Signs and symptoms associated with early pregnancy loss: findings from a population-based preconception cohort

STUDY QUESTION

What is the relationship between signs and symptoms of early pregnancy and pregnancy loss <20 weeks' gestation?

SUMMARY ANSWER

Vaginal bleeding is associated with increased incidence of early pregnancy loss, with more severe bleeding and bleeding accompanied by lower abdominal cramping associated with greater incidence of loss; conversely, vomiting is associated with decreased incidence of early pregnancy loss, even in the setting of vaginal bleeding, while nausea alone is not.

WHAT IS KNOWN ALREADY

Two previous cohort studies with preconception enrollment suggested that bleeding is associated with loss while nausea is inversely associated with loss though these studies were limited by small study size and reporting after loss ascertainment. No prior preconception cohort study has examined multiple signs and symptoms in relation to pregnancy loss.

STUDY DESIGN, SIZE, DURATION

Population-based preconception cohort of 501 couples discontinuing contraception to try for pregnancy in 16 counties in Michigan and Texas, USA. Participants were followed daily until positive home pregnancy test or 12 months of trying without an hCG pregnancy; women who became pregnant were followed daily from 2 to 7 weeks post-conception.

PARTICIPANTS, SETTING, METHODS

Three hundred and forty-seven women had a positive home pregnancy test denoting hCG pregnancy. Three hundred and forty-one women remained after excluding ineligible pregnancies. Women recorded daily from 2 to 7 weeks post-conception their signs and symptoms, including vaginal bleeding (none, spotting, light, moderate and heavy), lower abdominal cramping, nausea and vomiting. Pregnancy losses were ascertained by a subsequent negative home pregnancy test, clinical confirmation or onset of menses, depending on gestational age at loss; time-to-loss was measured in days post-conception. Cumulative incidence functions and 95% confidence intervals (CIs) were constructed for each sign or symptom, and hazard ratios (HRs) and 95% CIs for presence compared with absence of signs or symptoms were estimated using Cox proportional hazard models.

MAIN RESULTS AND THE ROLE OF CHANCE

Women experienced lower abdominal cramping (85%), nausea (48%), vomiting (46%) and light/moderate/heavy vaginal bleeding (24%) during early pregnancy. Ninety-five (28%) women experienced a loss. Cumulative incidence of pregnancy loss varied by symptomatology: 19% for vomiting, 27% for lower abdominal cramping, 35% for nausea only, 52% for vaginal bleeding, 81% for vaginal bleeding with lower abdominal cramping. Incidence of pregnancy loss was increased among women with vaginal bleeding (HR: 3.62, 95% CI: 2.29-5.74) and among women with vaginal bleeding and lower abdominal cramping (HR: 5.03, 95% CI: 2.07-12.20). Incidence of pregnancy loss was decreased for women with vomiting (HR: 0.51, 95% CI: 0.30-0.86). In the setting of vaginal bleeding with lower abdominal cramping, vomiting reduced the incidence of pregnancy loss (HR: 0.24, 95% CI: 0.11-0.56).

LIMITATIONS, REASONS FOR CAUTION

There were few losses beyond 14 weeks gestation; thus, the precision of our findings related to losses occurring after the first trimester is limited.

WIDER IMPLICATIONS OF THE FINDINGS

By using sensitive home pregnancy tests, we are able to document and characterize the cumulative incidence of the earliest pregnancy losses, which constitute the majority of losses. The use of daily, prospective capture of signs and symptoms relative to ascertainment of pregnancy loss minimizes potential biases associated with reporting after rather than before a loss, which could potentially distort the relationship between signs and symptoms and pregnancy loss. The findings of our study suggest that it may be useful to develop prognostic models for pregnancy loss based on signs and symptoms.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (contract numbers N01-HD-3-3355; N01-HD-3-3356; N01-HD-3-3358). The authors have no conflict of interest to declare.

Evaluation of Insecticides, Entomopathogenic Nematodes, and Physical Soil Barriers for Control of Diaprepes abbreviatus (Coleoptera: Curculionidae) in Citrus

The Diaprepes root weevil, Diaprepes abbreviatus L. (Coleoptera: Curculionidae), was discovered as the cause of early decline and death of citrus trees and ornamental plants along coastal Orange and Los Angeles Counties in 2005 and San Diego County in 2006. We established trials to evaluate the effectiveness of two tactics to manage life stages of Diaprepes root weevil that are found in the soil. The first tactic was soil applications of the pesticides bifenthrin or imidacloprid, with and without entomopathogenic nematodes, to kill larvae. The second tactic was attempting to block adult emergence from the soil using a thick wood-chip mulch layer, a small-meshed landscape fabric, and a dry soil barrier (created by subirrigation). We found that soil treatments with the two insecticides (bifenthrin and imidacloprid) at maximum label rates with and without Steinernema riobrave Cabanillas et al. at 5 million nematodes per tree significantly reduced numbers of soil-borne Diaprepes root weevil larvae in one trial compared with the control. Another entomopathogenic nematode, Heterorhabditis indica Poinar et al. applied in wax moth Galleria mellonella L. cadavers at 86 wax moth cadavers per tree was not effective. Adult emergence was reduced by almost 100% when the landscape fabric was kept intact (2009), but emergence occurred in 2010 when the fabric was torn by grove operations (60% reduction). Adult emergence was reduced to ≍70% compared with the control in the subirrigation treatment in 2009 when the summer was hot and dry, but emergence occurred in 2010 during periodic rains toward the end of summer. The mulch treatment kept the soil moist in between irrigations resulting in greater adult emergence rates compared with controls during 2009 and 2010. Health ratings of the trees were taken following several years of physical barrier treatments, and trees treated with the landscape fabric were significantly healthier (mean rating 0.9, scale 0 = healthy to 5 = dead) than those in the other treatments (mean rating of 3.6, 4.0, and 2.5 for control, mulch and subirrigation, respectively). Of the physical barrier methods studied, landscape fabric is most effective in reducing Diaprepes root weevil emergence, increases plant health, and is long lasting, but it is the most costly to install and can be damaged during harvest.

Stress, coping, and depression: testing a new hypothesis in a prospectively studied general population sample of U.S.-born Whites and Blacks

The scarcity of empirically supported explanations for the Black/White prevalence difference in depression in the U.S. is a conspicuous gap in the literature. Recent evidence suggests that the paradoxical observation of decreased risk of depression but elevated rates of physical illness among Blacks in the U.S. compared with Whites may be accounted for by the use of coping behaviors (e.g., alcohol and nicotine consumption, overeating) among Blacks exposed to high stress levels. Such coping behaviors may mitigate deleterious effects of stressful exposures on mental health while increasing the risk of physical ailments. The racial patterning in mental and physical health outcomes could therefore be explained by this mechanism if a) these behaviors were more prevalent among Blacks than Whites and/or b) the effect of these behavioral responses to stress was differential by race. The present study challenges this hypothesis using longitudinal, nationally-representative data with comprehensive DSM-IV diagnoses. Data are drawn from 34,653 individuals sampled in Waves 1 (2001-2002) and 2 (2004-2005) as part of the US National Epidemiologic Survey on Alcohol and Related Conditions. Results showed that a) Blacks were less likely to engage in alcohol or nicotine consumption at low, moderate, and high levels of stress compared to Whites, and b) there was a significant three-way interaction between race, stress, and coping behavior for BMI only (F = 2.11, df = 12, p = 0.03), but, contrary to the hypothesis, elevated BMI was protective against depression in Blacks at low, not high, levels of stress. Further, engagement in unhealthy behaviors, especially at pathological levels, did not protect against depression in Blacks or in Whites. In sum, the impact of stress and coping processes on depression does not appear to operate differently in Blacks versus Whites. Further research testing innovative hypotheses that would explain the difference in Black/White depression prevalence is warranted.

Stress, coping, and depression: testing a new hypothesis in a prospectively studied general population sample of U.S.-born Whites and Blacks

The scarcity of empirically supported explanations for the Black/White prevalence difference in depression in the U.S. is a conspicuous gap in the literature. Recent evidence suggests that the paradoxical observation of decreased risk of depression but elevated rates of physical illness among Blacks in the U.S. compared with Whites may be accounted for by the use of coping behaviors (e.g., alcohol and nicotine consumption, overeating) among Blacks exposed to high stress levels. Such coping behaviors may mitigate deleterious effects of stressful exposures on mental health while increasing the risk of physical ailments. The racial patterning in mental and physical health outcomes could therefore be explained by this mechanism if a) these behaviors were more prevalent among Blacks than Whites and/or b) the effect of these behavioral responses to stress was differential by race. The present study challenges this hypothesis using longitudinal, nationally-representative data with comprehensive DSM-IV diagnoses. Data are drawn from 34,653 individuals sampled in Waves 1 (2001-2002) and 2 (2004-2005) as part of the US National Epidemiologic Survey on Alcohol and Related Conditions. Results showed that a) Blacks were less likely to engage in alcohol or nicotine consumption at low, moderate, and high levels of stress compared to Whites, and b) there was a significant three-way interaction between race, stress, and coping behavior for BMI only (F = 2.11, df = 12, p = 0.03), but, contrary to the hypothesis, elevated BMI was protective against depression in Blacks at low, not high, levels of stress. Further, engagement in unhealthy behaviors, especially at pathological levels, did not protect against depression in Blacks or in Whites. In sum, the impact of stress and coping processes on depression does not appear to operate differently in Blacks versus Whites. Further research testing innovative hypotheses that would explain the difference in Black/White depression prevalence is warranted.

Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain

OBJECTIVE

To determine with intraoperative neurologic and language examinations the maximal tumor resection achievable with acceptable postoperative neurologic dysfunction in patients undergoing awake stereotactic glial tumor resection in eloquent regions of the brain.

PATIENTS AND METHODS

Between October 1995 and December 2000, 65 patients underwent frameless stereotactic resection of glial tumors located in functioning tissue. During the resection, continuous examinations by a neurologist and speech pathologist were performed. The goal of surgery was to resect the maximum neurologically permissible tumor volume defined on preoperative T2 imaging. Tumor resection was stopped at the onset of neurologic dysfunction. Novel segmentation software was used to measure tumor cytoreduction based on pre- and postoperative magnetic resonance imaging. All patients underwent 3-month postoperative neurologic examinations to determine functional outcomes.

RESULTS

The cortical and subcortical white matter tracts at risk for injury were the left frontal operculum in 15 patients, the central lobule in 38, the insula in 11, and the left angular gyrus in 1. Thirty-four (52%) had a greater than 90% reduction in T2 signal postoperatively. In 26 patients thought to have low-grade tumors based on preoperative imaging, 12 proved to have grade 3 gliomas. Forty-eight patients (74%) developed intraoperative deficits; 34 (71%) recovered to a modified Rankin grade of 0 or 1 at 3 months postoperatively, 11 (23%) achieved a modified Rankin grade of 2, and 3 patients (6%) achieved a modified Rankin grade of 3 or 4 at 3-month follow-up. There was no operative mortality; 17 patients (26%) died from tumor progression during the follow-up period.

CONCLUSIONS

Combining frameless computer-guided stereotaxis with cortical stimulation and repetitive neurologic and language assessments facilitates tumor resection in functioning brain regions. Resecting tumor until the onset of neurologic deficits allows for a good functional recovery. Imaging software can objectively and accurately measure preoperative and postoperative tumor volumes.

cDNA cloning and expression of a novel family of enzymes with calcium-independent phospholipase A2 and lysophospholipase activities

Previous studies have suggested that activation of calcium-independent PLA2 (CaIPLA2) is an early event in cell death after hypoxic injury in proximal tubule cells. An approximately 28-kD CaIPLA2 with preferential activity toward plasmalogen phospholipids has been recently purified from rabbit kidney cortex (D. Portilla and G. Dai, J Biol Chem 271, 15,451-15,457, 1996). Their report describes the cloning of a full-length rat cDNA encoding CaIPLA2, using sequences derived from the purified rabbit kidney cortex enzyme. In addition, cDNA from rabbit kidney that encode the rabbit homologue of the enzyme and a closely related isoform were isolated. The rat cDNA is predicted to encode an approximately 24-kD protein, and each cDNA contains the sequence G-F-S-Q-G, which fits the active site consensus sequence G-X-S-X-G of carboxylesterases. Several lines of evidence (DNA sequence comparison, Southern blot analysis, and examination of the expressed sequence tag database) show that CaIPLA2 enzymes are encoded by a multigene family in rats, mice, rabbits, and humans. Northern analysis of various tissues from the rat indicated that the CaIPLA2 gene is ubiquitously expressed, with highest mRNA abundance observed in the kidney and small intestine. The rat CaIPLA2 cDNA, when expressed in a baculovirus expression system, and the purified rabbit kidney cortex protein exhibit both CaIPLA2 and lysophospholipase activities. The cloned CaIPLA2 cDNA are expected to aid in understanding the role of CaIPLA2 in cell death after hypoxic/ischemic cell injury.

Resection of a large temporooccipital parenchymal arteriovenous fistula by using deep hypothermic circulatory bypass. Case report

The authors believe this to be the first published case in which a deep hypothermic cardiopulmonary bypass was used to facilitate resection of a large parenchymal arteriovenous fistula. The use of this procedure facilitated resection of the lesion by allowing compression and manipulation of large venous varices that were overlying the deeper arterial feeding vessels. The surgical rationale, technique, and intra- and postoperative management are discussed.

Relationships between leaf water status and transpiration of cowpea with progressive soil drying

It was previously reported that leaf water status of cowpea (Vigna unguiculata) exhibited only small changes with progressive soil drying over extended periods of time. In these studies, under field conditions, it was demonstrated that when soil water was not limiting, xylem pressure potential (ψ _x ) exhibited a linear relationship with transpirational flux density with no obvious hysteresis. With progressive soil drying, values of ψ _x and transpiration rate fell below the regression line established for nonlimiting soil conditions. It is proposed that paired measurements of ψ _x and transpirational flux density made between midday and sunset can provide a measure of the extent to which soil conditions are limiting water uptake. The relation between ψ _x and transpiration exhibits a family of curves, with more negative slopes and decreases in maximum transpiration rate indicating progressive limitation due to soil drying.

Stomatal closure with soil water depletion not associated with changes in Bulk leaf water status

It has previously been reported that canopy water loss by cowpea (Vigna unguiculata) decreases with small depletions in soil water. In these studies, under field conditions, it was demonstrated that with small changes in soil water status leaf conductance of cowpea decreases in a manner which is consistent with the sensitive regulation of canopy water loss.However, treatments which differed in leaf conductance, and presumably stomatal aperture, had similar leaf water potentials. It is hypothesized that the stomatal closure which results from soil water depletion is mediated by changes in root water status through effects on the flow of information from root to shoot. An efficient mechanism of this type could be partially responsible for the extreme drought avoidance exhibited by this plant.