcome.
Collapse
Affiliation(s)
- Yesim Akdemir
- Obstetrics and Gynecology Department, Bulent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Habibe Ayvaci
- Perinatology Department, Zeynep Kamil Women and Children's Training and Research Hospital, Istanbul, Turkey
| | | |
Collapse
|
38
|
Scheres LJ, Bistervels IM, Middeldorp S. Everything the clinician needs to know about evidence-based anticoagulation in pregnancy. Blood Rev 2019; 33:82-97. [DOI: 10.1016/j.blre.2018.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/25/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
|
39
|
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.
Collapse
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
| | | |
Collapse
|
40
|
Blomqvist L, Hellgren M, Strandell A. Acetylsalicylic acid does not prevent first-trimester unexplained recurrent pregnancy loss: A randomized controlled trial. Acta Obstet Gynecol Scand 2018; 97:1365-1372. [PMID: 29972884 DOI: 10.1111/aogs.13420] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Recurrent pregnancy loss occurs in about 1% of fertile couples. Without proper evidence for an effect, different treatments have been used when no etiological factor has been detected. The present trial is the first randomized trial to compare 75 mg acetylsalicylic acid with placebo for women with recurrent pregnancy loss. MATERIAL AND METHODS This randomized, double-blind, placebo-controlled trial was conducted at a single center between 2008 and 2015. Recurrent pregnancy loss was defined as at least 3 consecutive first-trimester miscarriages within the couple. Women < 40 years old with a body mass index < 35 kg/m2 were eligible if the workup was negative. Randomization was through a third party, who manufactured and delivered the study drugs, and occurred when fetal heartbeat was detected, to either 75 mg acetylsalicylic acid or placebo; 200 women in each group. Group allocation was concealed until all the study participants had a pregnancy outcome registered. All women attended the same control program. Primary outcome was live birth. Statistical analyses were according to intention-to-treat. RESULTS All 400 women completed the follow up. Live birth rate was 83.0% (n = 166) and 85.5% (n = 171) for the acetylsalicylic acid and placebo groups, respectively (P = 0.58). The difference was -2.5% (95% CI -10.1% to 5.1%). The risk ratio was 0.97 (95% CI 0.89-1.06). CONCLUSIONS Treatment with acetylsalicylic acid did not prevent recurrent miscarriage in women with at least three consecutive miscarriages in the first trimester, of unknown reasons and in the same relationship. The fertility prognosis is very good, the live birth rate being > 80% with or without acetylsalicylic acid.
Collapse
Affiliation(s)
- Lennart 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
| | - Margareta 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
| | - Annika 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
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Toth B, Würfel W, Bohlmann M, Zschocke J, Rudnik-Schöneborn S, Nawroth F, Schleußner E, Rogenhofer N, Wischmann T, von Wolff M, Hancke K, von Otte S, Kuon R, Feil K, Tempfer C. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/050). Geburtshilfe Frauenheilkd 2018; 78:364-381. [PMID: 29720743 PMCID: PMC5925690 DOI: 10.1055/a-0586-4568] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Official guideline of the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (ÖGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). The aim of this guideline was to standardize the diagnosis and treatment of couples with recurrent miscarriage (RM). Recommendations were based on the current literature and the views of the involved committee members. Methods Based on the current literature, the committee members developed the statements and recommendations of this guideline in a formalized process which included DELPHI rounds and a formal consensus meeting. Recommendations Recommendations for the diagnosis and treatment of patients with RM were compiled based on the international literature. Specific established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders were taken into consideration.
Collapse
Affiliation(s)
- Bettina Toth
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | | | | | - Johannes Zschocke
- Zentrum für Medizinische Genetik, Universität Innsbruck, Innsbruck, Austria
| | | | | | | | - Nina Rogenhofer
- Klinikum der Universität München - Frauenklinik Maistraße, München, Germany
| | - Tewes Wischmann
- Institut für Medizinische Psychologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael von Wolff
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Bern, Switzerland
| | - Katharina Hancke
- Klinik für Frauenheilkunde, Universitätsklinikum Ulm, Ulm, Germany
| | - Sören von Otte
- Kinderwunschzentrum, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Ruben Kuon
- Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Katharina Feil
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Clemens Tempfer
- Universitätsfrauenklinik, Ruhr-Universität Bochum, Bochum, Germany
| |
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Dobson SJA, Jayaprakasan KM. Aetiology of recurrent miscarriage and the role of adjuvant treatment in its management: a retrospective cohort review. J OBSTET GYNAECOL 2018; 38:967-974. [DOI: 10.1080/01443615.2018.1424811] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Kanna Mannadiar Jayaprakasan
- Derby Fertility Unit, Royal Derby Hospital, Derby, UK
- Division of Obstetrics and Gynaecology, The University of Nottingham, Nottingham, UK
| |
Collapse
|
45
|
Dugalić S, Petronijević M. Complication of pregnancy as sequence of hypoxemia of uteroplacental unit. MEDICINSKI PODMLADAK 2018. [DOI: 10.5937/mp69-16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
46
|
Ferreira CM, Figueiró-Filho EA, Oliveira VMD, Pereira ÉFDV. Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2017. [DOI: 10.1590/1806-93042017000400005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.
Collapse
|
47
|
Grandone E, De Stefano V, Tosetto A, Palareti G, Margaglione M, Castaman G, Rossi E, Ciminello A, Valdrè L, Legnani C, Luca Tiscia G, Bafunno V, Carraro S, Rodeghiero F, Simioni P, Tormene D. Obstetric complications and pregnancy-related venous thromboembolism: The effect of low-molecular-weight heparin on their prevention in carriers of factor V Leiden or prothrombin G20210A mutation. Thromb Haemost 2017; 107:477-84. [DOI: 10.1160/th11-07-0470] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 12/09/2011] [Indexed: 01/03/2023]
Abstract
SummaryWhether the administration of low-molecular-weight heparin (LMWH) during pregnancy is effective in preventing obstetric complications and pregnancy-related venous thromboembolism (VTE) in women who are carriers of factor V Leiden (FVL) and/or prothrombin variant G20210A (PTm) is controversial. This observational study investigated the possible efficacy of pharmacological treatment with LMWH ± aspirin (ASA) in pregnancy outcomes in 1,011 pregnancies of 416 women with thrombophilia (FVL and/or PTm). Most patients were chosen on the basis of previous obstetrical complications (36%), or because of familial or personal history of venous/arterial thromboembolism (28% and 18%, respectively); 74 patients (18%) were incidentally identified. The outcome was evaluated according to the type of treatment and of the period of pregnancy when the treatment was started. After adjustment for observation before and after diagnosis of thrombophilia, previous miscarriages and VTE, parity, age and centre, we observed that LMWH had a protective effect on miscarriages (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.29–0.94) and VTE (OR 0.05, 95% CI 0.01–0.21). ASA appeared to have no effect on the prevention of obstetric complications and VTE. A nested analysis performed in 116 women with two or more obstetric complications confirmed that the highest number of live births was recorded in the group under LMWH prophylaxis (OR 0.19, 95% CI 0.05–0.75). These results suggest that LMWH prophylaxis reduces the risk of obstetric complications in carriers of FVL and/or PTm, particularly in those with previous obstetric events. Furthermore, LMWH prophylaxis reduces the risk of pregnancy-related VTE.
Collapse
|
48
|
Mastrolia SA, Mazor M, Holcberg G, Leron E, Beharier O, Loverro G, Erez O. The physiologic anticoagulant and anti-inflammatory role of heparins and their utility in the prevention of pregnancy complications. Thromb Haemost 2017; 113:1236-46. [DOI: 10.1160/th14-10-0848] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/14/2015] [Indexed: 01/13/2023]
Abstract
SummaryAccumulating evidence supports the concept of increased thrombin generation, placental vascular lesions, and inflammation as crucial points in the development of the great obstetrical syndromes [preeclampsia, intrauterine growth restriction (IUGR), preterm labor (PTL), preterm prelabor rupture of membranes (PROM), fetal demise and recurrent abortions]. In light of this, the role of heparins for primary or secondary prevention of these syndromes is becoming more and more apparent, mainly due to the antithrombotic and anti-inflammatory effects of heparins. There is agreement regarding the use of heparin in the prevention of gestational complications in patients with antiphospholipid syndrome, while its use for other obstetrical complications is under debate. In the present review we will describe the physiologic role of heparins on coagulation and inflammation and we will discuss current evidence regarding the use of heparins for the prevention/ treatment of obstetrical syndromes.
Collapse
|
49
|
Abstract
The challenging nature of recurrent pregnancy loss (RPL) is multifactorial, but largely begins with determining who meets diagnostic criteria for RPL as definitions vary and frequently change. Many patients seek obstetrical intervention after losses, even if they do not meet the criteria for RPL, and even those strictly meeting criteria often present a conundrum as to the etiology of their condition. The contribution of hereditary thrombophilia to RPL, the impact of each disorder on the clotting cascade, available evidence regarding pregnancy outcomes, and current recommendations for evaluation and treatment is presented.
Collapse
|
50
|
Pasquier E. Much ado about antithrombotic therapy in pregnancy. Thromb Res 2017; 159:122-123. [PMID: 28967435 DOI: 10.1016/j.thromres.2017.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Elisabeth Pasquier
- EA 3878 (GETBO), Department of Internal Medicine and Chest Diseases, Brest University, Hospital, La Cavale Blanche Hospital, 29609 Brest, France.
| |
Collapse
|