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Ma SS, Yin WJ, Wang P, Wang HX, Zhang L, Jiang XM, Zhang Y, Tao R, Ge JF, Zhu P. Previous pregnancy loss and gestational cardiovascular health: A prospective cohort of nulliparous women. Front Public Health 2023; 11:1071706. [PMID: 37113178 PMCID: PMC10127104 DOI: 10.3389/fpubh.2023.1071706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/10/2023] [Indexed: 04/29/2023] Open
Abstract
Objectives To estimate the association of previous pregnancy loss with subsequent cardiovascular health during gestation and to examine the role of high-sensitivity C reactive protein (hs-CRP) in the association. Methods A total of 2,778 nulliparous pregnant women were recruited between March 2015 and November 2020 in Hefei city, China. Their cardiovascular health (CVH) including prepregnancy body mass index (BMI), blood pressure, total cholesterol, fasting plasma glucose, and smoke status were recorded at 24-28 weeks' gestation, as well as their reproductive history. Multivariate linear and logistic regression were performed to examine the association of pregnancy loss with cardiovascular health. And the role of hs-CRP between pregnancy loss and CVH was assessed by the mediation analysis. Results Compared with women who have no pregnancy loss, women with a history of spontaneous or induced abortions had higher BMI (β, 0.72, 95% CI, 0.50 to 0.94) and fasting plasma glucose (β, 0.04, 95% CI, 0.01 to 0.07), and had lower total CVH scores after adjusting for confounders (β, -0.09, 95% CI, -0.18 to -0.01). CVH scores were most significantly decreased among women with 3 or more induced abortions (β, -0.26, 95% CI, -0.49, -0.02). The contribution of pregnancy loss to poorer gestational CVH mediated by increased hs-CRP levels was 23.17%. Conclusion Previous pregnancy loss was associated with poorer cardiovascular health during gestation, which may be mediated by their gestational inflammatory status. Exposure to miscarriage alone was not a significant predictor of poorer CVH.
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Affiliation(s)
- Shuang-shuang Ma
- Department of Sleep Disorders, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
- Hefei Fourth People's Hospital, Hefei, China
- Anhui Mental Health Center, Hefei, Anhui, China
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Wan-jun Yin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Peng Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Hai-xia Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Lei Zhang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Xiao-min Jiang
- Department of Obstetrics and Gynecology, Anhui Women and Child Health Care Hospital, Hefei, Anhui, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ruixue Tao
- Department of Obstetrics and Gynecology, Hefei First People's Hospital, Hefei, Anhui, China
| | - Jin-fang Ge
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Jin-fang Ge,
| | - Peng Zhu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
- Peng Zhu,
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Jukic AMZ, Jahnke HR, MacNell N, Bradley D, Malloy SM, Baird DD. Feasibility of leveraging menstrual cycle tracking apps for preconception research recruitment. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:981878. [PMID: 36303662 PMCID: PMC9580765 DOI: 10.3389/frph.2022.981878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background Mobile applications (apps) present a new opportunity to study menstrual cycles and time to pregnancy. Understanding the characteristics of cycle tracking app users is important to evaluate the feasibility of recruiting participants for preconception research. Methods Users of a cycle tracking smartphone app, Ovia Fertility, aged 18 or older in the U.S. were randomly invited via email to complete a “fertility research” questionnaire that included demographic and reproductive characteristics. Among those attempting pregnancy without medical assistance, attempt duration, factors influencing pregnancy planning, health history and behaviors while attempting to conceive were queried. Respondents could choose to enter a raffle for a $50 gift card. Results Initially, 639 people responded to the demographics portion of the survey representing 49 states and Washington DC. Of these, 344 (54%) were trying to conceive and of those, 297 (86%) were not using medical treatments. Of those not trying to conceive, 12% reported that they planned to start in the next 3 months. Most participants were ages 26–35 (63%), of White race (70%), reported non-Hispanic ethnicity (87%), had at least a bachelor's degree (56%) and an income between $50,000 and $200,000 (58%). One-third were of recommended BMI (35%), 24% overweight, and 41% obese. Most participants reported no fertility-related health conditions (58%). Forty-eight participants (17%) had been trying to conceive for 1 month or less, 88 (31%) had been trying for 2 months or less, and 122 (43%) for 3 months or less. Interruptions in pregnancy attempts were common, 31% reported periods without intercourse. Of those attempting pregnancy, 47% of partners completed their own questionnaire. Conclusion This first-of its-kind analysis describes users of a cycle-tracking smartphone app who could be eligible for recruitment to a prospective time-to-pregnancy study. Survey respondents were diverse with respect to geographic location, BMI, and income. However, special recruitment efforts will be needed to recruit participants and partners who identify as other than non-Hispanic White. Participants with fertility-related conditions are not overly represented among app users who are trying to conceive. Targeting and pre-enrolling app users who are planning to begin a pregnancy attempt in the next 3 months may be an advantage of app-based recruitment.
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Affiliation(s)
- Anne Marie Z. Jukic
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, United States
- Correspondence: Anne Marie Z. Jukic
| | - Hannah R. Jahnke
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, United States
| | - Nathaniel MacNell
- Public Health Sciences, Social / Scientific Systems, Inc., a DLH Company, Durham, NC, United States
| | - Danielle Bradley
- Department of Clinical Services and Evidence, Ovia Health, Boston, MA, United States
| | - Shannon M. Malloy
- Department of Clinical Services and Evidence, Ovia Health, Boston, MA, United States
| | - Donna D. Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, United States
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Schliep KC, Hinkle SN, Kim K, Sjaarda LA, Silver RM, Stanford JB, Purdue-Smithe A, Plowden TC, Schisterman EF, Mumford SL. Prospectively assessed perceived stress associated with early pregnancy losses among women with history of pregnancy loss. Hum Reprod 2022; 37:2264-2274. [PMID: 35972454 PMCID: PMC9802052 DOI: 10.1093/humrep/deac172] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 07/06/2022] [Indexed: 01/05/2023] Open
Abstract
STUDY QUESTION What is the association between perceived stress during peri-conception and early pregnancy and pregnancy loss among women who have experienced a prior pregnancy loss? SUMMARY ANSWER Daily perceived stress above the median is associated with over a 2-fold risk of early pregnancy loss among women who have experienced a prior loss. WHAT IS KNOWN ALREADY? Women who have experienced a pregnancy loss may be more vulnerable to stress while trying to become pregnant again. While prior research has indicated a link between psychological stress and clinically confirmed miscarriages, research is lacking among a pre-conceptional cohort followed prospectively for the effects of perceived stress during early critical windows of pregnancy establishment on risk of both hCG-detected pregnancy losses and confirmed losses, while considering important time-varying confounders. STUDY DESIGN, SIZE, DURATION Secondary data analysis of the EAGeR trial (2007-2011) among women with an hCG-detected pregnancy (n = 797 women). PARTICIPANTS/MATERIALS, SETTING, METHODS Women from four US clinical centers enrolled pre-conceptionally and were followed ≤6 cycles while attempting pregnancy and, as applicable, throughout pregnancy. Perceived stress was captured via daily diaries and end-of-month questionnaires. Main outcome measures include hCG-detected and clinically recognized pregnancy losses. MAIN RESULTS AND THE ROLE OF CHANCE Among women who had an hCG-confirmed pregnancy, 188 pregnancies (23.6%) ended in loss. Women with high (>50th percentile) versus low (≤50th percentile) peri-implantation or early pregnancy weekly perceived stress had an elevated risk of experiencing any pregnancy loss (hazard ratio (HR): 1.69, 95% CI: 1.13, 2.54) or clinical loss (HR: 1.58, 95% CI: 0.96, 2.60), with higher risks observed for women experiencing an hCG-detected loss (HR: 2.16, 95% CI: 1.04, 4.46). Models accounted for women's age, BMI, employment, marital status, income, education, race, parity, prior losses, exercise and time-varying nausea/vomiting, caffeine, alcohol and smoking. LIMITATIONS, REASONS FOR CAUTION We were limited in our ability to clearly identify the mechanisms of stress on pregnancy loss due to our sole reliance on self-reported perceived stress, and the lack of biomarkers of different pathways of stress. WIDER IMPLICATIONS OF THE FINDINGS This study provides new insight on early pregnancy perceived stress and risk of pregnancy loss, most notably hCG-detected losses, among women with a history of a prior loss. Our study is an improvement over past studies in its ability to account for time-varying early pregnancy symptoms, such as nausea/vomiting, and lifestyle factors, such as caffeine, alcohol and smoking, which are also risk factors for psychological stress and pregnancy loss. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland (Contract numbers: HHSN267200603423, HHSN267200603424, HHSN267200603426, HHSN275201300023I). Additionally, K.C.S. was supported by the National Institute on Aging of the National Institutes of Health under Award Number K01AG058781. The authors have no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER #NCT00467363.
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Affiliation(s)
- Karen C Schliep
- Correspondence address. Department of Family and Preventive Medicine, University of Utah Health, 375 Chipeta Way, Suite A, Salt Lake City, UT, USA. Tel: +1-801-587-7271; E-mail:
| | - Stefanie N Hinkle
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Joseph B Stanford
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Alexandra Purdue-Smithe
- Department of Medicine, Division of Women’s Health at Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Torie Comeaux Plowden
- Department of Obstetrics and Gynecology, Womack Army Medical Center, Fort Bragg, NC, USA
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunni L Mumford
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Zhong Y, Brooks MM, Kennedy EH, Bodnar LM, Naimi AI. Use of Machine Learning to Estimate the Per-Protocol Effect of Low-Dose Aspirin on Pregnancy Outcomes: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2143414. [PMID: 35262718 PMCID: PMC8908068 DOI: 10.1001/jamanetworkopen.2021.43414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022] Open
Abstract
Importance In randomized clinical trials (RCTs), per-protocol effects may be of interest in the presence of nonadherence with the randomized treatment protocol. Using machine learning in per-protocol effect estimation can help avoid model misspecification owing to strong parametric assumptions, as is common with standard methods (eg, logistic regression). Objectives To demonstrate the use of ensemble machine learning with augmented inverse probability weighting (AIPW) for per-protocol effect estimation in RCTs and to evaluate the per-protocol effect size of aspirin on pregnancy. Design, Setting, and Participants This secondary analysis used data from 1227 women in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial, a multicenter, block-randomized, double-blind, placebo-controlled clinical trial of the effect of daily low-dose aspirin on pregnancy outcomes in women at high risk of pregnancy loss. Participants were recruited at 4 university medical centers in the US from June 15, 2007, to July 15, 2012. Women were followed up for 6 menstrual cycles for attempted pregnancy and 36 weeks of gestation if pregnancy occurred. Follow-up was completed on August 17, 2012. Data analyses were performed on July 9, 2021. Exposures Daily low-dose (81 mg) aspirin taken at least 5 of 7 days per week for at least 80% of follow-up time relative to placebo. Main Outcomes and Measures Pregnancy detected using human chorionic gonadotropin (hCG) levels. Results Among the 1227 women included in the analysis (mean SD age, 28.74 [4.80] years), 1161 (94.6%) were non-Hispanic White and 858 (69.9%) adhered to the protocol. Five machine learning models were combined into 1 meta-algorithm, which was used to construct an AIPW estimator for the per-protocol effect. Compared with adhering to placebo, adherence to the daily low-dose aspirin protocol for at least 5 of 7 days per week was associated with an increase in the probability of hCG-detected pregnancy of 8.0 (95% CI, 2.5-13.6) more hCG-detected pregnancies per 100 women in the sample, which is substantially larger than the estimated intention-to-treat estimate of 4.3 (95% CI, -1.1 to 9.6) more hCG-detected pregnancies per 100 women in the sample. Conclusions and Relevance These findings suggest that a low-dose aspirin protocol is associated with increased hCG-detected pregnancy in women who adhere to treatment for at least 5 days per week. With the presence of nonadherence, per-protocol treatment effect estimates differ from intention-to-treat estimates in the EAGeR trial. The results of this secondary analysis of clinical trial data suggest that machine learning could be used to estimate per-protocol effects by adjusting for confounders related to nonadherence in a more flexible way than traditional regressions. Trial Registration ClinicalTrials.gov Identifier: NCT00467363.
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Affiliation(s)
- Yongqi Zhong
- Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
| | - Maria M. Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward H. Kennedy
- Department of Data Science and Statistics, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Lisa M. Bodnar
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashley I. Naimi
- Department of Epidemiology, Emory University, Atlanta, Georgia
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Zhong Y, Kennedy EH, Bodnar LM, Naimi AI. AIPW: An R Package for Augmented Inverse Probability-Weighted Estimation of Average Causal Effects. Am J Epidemiol 2021; 190:2690-2699. [PMID: 34268567 PMCID: PMC8796813 DOI: 10.1093/aje/kwab207] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/26/2022] Open
Abstract
An increasing number of recent studies have suggested that doubly robust estimators with cross-fitting should be used when estimating causal effects with machine learning methods. However, not all existing programs that implement doubly robust estimators support machine learning methods and cross-fitting, or provide estimates on multiplicative scales. To address these needs, we developed AIPW, a software package implementing augmented inverse probability weighting (AIPW) estimation of average causal effects in R (R Foundation for Statistical Computing, Vienna, Austria). Key features of the AIPW package include cross-fitting and flexible covariate adjustment for observational studies and randomized controlled trials (RCTs). In this paper, we use a simulated RCT to illustrate implementation of the AIPW estimator. We also perform a simulation study to evaluate the performance of the AIPW package compared with other doubly robust implementations, including CausalGAM, npcausal, tmle, and tmle3. Our simulation showed that the AIPW package yields performance comparable to that of other programs. Furthermore, we also found that cross-fitting substantively decreases the bias and improves the confidence interval coverage for doubly robust estimators fitted with machine learning algorithms. Our findings suggest that the AIPW package can be a useful tool for estimating average causal effects with machine learning methods in RCTs and observational studies.
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Affiliation(s)
| | | | | | - Ashley I Naimi
- Correspondence to Dr. Ashley I. Naimi, Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322 (e-mail: )
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Naimi AI, Perkins NJ, Sjaarda LA, Mumford SL, Platt RW, Silver RM, Schisterman EF. The Effect of Preconception-Initiated Low-Dose Aspirin on Human Chorionic Gonadotropin-Detected Pregnancy, Pregnancy Loss, and Live Birth : Per Protocol Analysis of a Randomized Trial. Ann Intern Med 2021; 174:595-601. [PMID: 33493011 PMCID: PMC9109822 DOI: 10.7326/m20-0469] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A previous large randomized trial indicated that preconception-initiated low-dose aspirin (LDA) therapy did not have a positive effect on pregnancy outcomes. However, this trial was subject to nonadherence, which was not taken into account by the intention-to-treat approach. OBJECTIVE To estimate per protocol effects of preconception-initiated LDA on pregnancy loss and live birth. DESIGN The EAGeR (Effects of Aspirin on Gestation and Reproduction) trial was used to construct a prospective cohort for a post hoc analysis. (ClinicalTrials.gov: NCT00467363). SETTING 4 university medical centers in the United States. PARTICIPANTS 1227 women between the ages of 18 and 40 years who had 1 or 2 previous pregnancy losses and were attempting pregnancy. MEASUREMENTS Adherence to LDA or placebo, assessed by measuring pill bottle weights at regular intervals during follow-up. Primary outcomes were human chorionic gonadotropin (hCG)-detected pregnancies, pregnancy losses, and live births, determined by pregnancy tests and medical records. RESULTS Relative to placebo, adhering to LDA for 5 of 7 days per week led to 8 more hCG-detected pregnancies (95% CI, 4.64 to 10.96 pregnancies), 15 more live births (CI, 7.65 to 21.15 births), and 6 fewer pregnancy losses (CI, -12.00 to -0.20 losses) for every 100 women in the trial. In addition, compared with placebo, postconception initiation of LDA therapy led to a reduction in the estimated effects. Furthermore, effects were obtained in a minimum of 4 of 7 days per week. LIMITATION The EAGeR trial data for this study were analyzed as observational data, thus are subject to the limitations of prospective observational studies. CONCLUSION Per protocol results suggest that preconception use of LDA at least 4 days per week may improve reproductive outcomes for women who have had 1 or 2 pregnancy losses. Increasing adherence to daily LDA seems to be key to improving effectiveness. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
| | - Neil J. Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Lindsey A. Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Sunni L. Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Robert W. Platt
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Enrique F. Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Platelet activation and placenta-mediated adverse pregnancy outcomes: an ancillary study to the Effects of Aspirin in Gestation and Reproduction trial. Am J Obstet Gynecol 2020; 223:741.e1-741.e12. [PMID: 32434001 DOI: 10.1016/j.ajog.2020.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Platelet activation may play a role in the pathophysiology of placenta-mediated obstetrical complications, as evidenced by the efficacy of aspirin in preventing preeclampsia, but published data regarding the relationship between biomarkers for platelet activation and adverse obstetrical outcomes are sparse. In particular, it is unknown whether prepregnancy biomarkers of platelet activation are associated with adverse pregnancy outcomes. OBJECTIVE This study aimed to determine the following: (1) whether maternal plasma concentrations of platelet factor 4 are associated with risk of placenta-mediated adverse obstetrical outcomes, and (2) whether these associations are modified by low-dose aspirin. STUDY DESIGN This ancillary study included measurement of platelet factor 4 among 1185 of 1228 women of reproductive age enrolled in the Effects of Aspirin in Gestation and Reproduction trial with available plasma samples, with relevant outcomes assessed among 584 women with pregnancies lasting at least 20 weeks' gestation. We measured platelet factor 4 in plasma samples obtained at the prepregnancy study visit (before randomization to low-dose aspirin or placebo), 12 weeks' gestation, and 28 weeks' gestation. The primary outcome was a composite of hypertensive disorders of pregnancy, placental abruption, and small-for-gestational-age infant. We estimated the relative risks (RRs) and 95% confidence intervals (CIs) for the association between platelet factor 4 and the composite and individual outcomes at each time point using log-binomial regression that was weighted to account for potential selection bias and adjusted for age, body mass index, education, income, and smoking. To evaluate the potential effect modification of aspirin, we stratified the analyses by aspirin treatment assignment. RESULTS During follow-up, 95 women experienced the composite adverse obstetrical outcome, with 57 cases of hypertensive disorders of pregnancy, 35 of small for gestational age, and 6 of placental abruption. Overall, prepregnancy platelet factor 4 was positively associated with the composite outcome (third tertile vs first tertile; relative risk, 2.36; 95% confidence interval, 1.38-4.03) and with hypertensive disorders of pregnancy (third tertile vs first tertile; relative risk, 2.14; 95% confidence interval, 1.08-4.23). In analyses stratified by treatment group, associations were stronger in the placebo group (third tertile vs first tertile; relative risk, 3.36; 95% confidence interval, 1.42-7.93) than in the aspirin group (third tertile vs first tertile; relative risk, 1.78; 95% confidence interval, 0.90-3.50). CONCLUSION High concentrations of platelet factor 4 before pregnancy are associated with increased risk of placenta-mediated adverse pregnancy outcomes, particularly for hypertensive disorders of pregnancy. Aspirin may mitigate the increased risk of these outcomes among women with higher plasma concentrations of preconception platelet factor 4, but low-dose aspirin nonresponders may require higher doses of aspirin or alternate therapies to achieve obstetrical risk reduction.
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Plowden TC, Connell MT, Hill MJ, Mendola P, Kim K, Nobles CJ, Kuhr DL, Galai N, Gibbins KJ, Silver RM, Wilcox B, Sjaarda L, Perkins NJ, Schisterman EF, Mumford SL. Family history of autoimmune disease in relation to time-to-pregnancy, pregnancy loss, and live birth rate. J Transl Autoimmun 2020; 3:100059. [PMID: 32743539 PMCID: PMC7388372 DOI: 10.1016/j.jtauto.2020.100059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 12/27/2022] Open
Abstract
Several autoimmune conditions have adverse effects on reproductive outcomes, but the relationship between family history of autoimmune disease in women without these conditions and pregnancy is uncertain. The objective of this study was to determine if there is an association between a family history of an autoimmune condition and time-to-pregnancy (TTP), pregnancy loss, and live birth. This was a prospective cohort study from a RCT of 1228 adult women ages 18-40, who were healthy, had no history of infertility, were actively attempting to conceive, and had one or two prior pregnancy losses. Of these, 1172 women had data available regarding family history of autoimmune conditions. Women with an affected first-degree relative had similar TTP when compared to those without a FHx (fecundability odds ratio 0.90, 95% confidence interval [CI] 0.70, 1.15). Women with an affected first-degree relative had a lower likelihood of live birth (relative risk [RR] 0.83, 95% CI 0.69, 0.99). Among women who achieved pregnancy, FHx of autoimmune disease was associated with a higher likelihood of pregnancy loss (RR 1.49, 95% CI 1.10, 2.03). Women who had a first-degree relative with an autoimmune disease had a similar TTP as unaffected women but a lower likelihood of live birth and higher risk of pregnancy loss. This information may encourage clinicians to evaluate women with a family history of autoimmune conditions prior to pregnancy and highlights the need for further studies to ascertain the effects of autoimmunity and pregnancy.
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Affiliation(s)
- Torie C Plowden
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States.,Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Bethesda, MD 20892, United States
| | - Matthew T Connell
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States.,Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Bethesda, MD 20892, United States
| | - Micah J Hill
- Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Bethesda, MD 20892, United States
| | - Pauline Mendola
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Carrie J Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Daniel L Kuhr
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States.,Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Mail Stop MAC 5034, Cleveland, OH 44106, United States
| | - Noya Galai
- Department of Statistics, University of Haifa, Mt Carmel, Haifa, 31905, Israel
| | - Karen J Gibbins
- OB/GYN, University of Utah, Salt Lake City, UT, United States
| | - Robert M Silver
- OB/GYN, University of Utah, Salt Lake City, UT, United States
| | - Brian Wilcox
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Room 2B200 SOM, 50 North Medical Drive, Salt Lake City, UT 84132, United States
| | - Lindsey Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Neil J Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD 20892, United States
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Hamulyák EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev 2020; 5:CD012852. [PMID: 32358837 PMCID: PMC7195627 DOI: 10.1002/14651858.cd012852.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aspirin and heparin are widely used as preventive strategy to reduce the high risk of recurrent pregnancy loss in women with antiphospholipid antibodies (aPL). This review supersedes a previous, out-of-date review that evaluated all potential therapies for preventing recurrent pregnancy loss in women with aPL. The current review focusses on a narrower scope because current clinical practice is restricted to using aspirin or heparins, or both for women with aPL in an attempt to reduce pregnancy complications. OBJECTIVES To assess the effects of aspirin or heparin, or both for improving pregnancy outcomes in women with persistent (on two separate occasions) aPL, either lupus anticoagulant (LAC), anticardiolipin (aCL) or aβ2-glycoprotein-I antibodies (aβ2GPI) or a combination, and recurrent pregnancy loss (two or more, which do not have to be consecutive). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 June 2019), and reference lists of retrieved studies. Where necessary, we attempted to contact trial authors. SELECTION CRITERIA Randomised, cluster-randomised and quasi-randomised controlled trials that assess the effects of aspirin, heparin (either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH]), or a combination of aspirin and heparin compared with no treatment, placebo or another, on pregnancy outcomes in women with persistent aPL and recurrent pregnancy loss were eligible. All treatment regimens were considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion criteria and risk of bias. Two review authors independently extracted data and checked them for accuracy and the certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Eleven studies (1672 women) met the inclusion criteria; nine randomised controlled trials and two quasi-RCTs. The studies were conducted in the USA, Canada, UK, China, New Zealand, Iraq and Egypt. One included trial involved 1015 women, all other included trials had considerably lower numbers of participants (i.e. 141 women or fewer). Some studies had high risk of selection and attrition bias, and many did not include sufficient information to judge the risk of reporting bias. Overall, the certainty of evidence is low to very low due to the small numbers of women in the studies and to the risk of bias. The dose and type of heparin and aspirin varied among studies. One study compared aspirin alone with placebo; no studies compared heparin alone with placebo and there were no trials that had a no treatment comparator arm during pregnancy; five studies explored the efficacy of heparin (either UFH or LMWH) combined with aspirin compared with aspirin alone; one trial compared LMWH with aspirin; two trials compared the combination of LMWH plus aspirin with the combination of UFH plus aspirin; two studies evaluated the combination of different doses of heparin combined with aspirin. All trials used aspirin at a low dose. Aspirin versus placebo We are very uncertain if aspirin has any effect on live birth compared to placebo (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71 to 1.25, 1 trial, 40 women, very low-certainty evidence). We are very uncertain if aspirin has any effect on the risk of pre-eclampsia, pregnancy loss, preterm delivery of a live infant, intrauterine growth restriction or adverse events in the child, compared to placebo. We are very uncertain if aspirin has any effect on adverse events (bleeding) in the mother compared with placebo (RR 1.29, 95% CI 0.60 to 2.77, 1 study, 40 women). The certainty of evidence for these outcomes is very low because of imprecision, due to the low numbers of women involved and the wide 95% CIs, and also because of risk of bias. Venous thromboembolism and arterial thromboembolism were not reported in the included studies. Heparin plus aspirin versus aspirin alone Heparin plus aspirin may increase the number of live births (RR 1.27, 95% CI 1.09 to 1.49, 5 studies, 1295 women, low-certainty evidence). We are uncertain if heparin plus aspirin has any effect on the risk of pre-eclampsia, preterm delivery of a live infant, or intrauterine growth restriction, compared with aspirin alone because of risk of bias and imprecision due to the low numbers of women involved and the wide 95% CIs. We are very uncertain if heparin plus aspirin has any effect on adverse events (bleeding) in the mother compared with aspirin alone (RR 1.65, 95% CI 0.19 to 14.03, 1 study, 31 women). No women in either the heparin plus aspirin group or the aspirin alone group had heparin-induced thrombocytopenia, allergic reactions, or venous or arterial thromboembolism. Similarly, no infants had congenital malformations. Heparin plus aspirin may reduce the risk of pregnancy loss (RR 0.48, 95% CI 0.32 to 0.71, 5 studies, 1295 women, low-certainty evidence). When comparing LMWH plus aspirin versus aspirin alone the pooled RR for live birth was 1.20 (95% CI 1.04 to 1.38, 3 trials, 1155 women). In the comparison of UFH plus aspirin versus aspirin alone, the RR for live birth was 1.74 (95% CI 1.28 to 2.35, 2 trials, 140 women). AUTHORS' CONCLUSIONS The combination of heparin (UFH or LMWH) plus aspirin during the course of pregnancy may increase live birth rate in women with persistent aPL when compared with aspirin treatment alone. The observed beneficial effect of heparin was driven by one large study in which LMWH plus aspirin was compared with aspirin alone. Adverse events were frequently not, or not uniformly, reported in the included studies. More research is needed in this area in order to further evaluate potential risks and benefits of this treatment strategy, especially among women with aPL and recurrent pregnancy loss, to gain consensus on the ideal prevention for recurrent pregnancy loss, based on a risk profile.
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Affiliation(s)
- Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luuk Jj Scheres
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mauritia C Marijnen
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Jukic AMZ, Padiyara P, Bracken MB, McConnaughey DR, Steiner AZ. Analgesic use at ovulation and implantation and human fertility. Am J Obstet Gynecol 2020; 222:476.e1-476.e11. [PMID: 31738897 DOI: 10.1016/j.ajog.2019.11.1251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies investigating the effects of pain-relieving medication use on conceiving a pregnancy have shown conflicting results. Furthermore, no previous study has examined medication use around ovulation or implantation and the associations with the probability of conception, fecundability. OBJECTIVE The objective of the study was to explore the association between fecundability and analgesic use in 3 different menstrual cycle windows (preovulation, periovulation, and implantation) as well as across the entire menstrual cycle. STUDY DESIGN We analyzed data from a prospective cohort study of women between 30 and 44 years of age who were trying to conceive naturally from 2008 through 2015. Using daily diaries, medication usage was classified as acetaminophen, aspirin, or nonaspirin nonsteroidal antiinflammatory drug during 4 time periods of interest (preovulatory, periovulatory, and implantation) as well as the overall nonmenstrual bleeding days of the cycle. Menstrual cycles during the prospective attempt to become pregnant were enumerated using daily diary menstrual bleeding information. Conception was defined as a positive home pregnancy test. Discrete time fecundability models were used to estimate the fecundability ratio and 95% confidence interval in each of the 4 time windows of interest and for each pain reliever (aspirin use, nonaspirin nonsteroidal antiinflammatory drug use, acetaminophen) compared with no medication use after adjustment for several covariates including age, race, education, body mass index, alcohol and caffeine use, frequency of intercourse, and a history of migraines or uterine fibroids. RESULTS Medication use was infrequent in the 858 women and 2366 cycles in this analysis. Use of nonaspirin nonsteroidal antiinflammatory drugs or acetaminophen was not associated with fecundability in any of the time windows of interest. Although the sample size was small, aspirin use during the implantation window was associated with increased fecundability (adjusted fecundability ratio [confidence interval]: 2.05 [1.23-3.41]). This association remained when limiting the analysis to cycles with minimal missing data or when adjusting for gravidity. None of the other medications were associated with fecundability. CONCLUSION Aspirin use around implantation was associated with increased fecundability. These results expand previous literature to suggest the following: (1) implantation may be an important target for the effects of aspirin on conception and (2) aspirin may be beneficial, regardless of pregnancy loss history. These observations should be tested with a clinical trial.
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Affiliation(s)
- Anne Marie Z Jukic
- Department of Chronic Disease Epidemiology, New Haven, CT; Center for Perinatal Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT.
| | - Ponnu Padiyara
- Department of Chronic Disease Epidemiology, New Haven, CT; Center for Perinatal Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT
| | - Michael B Bracken
- Department of Chronic Disease Epidemiology, New Haven, CT; Center for Perinatal Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT
| | | | - Anne Z Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
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Preconception Perceived Stress Is Associated with Reproductive Hormone Levels and Longer Time to Pregnancy. Epidemiology 2019; 30 Suppl 2:S76-S84. [PMID: 31569156 PMCID: PMC7536839 DOI: 10.1097/ede.0000000000001079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women who experience pregnancy loss are especially prone to high stress, though the effects of stress on reproductive outcomes in this vulnerable population are unknown. We assessed relationships between perceived stress and hormones, anovulation, and fecundability among women with prior loss. METHODS One thousand two hundred fourteen women with 1-2 prior losses were followed for ≤6 cycles while attempting pregnancy and completed end-of-cycle stress assessments. For cycles 1 and 2, women also collected daily urine and completed daily perceived stress assessments. We assessed anovulation via. an algorithm based on human chorionic gonadotropin (hCG), pregnanediol-3-glucuronide (PdG), luteinizing hormone (LH), and fertility monitor readings. Pregnancy was determined via. hCG. Adjusted weighted linear mixed models estimated the effect of prospective phase-varying (menses, follicular, periovulatory, and luteal) perceived stress quartiles on estrone-1-glucuronide (E1G), PdG, and LH concentrations. Marginal structural models accounted for time-varying confounding by hormones and lifestyle factors affected by prior stress. Poisson and Cox regression estimated risk ratios and fecundability odds ratios of cycle-varying stress quartiles on anovulation and fecundability. Models were adjusted for age, race, body mass index (BMI), parity, and time-varying caffeine, alcohol, smoking, intercourse, and pelvic pain. RESULTS Women in the highest versus lowest stress quartile had lower E1G and PdG concentrations, a marginally higher risk of anovulation [1.28; 95% confidence interval (CI) = 1.00, 1.63], and lower fecundability (0.71; 95% CI = 0.55, 0.90). CONCLUSION Preconception perceived stress appears to adversely affect sex steroid synthesis and time to pregnancy. Mechanisms likely include the effects of stress on ovulatory function, but additional mechanisms, potentially during implantation, may also exist.
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Plowden TC, Zarek SM, DeVilbiss EA, Radoc JG, Kim K, Sjaarda LA, Schisterman EF, Silver RM, Kuhr DL, Omosigho UR, Yeung EH, Mumford SL. Preconception Leptin and Fecundability, Pregnancy, and Live Birth Among Women With a History of Pregnancy Loss. J Endocr Soc 2019; 3:1958-1968. [PMID: 31620666 PMCID: PMC6786004 DOI: 10.1210/js.2019-00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/15/2019] [Indexed: 11/19/2022] Open
Abstract
Context With the increase of obesity, it is imperative to understand the neuroendocrine mechanisms, including the neuroendocrine hormone leptin, by which obese or overweight women are at increased risk for subfertility and infertility. Objective The objective was to examine associations between preconception serum leptin concentrations, fecundability, pregnancy, and live birth. Design Secondary analysis of a prospective cohort among women with prior pregnancy losses. Setting The study was conducted at four US medical centers (2006 to 2012). Intervention Not available. Materials and Methods Preconception serum leptin concentrations were measured at baseline, and women were followed for up to six menstrual cycles, and throughout pregnancy if they conceived. Discrete Cox proportional hazard regression models were used to assess fecundability odds ratios (FORs) and log-binomial regression to estimate risk ratios (RRs) for pregnancy and live birth. Models were adjusted for age, physical activity, treatment arm, and adiposity, either by measured waist-to-hip ratio or body mass index (BMI). Results High leptin concentrations were associated with decreased fecundability (FOR 0.72, 95% CI 0.58, 0.90), reduced risk of pregnancy (RR 0.87, 95% CI 0.78, 0.96) and live birth (RR 0.76, 95% CI 0.65, 0.89) comparing the upper to the lower tertile. However, adjustment for BMI in lieu of waist-to-hip ratio nullified observed associations. Conclusions In women with a history of pregnancy loss, relations between higher preconception leptin and fecundability were attenuated after adjustment for BMI, although not after adjustment for other markers of adiposity. Leptin may serve as a complementary marker of adiposity for assessment of obesity and reproductive outcomes.
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Affiliation(s)
- Torie C Plowden
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Shvetha M Zarek
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri School of Medicine, Columbia, Missouri
| | - Elizabeth A DeVilbiss
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Jeannie G Radoc
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah.,Intermountain Healthcare, Salt Lake City, Utah
| | - Daniel L Kuhr
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.,Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Ukpebo R Omosigho
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Edwina H Yeung
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Duley L, Meher S, Hunter KE, Seidler AL, Askie LM. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev 2019; 2019:CD004659. [PMID: 31684684 PMCID: PMC6820858 DOI: 10.1002/14651858.cd004659.pub3] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia. OBJECTIVES To assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing pre-eclampsia. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (30 March 2018), and reference lists of retrieved studies. We updated the search in September 2019 and added the results to the awaiting classification section of the review. SELECTION CRITERIA All randomised trials comparing antiplatelet agents with either placebo or no antiplatelet agent were included. Studies only published in abstract format were eligible for inclusion if sufficient information was available. We would have included cluster-randomised trials in the analyses along with individually-randomised trials, if any had been identified in our search strategy. Quasi-random studies were excluded. Participants were pregnant women at risk of developing pre-eclampsia. Interventions were administration of an antiplatelet agent (such as low-dose aspirin or dipyridamole), comparisons were either placebo or no antiplatelet. DATA COLLECTION AND ANALYSIS Two review authors assessed trials for inclusion and extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For this update we incorporated individual participant data (IPD) from trials with this available, alongside aggregate data (AD) from trials where it was not, in order to enable reliable subgroup analyses and inclusion of two key new outcomes. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS Seventy-seven trials (40,249 women, and their babies) were included, although three trials (relating to 233 women) did not contribute data to the meta-analysis. Nine of the trials contributing data were large (> 1000 women recruited), accounting for 80% of women recruited. Although the trials took place in a wide range of countries, all of the nine large trials involved only women in high-income and/or upper middle-income countries. IPD were available for 36 trials (34,514 women), including all but one of the large trials. Low-dose aspirin alone was the intervention in all the large trials, and most trials overall. Dose in the large trials was 50 mg (1 trial, 1106 women), 60 mg (5 trials, 22,322 women), 75mg (1 trial, 3697 women) 100 mg (1 trial, 3294 women) and 150 mg (1 trial, 1776 women). Most studies were either low risk of bias or unclear risk of bias; and the large trials were all low risk of bas. Antiplatelet agents versus placebo/no treatment The use of antiplatelet agents reduced the risk of proteinuric pre-eclampsia by 18% (36,716 women, 60 trials, RR 0.82, 95% CI 0.77 to 0.88; high-quality evidence), number needed to treat for one women to benefit (NNTB) 61 (95% CI 45 to 92). There was a small (9%) reduction in the RR for preterm birth <37 weeks (35,212 women, 47 trials; RR 0.91, 95% CI 0.87 to 0.95, high-quality evidence), NNTB 61 (95% CI 42 to 114), and a 14% reduction infetal deaths, neonatal deaths or death before hospital discharge (35,391 babies, 52 trials; RR 0.85, 95% CI 0.76 to 0.95; high-quality evidence), NNTB 197 (95% CI 115 to 681). Antiplatelet agents slightly reduced the risk of small-for-gestational age babies (35,761 babies, 50 trials; RR 0.84, 95% CI 0.76 to 0.92; high-quality evidence), NNTB 146 (95% CI 90 to 386), and pregnancies with serious adverse outcome (a composite outcome including maternal death, baby death, pre-eclampsia, small-for-gestational age, and preterm birth) (RR 0.90, 95% CI 0.85 to 0.96; 17,382 women; 13 trials, high-quality evidence), NNTB 54 (95% CI 34 to 132). Antiplatelet agents probably slightly increase postpartum haemorrhage > 500 mL (23,769 women, 19 trials; RR 1.06, 95% CI 1.00 to 1.12; moderate-quality evidence due to clinical heterogeneity), and they probably marginally increase the risk of placental abruption, although for this outcome the evidence was downgraded due to a wide confidence interval including the possibility of no effect (30,775 women; 29 trials; RR 1.21, 95% CI 0.95 to 1.54; moderate-quality evidence). Data from two large trials which assessed children at aged 18 months (including results from over 5000 children), did not identify clear differences in development between the two groups. AUTHORS' CONCLUSIONS Administering low-dose aspirin to pregnant women led to small-to-moderate benefits, including reductions in pre-eclampsia (16 fewer per 1000 women treated), preterm birth (16 fewer per 1000 treated), the baby being born small-for-gestational age (seven fewer per 1000 treated) and fetal or neonatal death (five fewer per 1000 treated). Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes. The quality of evidence for all these outcomes was high. Aspirin probably slightly increased the risk of postpartum haemorrhage of more than 500 mL, however, the quality of evidence for this outcome was downgraded to moderate, due to concerns of clinical heterogeneity in measurements of blood loss. Antiplatelet agents probably marginally increase placental abruption, but the quality of the evidence was downgraded to moderate due to low event numbers and thus wide 95% CI. Overall, antiplatelet agents improved outcomes, and at these doses appear to be safe. Identifying women who are most likely to respond to low-dose aspirin would improve targeting of treatment. As almost all the women in this review were recruited to the trials after 12 weeks' gestation, it is unclear whether starting treatment before 12 weeks' would have additional benefits without any increase in adverse effects. While there was some indication that higher doses of aspirin would be more effective, further studies would be warranted to examine this.
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Affiliation(s)
- Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | | | - Kylie E Hunter
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
| | - Anna Lene Seidler
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
| | - Lisa M Askie
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
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Yeung EH, Park H, Nobles C, Mumford SL, Silver R, Schisterman EF. Cardiovascular disease family history and risk of pregnancy loss. Ann Epidemiol 2019; 34:40-44. [PMID: 31076211 DOI: 10.1016/j.annepidem.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine whether family history of cardiovascular disease (CVD) is a risk factor for pregnancy loss, given potential shared etiology, including vascular mechanisms involved in reproduction and placentation. METHODS In a prospective study, first-degree family histories were self-reported before pregnancy among women with 1-2 previous losses. Women were followed for up to 6 menstrual cycles while attempting pregnancy and through pregnancy. Pregnancies were ascertained by urinary human chorionic gonadotropin and confirmed by ultrasound. Risk ratios and 95% confidence intervals for pregnancy loss were estimated using weighted Poisson regression models with robust standard errors adjusted for covariates including prepregnancy body mass index and sociodemographics. RESULTS Of 1228 women enrolled, 742 had a clinically confirmed pregnancy, and of these, 18% experienced a clinical pregnancy loss. Forty six percent of women reported family history of CVD, diabetes, hypertension, or hypercholesterolemia/dyslipidemia. Family history of CVD was not associated with the risk of pregnancy loss overall (1.01; 95% confidence interval: 0.64, 1.59) or among women with 2 previous losses (1.05; 0.51, 2.17). Family history of hypertension was also not associated with pregnancy loss (0.98; 0.65, 1.46). CONCLUSIONS Family history of CVD is not providing additional information helpful in determining the risk of subsequent pregnancy loss in an at-risk group.
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Affiliation(s)
- Edwina H Yeung
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.
| | - Hyojun Park
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Carrie Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City; Intermountain Healthcare, Maternal Fetal Medicine, Salt Lake City, UT
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Russo LM, Whitcomb BW, Mumford SL, Hawkins M, Radin RG, Schliep KC, Silver RM, Perkins NJ, Kim K, Omosigho UR, Kuhr DL, Holland TL, Sjaarda LA, Schisterman EF. A prospective study of physical activity and fecundability in women with a history of pregnancy loss. Hum Reprod 2019; 33:1291-1298. [PMID: 29648647 DOI: 10.1093/humrep/dey086] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/21/2018] [Indexed: 02/02/2023] Open
Abstract
STUDY QUESTION Is physical activity (PA) associated with fecundability in women with a history of prior pregnancy loss? SUMMARY ANSWER Higher fecundability was related to walking among overweight/obese women and to vigorous PA in women overall. WHAT IS KNOWN ALREADY PA may influence fecundability through altered endocrine function. Studies evaluating this association have primarily utilized Internet-based recruitment and self-report for pregnancy assessment and have yielded conflicting results. STUDY DESIGN, SIZE, DURATION This is a secondary analysis of the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial (2007-2011), a multisite, randomized controlled trial of preconception-initiated low-dose aspirin. PARTICIPANTS/MATERIALS, SETTING, METHODS Healthy women (n = 1214), aged 18-40 and with 1-2 prior pregnancy losses, were recruited from four US medical centers. Participants were followed for up to six menstrual cycles while attempting pregnancy and through pregnancy for those who became pregnant. Time to hCG detected pregnancy was assessed using discrete-time Cox proportional hazard models to estimate fecundability odds ratios (FOR) adjusted for covariates, accounting for left truncation and right censoring. MAIN RESULTS AND THE ROLE OF CHANCE The association of walking with fecundability varied significantly by BMI (P-interaction = 0.01). Among overweight/obese women, walking ≥10 min at a time was related to improved fecundability (FOR = 1.82, 95% CI: 1.19, 2.77). In adjusted models, women reporting >4 h/wk of vigorous activity had significantly higher fecundability (FOR = 1.69, 95% CI: 1.24, 2.31) compared to no vigorous activity. Associations of vigorous activity with fecundability were not significantly different by BMI (P-interaction = 0.9). Moderate activity, sitting, and International Physical Activity Questionnaire (IPAQ) categories were not associated with fecundability overall or in BMI-stratified analyses. LIMITATIONS, REASONS FOR CAUTION Some misclassification of PA levels as determined by the short form of the IPAQ is likely to have occurred, and may have led to non-differential misclassification of exposure in our study. Information on diet and change in BMI was not collected and may have contributed to some residual confounding in our results. The generalizability of our results may be limited as our population consisted of women with a history of one or two pregnancy losses. WIDER IMPLICATIONS OF THE FINDINGS These findings provide positive evidence for the benefits of PA in women attempting pregnancy, especially for walking among those with higher BMI. Further study is necessary to clarify possible mechanisms through which walking and vigorous activity might affect time-to-pregnancy. STUDY FUNDING/COMPETING INTEREST(S) This work was funded by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors report no conflicts of interest in this work. TRIAL REGISTRATION NUMBER #NCT00467363.
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Affiliation(s)
- Lindsey M Russo
- Department of Biostatistics & Epidemiology, University of Massachusetts Amherst, 715 N Pleasant Street, Amherst, MA, USA
| | - Brian W Whitcomb
- Department of Biostatistics & Epidemiology, University of Massachusetts Amherst, 715 N Pleasant Street, Amherst, MA, USA
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Marquis Hawkins
- Department of Biostatistics & Epidemiology, University of Massachusetts Amherst, 715 N Pleasant Street, Amherst, MA, USA
| | - Rose G Radin
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Karen C Schliep
- Department of Family and Preventive Medicine, University of Utah Health, 375 Chipeta Way Ste. A, Salt Lake City, UT, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, 30 North 1900 East, Salt Lake City, UT, USA
| | - Neil J Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Ukpebo R Omosigho
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Daniel L Kuhr
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Tiffany L Holland
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Dr. MSC 7004, Bethesda, MD, USA
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16
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Levine LD, Holland TL, Kim K, Sjaarda LA, Mumford SL, Schisterman EF. The role of aspirin and inflammation on reproduction: the EAGeR trial 1. Can J Physiol Pharmacol 2018; 97:187-192. [PMID: 30562044 DOI: 10.1139/cjpp-2018-0368] [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] [Indexed: 12/12/2022]
Abstract
Inflammation has been linked to several complications in pregnancy, including pregnancy loss. Due to its anti-inflammatory properties, aspirin, a widely available and inexpensive therapy, has potential to help mitigate the negative effects of inflammation along the reproductive pathway. Therefore, the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial was designed to elucidate whether preconception-initiated daily low-dose aspirin would increase the live birth rate in women with 1-2 prior pregnancy losses and no infertility diagnosis and attempting unassisted conception. Here, we present an overview of the collected findings. Low-dose aspirin was associated with an increased live birth rate among women with a single loss at <20 weeks gestation within the past year. When stratified by tertile of C-reactive protein (CRP), a biomarker of inflammation, treatment with aspirin restored a decrement in the live birth rate in women in the highest CRP tertile (relative risk 1.35, 95% confidence interval 1.08-1.67), increasing to similar rates as women of the lower and mid-CRP tertiles. The same effect modification by inflammation status was observed when examining the effect of low-dose aspirin on offspring sex ratio. These results suggest that inflammation plays an important role in reproduction, and that chronic, low-grade inflammation may be amenable to aspirin treatment.
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Affiliation(s)
- Lindsay D Levine
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Tiffany L Holland
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
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Andrikopoulou M, Purisch SE, Handal-Orefice R, Gyamfi-Bannerman C. Low-dose aspirin is associated with reduced spontaneous preterm birth in nulliparous women. Am J Obstet Gynecol 2018; 219:399.e1-399.e6. [PMID: 29913174 DOI: 10.1016/j.ajog.2018.06.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/03/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor. OBJECTIVE Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities. STUDY DESIGN This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13-25 weeks' gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks' gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth. RESULTS Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26-0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71-1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72-1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23-0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo. CONCLUSION Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.
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18
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Kim K, Schisterman EF, Silver RM, Wilcox BD, Lynch AM, Perkins NJ, Browne RW, Lesher LL, Stanford JB, Ye A, Wactawski-Wende J, Mumford SL. Shorter Time to Pregnancy With Increasing Preconception Carotene Concentrations Among Women With 1-2 Previous Pregnancy Losses. Am J Epidemiol 2018; 187:1907-1915. [PMID: 29767694 DOI: 10.1093/aje/kwy101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 04/30/2018] [Indexed: 01/08/2023] Open
Abstract
Although maternal nutrition may affect fecundity, associations between preconception micronutrient levels and time to pregnancy (TTP) have not been examined. We assessed the relationship between preconception fat-soluble micronutrient concentrations and TTP among women with 1-2 prior pregnancy losses. This was a prospective cohort study of 1,228 women set within the Effects of Aspirin in Gestation and Reproduction (EAGeR) Trial (United States, 2007-2011), which assessed the association of preconception-initiated daily low-dose aspirin with reproductive outcomes. We measured preconception levels of zeaxanthin, cryptoxanthin, lycopene, α- and β-carotene, and α- and γ-tocopherol in serum. We used discrete Cox regression models, accounting for left-truncation and right-censoring, to calculate fecundability odds ratios and 95% confidence intervals. The models adjusted for age, body mass index, race, smoking, alcohol, physical activity, income, vitamin use, cholesterol, treatment arm, and study site. Serum α-carotene levels (per log unit (μg/dL) increase, fecundability odds ratio (FOR) = 1.17, 95% confidence interval (CI): 1.00, 1.36) and serum α-carotene concentrations at or above the US average (2.92 μg/dL) versus below the average (FOR = 1.21, 95% CI: 1.02, 1.44) were associated with shorter TTP. Compared with levels below the US average (187 μg/dL), γ-tocopherol concentrations at or above the average were associated with longer TTP (FOR = 0.83, 95% CI: 0.69, 1.00). The potential for these nutrients to influence fecundability deserves further exploration.
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Affiliation(s)
- Keewan Kim
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Enrique F Schisterman
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Brian D Wilcox
- Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Anne M Lynch
- Departments of Clinical Ophthalmology and Obstetrics and Gynecology, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Neil J Perkins
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Richard W Browne
- Department of Biotechnical and Clinical Laboratory Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Laurie L Lesher
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Joseph B Stanford
- Department of Family and Preventive Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Aijun Ye
- Glotech, Inc., Rockville, Maryland
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, New York
| | - Sunni L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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19
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Association of testosterone and antimüllerian hormone with time to pregnancy and pregnancy loss in fecund women attempting pregnancy. Fertil Steril 2018; 109:540-548.e1. [PMID: 29428315 DOI: 10.1016/j.fertnstert.2017.11.014] [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: 05/04/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To examine whether higher T and/or antimüllerian hormone (AMH) was associated with anovulation, time to pregnancy (TTP), or pregnancy loss risk among healthy, fecund women without diagnosed polycystic ovary syndrome. DESIGN Prospective cohort study conducted as a secondary analysis from the Effects of Aspirin in Gestation and Reproduction randomized trial. SETTING University medical centers. PATIENT(S) A total of 1,198 healthy, eumenorrheic women aged 18-40 years attempting spontaneous pregnancy with one to two prior pregnancy losses were included. Women were categorized by baseline antimüllerian hormone (AMH), as a surrogate marker of antral follicle count, and T concentrations; the highest quartile for each was "high," and below the top quartile (i.e., lower 75% of values) was "norm," forming four groups: norm T/norm AMH (n = 742), norm T/high AMH (n = 156), high T/norm AMH (n = 157), and high T/high AMH (n = 143). INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Anovulation, pregnancy incidence, TTP, and pregnancy loss incidence. RESULT(S) Women with high T/high AMH had a greater anovulation risk (risk ratio 1.58, 95% confidence interval 1.13-2.22) compared with women with norm T/norm AMH, but with imprecise differences in incidence of pregnancy, TTP, or pregnancy loss. CONCLUSION(S) Women with higher T and AMH had more frequent anovulatory cycles but with marginal impacts on TTP or pregnancy loss. A continuum of mild inefficiency in reproductive function may be related to higher T and AMH, including in fecund women with normal menstrual cycles and no clinical diagnosis of polycystic ovary syndrome, but with unclear effects on fecundability and pregnancy loss. CLINICAL TRIAL REGISTRATION NUMBER NCT00467363.
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Fehring RJ, Raviele K. Current Medical Research: Winter/Spring 2017. LINACRE QUARTERLY 2018; 85:74-85. [PMID: 29970939 PMCID: PMC6027111 DOI: 10.1177/0024363918756392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Radin RG, Sjaarda LA, Silver RM, Nobles CJ, Mumford SL, Perkins NJ, Wilcox BD, Pollack AZ, Schliep KC, Plowden TC, Schisterman EF. C-Reactive protein in relation to fecundability and anovulation among eumenorrheic women. Fertil Steril 2018; 109:232-239.e1. [PMID: 29317123 DOI: 10.1016/j.fertnstert.2017.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To assess systemic inflammation in relation to fecundability and anovulation. DESIGN Prospective cohort study among participants in the Effects of Aspirin in Gestation and Reproduction trial who were assigned to the placebo. SETTING Academic medical centers. PATIENT(S) Healthy eumenorrheic women (n = 572), 18-40 years of age, with one or two pregnancy losses, attempting spontaneous pregnancy. INTERVENTION(S) Baseline serum high-sensitivity C-reactive protein (hsCRP) values <10 mg/L were categorized into tertiles. MAIN OUTCOME MEASURE(S) Discrete Cox proportional hazards models estimated the fecundability odds ratio (FOR) and 95% confidence interval (CI) and adjusted for potential confounders. Log-binomial regression estimated the risk ratio (RR) and 95% CI of anovulation. The algorithm to define anovulation used data on urinary concentrations of hCG, pregnanediol-3-glucuronide, and LH as well as fertility monitor readings. RESULT(S) Higher hsCRP was associated with reduced fecundability but not with an increased risk of anovulation. CONCLUSION(S) Among healthy women attempting pregnancy after one or two pregnancy losses, we found preliminary evidence that systemic inflammation is associated with reduced fecundability, but not independently from adiposity. Sporadic anovulation did not appear to drive this association. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT00467363.
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Affiliation(s)
- Rose G Radin
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Carrie J Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Neil J Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Brian D Wilcox
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Anna Z Pollack
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Karen C Schliep
- Department of Family and Community Health, University of Utah School of Medicine, Salt Lake City, Utah
| | - Torie C Plowden
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.
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Connell MT, Sjaarda LA, Radin RG, Kuhr D, Mumford SL, Plowden TC, Silver RM, Schisterman EF. The Effects of Aspirin in Gestation and Reproduction (EAGeR) Trial: A Story of Discovery. Semin Reprod Med 2017; 35:344-352. [PMID: 29036741 PMCID: PMC6234510 DOI: 10.1055/s-0037-1606384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Human reproduction is an inefficient process. There are several drivers of complications along the path to and during pregnancy, one of which is inflammation. Treatments to mitigate the deleterious effects of aberrant inflammation with something inexpensive and widely available like aspirin could have dramatic global impact. The Effects of Aspirin in Gestation and Reproduction (EAGeR) trial enrolled women aged 18 to 40 years with one to two prior pregnancy losses and no diagnosis of infertility. Patients were randomized to either low-dose aspirin or placebo. Here, we review the collective findings of the EAGeR trial to date and discuss several important lessons learned from the unique data resulting from this groundbreaking trial. Findings reported from this trial provide significant advances in the understanding of aspirin’s potential mechanisms in modulating reproductive processes and the role of inflammation in these processes. This review describes the collective findings of the EAGeR trial in the context of the existing literature regarding aspirin and inflammation in reproduction to inform relevant next steps in fertility and obstetric research, as well as potential implications for clinical care.
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Affiliation(s)
- Matthew T. Connell
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
- Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A. Sjaarda
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Rose G. Radin
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Daniel Kuhr
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Sunni L. Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
| | - Torie C. Plowden
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
- Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, Utah
| | - Enrique F. Schisterman
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Marylan
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Radin RG, Sjaarda LA, Perkins NJ, Silver RM, Chen Z, Lesher LL, Galai N, Wactawski-Wende J, Mumford SL, Schisterman EF. Low-Dose Aspirin and Sporadic Anovulation in the EAGeR Randomized Trial. J Clin Endocrinol Metab 2017; 102:86-92. [PMID: 27754808 PMCID: PMC5413097 DOI: 10.1210/jc.2016-2095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/12/2016] [Indexed: 12/16/2022]
Abstract
CONTEXT Among women with a single, recent pregnancy loss, daily preconception low-dose aspirin (LDA) increased the live birth rate with no effect on pregnancy loss. Ovulation is a potential mechanism underlying this effect. OBJECTIVE We estimated the effect of LDA on the per-cycle risk of anovulation among eumenorrheic women. DESIGN Multicenter, randomized, double-blind, placebo-controlled trial of daily LDA on reproductive outcomes. Preconception follow-up lasted 1 to 6 menstrual cycles (ClinicalTrials.gov, NCT00467363). SETTING Four US medical centers during 2007 to 2011. PATIENTS OR OTHER PARTICIPANTS Healthy women (n = 1214), age 18 to 40, were attempting pregnancy, had regular menstrual cycles (21 to 42 days), and had a history of 1 to 2 documented pregnancy losses, ≤2 live births, and no infertility. All participants completed at least 1 menstrual cycle of follow-up; none withdrew due to adverse events. INTERVENTION Aspirin (81 mg) daily for 1 to 6 menstrual cycles. MAIN OUTCOME MEASURE Per-cycle risk of anovulation, defined as the absence of both a positive spot-urine pregnancy test and a luteinizing hormone (LH) peak (2.5-fold increase in daily urinary LH). Hypothesis formulation preceded data collection. RESULTS Among 4340 cycles, LDA was not associated with anovulation (LDA: 13.4%, placebo: 11.1%; risk ratio = 1.16, 95% confidence interval, 0.88 to 1.52). Results were similar among women with a single, recent loss. CONCLUSIONS Daily LDA had no effect on anovulation among women with a history of 1 to 2 pregnancy losses. LDA may affect fertility via other pathways, and these warrant further study.
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Affiliation(s)
- Rose G. Radin
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
| | - Lindsey A. Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
| | - Neil J. Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, School of Medicine, Salt Lake City, Utah 84132;
| | - Zhen Chen
- Biostatistics and Bioinformatics Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
| | - Laurie L. Lesher
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, School of Medicine, Salt Lake City, Utah 84132;
| | - Noya Galai
- Department of Statistics, University of Haifa, Haifa, 3498838 Israel; and
| | - Jean Wactawski-Wende
- Department of Social and Preventive Medicine, University at Buffalo, Buffalo, New York 14228
| | - Sunni L. Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
| | - Enrique F. Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20817;
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Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait. Obstet Gynecol 2016; 127:204-12. [PMID: 26942344 DOI: 10.1097/aog.0000000000001159] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare time to pregnancy and live birth among couples with varying intervals of pregnancy loss date to subsequent trying to conceive date. METHODS In this secondary analysis of the Effects of Aspirin in Gestation and Reproduction trial, 1,083 women aged 18-40 years with one to two prior early losses and whose last pregnancy outcome was a nonectopic or nonmolar loss were included. Participants were actively followed for up to six menstrual cycles and, for women achieving pregnancy, until pregnancy outcome. We calculated intervals as start of trying to conceive date minus pregnancy loss date. Time to pregnancy was defined as start of trying to conceive until subsequent conception. Discrete Cox models, accounting for left truncation and right censoring, estimated fecundability odds ratios (ORs) adjusting for age, race, body mass index, education, and subfertility. Although intervals were assessed prior to randomization and thus reasoned to have no relation with treatment assignment, additional adjustment for treatment was evaluated given that low-dose aspirin was previously shown to be predictive of time to pregnancy. RESULTS Couples with a 0-3-month interval (n=765 [76.7%]) compared with a greater than 3-month (n=233 [23.4%]) interval were more likely to achieve live birth (53.2% compared with 36.1%) with a significantly shorter time to pregnancy leading to live birth (median [interquartile range] five cycles [three, eight], adjusted fecundability OR 1.71 [95% confidence interval 1.30-2.25]). Additionally adjusting for low-dose aspirin treatment did not appreciably alter estimates. CONCLUSION Our study supports the hypothesis that there is no physiologic evidence for delaying pregnancy attempt after an early loss.
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McInerney KA, Hatch EE, Wesselink AK, Rothman KJ, Mikkelsen EM, Wise LA. Preconception use of pain-relievers and time-to-pregnancy: a prospective cohort study. Hum Reprod 2016; 32:103-111. [PMID: 27816920 DOI: 10.1093/humrep/dew272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 09/27/2016] [Accepted: 10/19/2016] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION To what extent is preconception use of pain-relieving medication associated with female fecundability? SUMMARY ANSWER Women who used naproxen or opioids had slightly lower fecundability than women who did not use any pain-relieving medications; use of acetaminophen, aspirin and ibuprofen was not appreciably associated with fecundability. WHAT IS KNOWN ALREADY Over-the-counter pain-relieving medications are commonly used by women of reproductive age in the USA. Studies investigating the effects of pain-relieving medication use on ovulation, implantation and fecundability have shown conflicting results. STUDY DESIGN, SIZE, DURATION We analyzed data from an internet-based prospective cohort study of 2573 female pregnancy planners aged 21-45 years from the USA and Canada. Participants were enrolled and followed from June 2013 through September 2015. Participants completed a baseline questionnaire and bimonthly follow-up questionnaires until a reported pregnancy or for 12 months, whichever occurred first. Over 80% of participants completed at least one follow-up questionnaire. PARTICIPANTS/MATERIALS, SETTING, METHODS Use of pain-relieving medication during the past month was assessed at baseline and on each follow-up questionnaire. Medications were categorized according to type (acetaminophen, aspirin, ibuprofen, naproxen and opioids) and total monthly dose. Self-reported pregnancy was assessed at each follow-up. Multivariable-adjusted fecundability ratios (FRs) and 95% CI were calculated using proportional probabilities regression. Models were adjusted for demographic, lifestyle and anthropometric factors; reproductive history; gynecologic morbidity; and indications for use of pain medications. Models were also run with and without adjustment for parity. After restricting to women with 6 or fewer months of attempt time at study entry, 1763 were included in the analyses. MAIN RESULTS AND THE ROLE OF CHANCE At baseline, 1279 (73%) women reported using ≥1 pain-relieving medications in the previous month. When compared with non-use of pain-relieving medications, FRs for use of naproxen and opioids at baseline were 0.78 (95% CI: 0.64-0.97) and 0.81 (95% CI: 0.60-1.10), respectively. A dose-response relation was observed between naproxen use and fecundability; FRs for use of <1500 and ≥1500 mg of naproxen were 0.85 (95% CI: 0.68-1.07) and 0.58 (95% CI: 0.36-0.94), respectively. Small numbers (n = 74) precluded the examination of opioid use by dose. Overall, there was little evidence of an association between fecundability and acetaminophen (FR 1.04, 95% CI: 0.92-1.18), aspirin (FR 1.00, 95% CI: 0.80-1.25), or ibuprofen (FR 1.00, 95% CI: 0.89-1.11). Similar results were observed when exposure information was updated over time. LIMITATIONS, REASONS FOR CAUTION Numbers of opioid users were small. Information collected on reason for use of pain medications was not specific to each type of pain medication. Therefore, we cannot rule out confounding by indication as an explanation of these results. WIDER IMPLICATIONS OF THE FINDINGS Use of naproxen and opioids was associated with a small reduction in fecundability, but there was little association between other pain-relieving medications and fecundability. STUDY FUNDING/COMPETING INTERESTS This study was supported through funds provided by National Institute of Child Health and Human Development, National Institute of Health (R21 HD072326, T32 HD052458). The authors have no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Kathryn A McInerney
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, 3rd Floor, Boston, MA 02118, USA
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, 3rd Floor, Boston, MA 02118, USA
| | - Amelia K Wesselink
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, 3rd Floor, Boston, MA 02118, USA
| | - Kenneth J Rothman
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, 3rd Floor, Boston, MA 02118, USA.,RTI Health Solutions, PO Box 12194, Research Triangle Park, NC 27709, USA
| | - Ellen M Mikkelsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus, Denmark
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, 3rd Floor, Boston, MA 02118, USA
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