The relationship between serum prolactin concentration and pregnancy outcome in women with unexplained recurrent miscarriage

Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Expanding the role of chromosomal microarray analysis in the evaluation of recurrent pregnancy loss

Multiple factors contribute to recurrent pregnancy loss (RPL). This review highlights the latest international guidelines for RPL workup, including immunological testing, by the American Society for Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE), and the Royal College of Obstetricians and Gynaecologists (RCOG). These three societies recommend testing for antiphospholipid syndrome. ESHRE and RCOG also recommend thyroid peroxidase antibody testing, whereas ASRM does not. All guidelines advise against testing of natural killer cells, cytokines, antinuclear antibodies, human leukocyte antigen (HLA) compatibility, anti-HLA antibodies, and anti-sperm antibodies. However, when following ASRM, ESHRE or RCOG diagnostic guidelines, over 50% of cases have no identifiable cause. Genetic testing of products of conception (POC) can improve our understanding of unexplained RPL as aneuploidy is a common cause of RPL. Based on studies reporting results from chromosomal microarray analysis (CMA) of POC, we propose a novel algorithm for RPL evaluation. The algorithm involves following evidence-based societal guidelines (published by ASRM, ESHRE, or RCOG), excluding parental karyotyping, in combination with CMA testing of miscarriage tissue. When utilizing this new evaluation algorithm, the number of unexplained cases of RPL decreases from over 50% to less than 10%. As a result, most patients are provided an explanation for their loss and healthcare costs are potentially reduced. Patients with an otherwise negative workup with euploid POC, are classified as "truly unexplained RPL". These patients are excellent candidates for enrollment in randomized, controlled trials examining novel immunological testing and treatment protocols.

Recurrent MiscarriageGreen-top Guideline No. 17

In this guideline, recurrent miscarriage has been defined as three or more first trimester miscarriages. However, clinicians are encouraged to use their clinical discretion to recommend extensive evaluation after two first trimester miscarriages, if there is a suspicion that the miscarriages are of pathological and not of sporadic nature. Women with recurrent miscarriage should be offered testing for acquired thrombophilia, particularly for lupus anticoagulant and anticardiolipin antibodies, prior to pregnancy. [Grade C] Women with second trimester miscarriage may be offered testing for Factor V Leiden, prothrombin gene mutation and protein S deficiency, ideally within a research context. [Grade C] Inherited thrombophilias have a weak association with recurrent miscarriage. Routine testing for protein C, antithrombin deficiency and methylenetetrahydrofolate reductase mutation is not recommended. [Grade C] Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s) and in any second trimester miscarriage. [Grade D] Parental peripheral blood karyotyping should be offered for couples in whom testing of pregnancy tissue reports an unbalanced structural chromosomal abnormality [Grade D] or there is unsuccessful or no pregnancy tissue available for testing. [GPP] Women with recurrent miscarriage should be offered assessment for congenital uterine anomalies, ideally with 3D ultrasound. [Grade B] Women with recurrent miscarriage should be offered thyroid function tests and assessment for thyroid peroxidase (TPO) antibodies. [Grade C] Women with recurrent miscarriage should not be routinely offered immunological screening (such as HLA, cytokine and natural killer cell tests), infection screening or sperm DNA testing outside a research context. [Grade C] Women with recurrent miscarriage should be advised to maintain a BMI between 19 and 25 kg/m2 , smoking cessation, limit alcohol consumption and limit caffeine to less than 200 mg/day. [Grade D] For women diagnosed with antiphospholipid syndrome, aspirin and heparin should be offered from a positive test until at least 34 weeks of gestation, following discussion of potential benefits versus risks. [Grade B] Aspirin and/or heparin should not be given to women with unexplained recurrent miscarriage. [Grade B] There are currently insufficient data to support the routine use of PGT-A for couples with unexplained recurrent miscarriage, while the treatment may carry a significant cost and potential risk. [Grade C] Resection of a uterine septum should be considered for women with recurrent first or second trimester miscarriage, ideally within an appropriate audit or research context. [Grade C] Thyroxine supplementation is not routinely recommended for euthyroid women with TPO who have a history of miscarriage. [Grade A] Progestogen supplementation should be considered in women with recurrent miscarriage who present with bleeding in early pregnancy (for example 400 mg micronised vaginal progesterone twice daily at the time of bleeding until 16 weeks of gestation). [Grade B] Women with unexplained recurrent miscarriage should be offered supportive care, ideally in the setting of a dedicated recurrent miscarriage clinic. [Grade C].

Diagnostic workup of endocrine dysfunction in recurrent pregnancy loss: a cross-sectional study in Northeast China

Objective

To evaluate the prevalence of abnormal endocrine dysfunction for recurrent pregnancy loss (RPL) amongst patients with two versus three or more pregnancy losses.

Methods

This cross-sectional study retrospectively collected pre-pregnancy data of 537 women diagnosed with RPL in Shengjing Hospital of China Medical University from 2017 to 2022, including the baseline data of patients and the test results of endocrine factors. Several endocrine dysfunction included in this study were: thyroid dysfunction, obesity, hyperprolactinemia, polycystic ovary syndrome and blood glucose abnormality. Furthermore, vitamin D level were collected to study its relationship with endocrine dysfunction. Finally, we subdivided the patients according to the number of previous pregnancy loss and compared the prevalence of endocrine dysfunction between subgroups.

Results

Among 537 RPL patients, 278 (51.8%) patients had abnormal endocrine test results. The highest incidence of endocrine dysfunction was thyroid dysfunction (24.39%, 131/537), followed by hyperprolactinemia (17.34%, 85/490), obesity (10.8%, 58/537), polycystic ovary syndrome (10.50%, 56/533), and abnormal blood glucose (5.29%, 27/510). Only 2.47%(13/527) of patients have vitamin D level that reach the standard. After subdividing the population according to the number of pregnancy loss, we did not find that the incidence of endocrine dysfunction (P=0.813), thyroid dysfunction (P=0.905), hyperprolactinemia (P=0.265), polycystic ovary syndrome (P=0.638), blood glucose abnormality (P=0.616) and vitamin D deficiency (P=0.908) were different among patients with two versus three or more pregnancy losses. However, obesity (P=0.003) was found more frequently observed in patients with more times of pregnancy loss.

Conclusion

The prevalence of endocrine dysfunction in RPL population is high. There is no difference in the prevalence of endocrine dysfunction, except for obesity, among patients with two or more pregnancy losses, which may suggest investigations of endocrine dysfunction when patients have two pregnancy losses.

The Diagnostics and Treatment of Recurrent Pregnancy Loss

Recurrent pregnancy loss is a common problem in the reproductive age population of women. It can be caused by many different conditions. This problem is addressed in international guidelines that take a slightly different approach to its diagnosis and treatment. The guidelines used in this review mainly use the guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), American Society of Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE). This review shows how much the approach to miscarriages has changed and how much more needs to be explored and refined. The review also addresses the topic of unexplained pregnancy loss, which continues to be a challenge for clinicians.

Recurrent Spontaneous Miscarriage: a Comparison of International Guidelines

While roughly 30% of all women experience a spontaneous miscarriage in their lifetime, the incidence of recurrent (habitual) spontaneous miscarriage is 1 – 3% depending on the employed definition. The established risk factors include endocrine, anatomical, infection-related, genetic, haemostasis-related and immunological factors. Diagnosis is made more difficult by the sometimes diverging recommendations of the respective international specialist societies. The present study is therefore intended to provide a comparison of existing international guidelines and recommendations. The guidelines of the ESHRE, ASRM, the DGGG/OEGGG/SGGG and the recommendations of the RCOG were analysed. It was shown that investigation is indicated after 2 clinical pregnancies and the diagnosis should be made using a standardised timetable that includes the most frequent causes of spontaneous miscarriage. The guidelines concur that anatomical malformations, antiphospholipid syndrome and thyroid dysfunction should be excluded. Moreover, the guidelines recommend carrying out pre-conception chromosomal analysis of both partners (or of the aborted material). Other risk factors have not been included in the recommendations by all specialist societies, on the one hand because of a lack of diagnostic criteria (luteal phase insufficiency) and on the other hand because of the different age of the guidelines (chronic endometritis). In addition, various economic and consensus aspects in producing the guidelines influence the individual recommendations. An understanding of the underlying decision-making process should lead in practice to the best individual diagnosis and resulting treatment being offered to each couple.

Comparative Study on Different Hormones between Normal Pregnant Women and Women Experiencing Miscarriage

Background:

Pregnancy leads to a complex alteration in hormonal levels and metabolism in the maternal and fetal system and if undesirable alteration is experienced, complications may be seen. Common complications of pregnancy include gestational diabetes, preeclampsia, preterm labor, and pregnancy loss or miscarriage. Miscarriage is defined as a spontaneous pregnancy loss occurring before 20 weeks of gestation. It has been seen in around 10%–15% of clinically recognized pregnancies.

Aim:

This study was designed to evaluate the levels of different serum hormones between cases and controls group.

Materials and Methods:

Pregnant women before 20 weeks of gestation were selected based on inclusion and exclusion criteria, visiting Adesh hospital Bathinda. After recording the history, blood was drawn and serum thyroid-stimulating hormones (TSH), total tri-iodothyronine (TT3), total thyroxine (TT4), prolactin and beta-human chorionic gonadotropin (β-hCG) were analyzed using TSOSH automated immunoassay analyzer.

Results:

Overall data and data of the 1^st trimester suggested significant differences in the mean level of serum TT3, TSH, β-hCG, and prolactin between controls and cases (P ≤ 0.05). However, serum TT4 did not show a significant difference (P > 0.05). In 2^nd-trimester significant difference in the mean level of serum TSH was only observed between controls and cases (P ≤ 0.05). Similarly, after applying Pearson's correlation, an inverse relation was only observed between serum TT3 and TSH of both control and cases (P ≤ 0.05).

Conclusion:

This study emphasized that screening of women during pregnancy for different serum hormones may provide useful lead about the fate of pregnancy and better understanding of different hormones may reduce the rate of miscarriages and other complications related to pregnancy.

Adverse childhood experiences are associated with increased risk of miscarriage in a national population-based cohort study in England

STUDY QUESTION

Is there an association between adverse childhood experiences (ACE) and the risk of miscarriage in the general population?

SUMMARY ANSWER

Specific ACE as well as the summary ACE score were associated with an increased risk of single and recurrent miscarriages.

WHAT IS KNOWN ALREADY

There is scarce evidence on the association between ACE and miscarriage risk.

STUDY DESIGN, SIZE, DURATION

We conducted a retrospective national cohort study. The sample consisted of 2795 women aged 55-89 years from the English Longitudinal Study of Ageing (ELSA).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Our study was population-based and included women who participated in the ELSA Life History Interview in 2007. We estimated multinomial logistic regression models of the associations of the summary ACE score and eight individual ACE variables (pertaining to physical and sexual abuse, family dysfunction and experiences of living in residential care or with foster parents) with self-reported miscarriage (0, 1, ≥2 miscarriages).

MAIN RESULTS AND THE ROLE OF CHANCE

Five hundred and fifty-three women (19.8% of our sample) had experienced at least one miscarriage in their lifetime. Compared with women with no ACE, women with ≥3 ACE were two times more likely to experience a single miscarriage in their lifetime (relative risk ratio 2.00, 95% CI 1.25-3.22) and more than three times more likely to experience recurrent miscarriages (≥2 miscarriages) (relative risk ratio 3.10, 95% CI 1.63, 5.89) after adjustment for birth cohort, age at menarche and childhood socioeconomic position. Childhood experiences of physical and sexual abuse were individually associated with increased risk of miscarriage.

LIMITATIONS, REASONS FOR CAUTION

Given the magnitude of the observed associations, their biological plausibility, temporal order and consistency with evidence suggesting a positive association between ACE and adverse reproductive outcomes, it is unlikely that our findings are spurious. Nevertheless, the observed associations should not be interpreted as causal as our study was observational and potentially susceptible to bias arising from unaccounted confounders. Non-response and ensuing selection bias may have also biased our findings. Retrospectively measured ACE are known to be susceptible to underreporting. Our study may have misclassified cases of ACE and possibly underestimated the magnitude of the association between ACE and the risk of miscarriage.

WIDER IMPLICATIONS OF THE FINDINGS

Our study highlights experiences of psychosocial adversity in childhood as a potential risk factor for single and recurrent miscarriages. Our findings contribute to a better understanding of the role of childhood trauma in miscarriage and add an important life course dimension to the study of miscarriage.

STUDY FUNDING/COMPETING INTEREST(S)

ELSA is currently funded by the National Institute on Aging in USA (R01AG017644) and a consortium of UK government departments coordinated by the National Institute for Health Research. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the article. The authors have no actual or potential competing financial interests to disclose.

[Advance of diagnosis and treatment of Haglund syndrome]

OBJECTIVE

To review the current research on the diagnosis and treatment of Haglund syndrome.

METHODS

The domestic and foreign literature about Haglund syndrome in recent years was extensively reviewed to summarize and analyze the etiology, anatomy, clinical manifestations, diagnosis, and treatment of Haglund syndrome.

RESULTS

The etiology of Haglund syndrome is not very clear, and it may be related to local friction and high gastrocnemius muscle tension, and there may be a certain genetic tendency. The local anatomy is more complex and there are many adjacent tissue structures. Haglund malformation may cause the impingement of the posterior heel bursa and Achilles tendon insertion, lead to wear of the posterior heel bursa and the Achilles tendon insertion, and finally result in pain. The FPA (Fowler-Philipp angle), CPA (calcaneal pith angle), PPL (parallel pitch lines), CLA (Chauveaux-Liet angle), and X/Y ratios (ratio of total calcaneal length to calcaneal tuberosity length) measured on X-ray film can be used for the diagnostic measurement of Haglund malformation. Treatment includes conservative and surgical treatment (open Haglund ostectomy, dorsal closed wedge osteotomy of the calcaneus, and arthroscopic Haglund osteotomy).

CONCLUSION

Both open and arthroscopic Haglund ostectomy and dorsal closed wedge osteotomy of the calcaneus can achieve satisfactory results, but minimally invasive treatment is the current development trend. Surgeons should pay attention to the management of the calcification of Achilles tendon insertion and reconstruction of Achilles tendon insertion.

Endocrine causes of recurrent pregnancy loss

OBJECTIVE

To review the available data on endocrine disorders and recurrent pregnancy loss.

FINDINGS

Our group found that most endocrine disorders do not seem to be correlated with a diagnosis of recurrent pregnancy loss (RPL). The exception to this is testing for thyroid stimulating hormone and thyroid antibodies, which is recommended due to a strong correlation with recurrent pregnancy loss and positive anti-thyroid peroxidase antibodies.

CONCLUSION

The available literature supports testing thyroid function and antibodies in women with RPL. Testing for other endocrine disorders is only warranted if otherwise clinically indicated, independent from a history of recurrent pregnancy loss.

Recurrent pregnancy loss and vitamin D: A review of the literature

Recurrent pregnancy loss (RPL) affects approximately 1%-2% of reproductive women. Auto- and cellular immune responses seem to be associated with RPL. Vitamin D (VD) has been shown to play a role in the modulation of the immune system. Effects of VD deficiency (VDD) in pregnancy have been associated with preeclampsia, gestational diabetes, fetal growth restriction, preterm labor, and sporadic spontaneous abortion (SA). We systematically reviewed articles that studied women with 2 or more SA and its association with VD. Eleven studies were included. Studies reported a high prevalence of VD insufficiency (VDI) or VDD in women with RPL and suggested that this could be associated with immunological dysregulation and consequently with RPL. Immunological benefits were reported in the peripheral blood of women with RPL after VD exposure. Thus, it is possible to speculate a beneficial role for VD supplementation in RPL. It seems that there are not differences in the vitamin D receptor (VDR) and CYP27B1 expression in endometrium of women with RPL but, in villous and decidual tissues, RPL women seem to have a decreased expression of VDR and, perhaps, a decreased expression of CYP27B1. Further randomized controlled studies are required to investigate the association between VDD or VDI and RPL.

ESHRE guideline: recurrent pregnancy loss

STUDY QUESTION

What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized.

WHAT IS KNOWN ALREADY

A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL.

LIMITATIONS, REASONS FOR CAUTION

Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest.

ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.

Reproductive Endocrinology in Recurrent Pregnancy Loss

Endocrine disruptions may be important in patients experiencing recurrent pregnancy loss (RPL). This review focuses on data available on RPL and the endocrine system to investigate relevant, and perhaps modifiable, endocrine factors of importance for the disorder. Evidence indicates that some hormones may be important as immune modulators and a better understanding of this interplay has potential for improving pregnancy outcome in RPL. To date there is a lack of consensus on the effect of endocrine treatment options in RPL and there is a strong need for large randomized-controlled trials.

Endocrine dysfunction and recurrent spontaneous abortion: An overview

Miscarriage is the spontaneous loss of a fetus before it is viable, occurring at a rate of 15–20%. Recurrent spontaneous abortion (RSA) or habitual miscarriage is defined as repeated occurrence of 3 or more miscarriages before 20^th week of gestation accounting for the most common complication of early pregnancy in humans. Various etiological factors responsible for recurrent miscarriage are anatomical, genetical, endocrinological, immunological, and infectious. The endocrinological abnormalities may be polycystic ovarian syndrome, hyperprolactinemia, luteal phase defect, thyroid dysfunction, diabetes, or hyperandrogenism contributing to recurrent pregnancy loss. In the present article, the role of endocrinological disorders in patients with RSA has been reviewed. The article search was done using electronic databases, Google scholarly articles, and PubMed based on different key words. We have further combined the searches and made grouping as per various endocrine abnormalities, which might be responsible to cause spontaneous loss of fetus.

Mutant prolactin receptor and familial hyperprolactinemia

Hyperprolactinemia that is not associated with gestation or the puerperium is usually due to tumors in the anterior pituitary gland and occurs occasionally in hereditary multiple endocrine neoplasia syndromes. Here, we report data from three sisters with hyperprolactinemia, two of whom presented with oligomenorrhea and one with infertility. These symptoms were not associated with pituitary tumors or multiple endocrine neoplasia but were due to a heterozygous mutation in the prolactin receptor gene, PRLR, resulting in an amino acid change from histidine to arginine at codon 188 (His188Arg). This substitution disrupted the high-affinity ligand-binding interface of the prolactin receptor, resulting in a loss of downstream signaling by Janus kinase 2 (JAK2) and signal transducer and activator of transcription 5 (STAT5). Thus, the familial hyperprolactinemia appears to be due to a germline, loss-of-function mutation in PRLR, resulting in prolactin insensitivity.