Recurrent pregnancy loss: what is the impact of consecutive versus non-consecutive losses?

STUDY QUESTION

Is there a different prognostic impact for consecutive and non-consecutive early pregnancy losses in women with secondary recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

Only consecutive early pregnancy losses after the last birth have a statistically significant negative prognostic impact in women with secondary RPL.

WHAT IS KNOWN ALREADY

The risk of a new pregnancy loss increases with the number of previous pregnancy losses in patients with RPL. Second trimester losses seem to exhibit a stronger negative impact than early losses. It is unknown whether the sequence of pregnancy losses plays a role for the prognosis in patients with a prior birth.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study of pregnancy outcome in patients with unexplained secondary RPL included in three previously published, Danish double-blinded placebo-controlled trials of intravenous immunoglobulin (IvIg) conducted from 1991 to 2014. No other treatments were given. Patients with documented explained pregnancy losses (ectopic pregnancies and aneuploid miscarriages) were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 168 patients included in the trials, 127 had secondary RPL and experienced a subsequent live birth or unexplained pregnancy loss in the first pregnancy after giving informed consent to participate in the trials (the index pregnancy). Data analyzed by multivariate analysis included the independent variables age, the number of early pregnancy losses before and after the last birth, respectively and a second trimester pregnancy loss before or after the last birth, respectively. The outcome variable was unexplained loss in the index pregnancy.

MAIN RESULTS AND THE ROLE OF CHANCE

In patients with secondary RPL, both a late and each early loss before the last birth did not significantly influence the risk of a new pregnancy loss in the index pregnancy: incidence rate ratio (IRR) 1.31 (95% CI 0.62-2.77) and IRR 0.88 (95% CI 0.70-1.11), respectively. In contrast, the impact on risk of pregnancy loss conferred by a late and by each early pregnancy loss occurring after the birth was significant: IRR 2.15 (95% CI 1.57-2.94, P < 0.0001) and IRR 1.14 (95% CI 1.04-1.24, P = 0.002), respectively.

LIMITATIONS, REASONS FOR CAUTION

Of the patients, 48% were treated with IvIg, which could influence the results. However, allocation to IvIg was random and prognostic variables were equally distributed in IvIg and placebo-treated patients.

WIDER IMPLICATIONS OF THE FINDINGS

A birth in women with secondary RPL eradicates the negative prognostic impact of previous pregnancy losses and this finding is important for our understanding of the pathogenesis. It indicates that only consecutive pregnancy losses should count in the definition of RPL.

STUDY FUNDING/COMPETING INTERESTS

There was no particular funding for this study. The authors declare that there is no conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable for two of the included randomized controlled trials. For the last trial: Clinical.Gov NCT00722475.

Mitochondrial Genetic Diversity of Eurasian Red Squirrels (Sciurus vulgaris) from Denmark

Melanistic Eurasian red squirrels Sciurus vulgaris are commonly found on the Danish island of Funen. They are thought to represent native Danish squirrel types and are presently under threat from admixture with introduced red squirrels. In response, a conservation program was started in 2009 that involves the translocation of melanistic squirrels from Funen to the squirrel-free island of Langeland. Using mitochondrial DNA of 101 historical and modern samples from throughout Denmark, we assess for the first time population structure and mitochondrial genetic diversity of Danish squirrels compared to its larger pan-Eurasian distribution. We find that Danish squirrels have low levels of genetic diversity, especially melanistic individuals. Bayesian skyline reconstructions show that Danish squirrels have most probably experienced a severe bottleneck within the last 200 years. Also, fine-scale genetic structure was found between squirrels from the regions of Funen, Zealand and Jutland, which mimics the insular geography of Denmark. Additional nuclear DNA analyses will be required to determine the precise admixture levels between original Danish and introduced squirrels and to locate unmixed candidate populations for specific conservation efforts.

Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection

OBJECTIVE

The authors compared clinical bowel function and complications of a low anterior resection with either a straight or colonic J pouch anastomosis.

SUMMARY BACKGROUND DATA

Urgency and frequent bowel movements after rectal resection with a low anastomosis have been related to the loss of rectal reservoir function. Reconstruction with a colonic J pouch possibly can obviate some of this dysfunction. Earlier reports have been favorable, but they must be verified in randomized trials.

METHOD

One hundred patients with rectal cancer in whom a sphincter-saving procedure was appropriate were randomized to reconstruction with either a straight or a colonic J pouch anastomosis.

RESULTS

The incidence of symptomatic anastomotic leakage was lower in the pouch group (2% vs. 15%, p = 0.03). Eighty-nine patients could be evaluated after 1 year. The pouch patients had significantly fewer bowel movements per 24 hours, and less nocturnal evacuations, urgency, and incontinence. Overall well-being owing to the bowel function was rated significantly higher by the pouch patients.

CONCLUSION

Reconstruction with a colonic J pouch was associated with a lower incidence of anastomotic leakage and better clinical bowel function when compared with the traditional straight anastomosis. Functional superiority was especially evident during the first 2 months.

A technique for segmental rectal and colonic perfusion in humans

To enable a better characterization of pathophysiologic processes in colon and rectum, we have developed a perfusion technique for collection of soluble substances and cells from standardized intestinal segments. A tube with balloons attached to its outer wall was endoscopically introduced into the rectum and sigmoid colon, and its position ascertained fluoroscopically. The balloons delimited two segments, one in the sigmoid colon and one in the rectum. The segments were simultaneously perfused by a buffer at 37 degrees C. After a 30-min rinsing period, perfusate and cells were collected at 20-min intervals. Of 51 attempted perfusions, 45 were successfully completed. Recovered volumes equaled those infused. Leakage from the proximal intestine to the segments was negligible. In 18 healthy volunteers, the mean perfusate concentration from the rectal segment was 57.5 (27.5-120.2) mg/L for albumin, 1.3 (1.0-1.7) micrograms/L for eosinophil cationic protein, 5.1 (2.8-9.5) ng/L for prostaglandin E2, and 61.7 (41.7-89.1) micrograms/L for hyaluronan, and all values were lower in the sigmoid segment. Steady state conditions were achieved from the second perfusion period. The perfusate contained 4-80 x 10(4) cells, more than 95% of which were epithelial cells. The technique is safe, has a good subject compliance, and seems to be a valuable tool in investigations on quantitative release of soluble substances and cells in, e.g., colorectal inflammation.

Delorme's operation for rectal prolapse in elderly or unfit patients

OBJECTIVE

To evaluate the results after Delorme's operation for rectal prolapse in elderly and unfit patients.

DESIGN

Retrospective analysis and telephone interview.

SETTING

Akademiska sjukhuset, Uppsala, Sweden.

SUBJECTS

A consecutive series of 14 women (median age 82, range 32-92) operated on for rectal prolapse 1987-1992 and followed up after a median of 18 months.

RESULTS

There were no serious postoperative complications. Continence was improved in 6/11 incontinent patients. The recurrence rate was 3/14 (21%).

CONCLUSION

Delorme's operation is an attractive alternative in elderly or unfit patients, but is not recommended for younger and low risk patients because of the recurrence rate.

Cell recovery during segmental intestinal perfusion in healthy subjects and patients with Crohn's disease

The recovery of cells arising from small intestinal mucosa alone was studied during continuous perfusion of a closed segment of jejunum. The perfusion technique minimised the contamination of the perfused segment with, for example, proteolytic enzymes from pancreas, allowing recovery of viable cells. The use of hyaluronidase in the perfusion fluid increased the recovery of cells fivefold, the median recovery being 8 x 10(6) cells. The cells were analysed with monoclonal antibodies and flow cytometry. Nearly all cells (98-99%) recovered during perfusion of healthy control subjects and patients with Crohn's disease were epithelial cells. The jejunal cells expressed HLA-DR in similar proportions--around 30%--in patients and control subjects. The ratio between CD4+ and CD8+ lymphocytes was similar (0.2) in control subjects and patients with inactive Crohn's disease but decreased (0.03) in patients with active Crohn's disease in the ileum.

An alternative placement of implantable central venous access systems

A modified technique of inserting an implantable venous access system in the inferior epigastric vein is described. This route can be used in cases where the jugular or subclavian veins are unsuitable. After exposure of the inferior epigastric vein in the lower part of the rectus sheath, the catheter is placed in the vein with its tip at the junction to the iliac vein, with the aid of fluoroscopy and x-ray contrast. Protrusion of the tip into the lumen of the iliac vein is avoided. The technique was successful in four of the five patients where an attempt was made to insert the catheter. In the fifth case the vein was too narrow to allow catheterization. In the four cases where the catheter was successfully inserted there were no complications. This technique may allow use of the inferior vena cava for venous access without the high risk of intravenous thrombosis which is inherent with current methods.

Early outcome after emergency and elective surgery for ulcerative colitis

The early outcome after surgical treatment of ulcerative colitis was retrospectively analyzed in 185 patients. The operation was performed on emergency indications in 25 cases, and was subacute in 53 and elective in 107. The postoperative mortality was 7% overall, 24% in the emergency group, 8% in the subacute group and 2% in the elective group. At least one early postoperative complication occurred in 71 (38%) of the 185 patients (92%, 38% and 26% in the respective groups). Infection was the predominant problem, occurring in 26% of the patients. The mortality was highest after colectomy and ileostomy, but this procedure was used in the most sick patients. Proctocolectomy was associated with the highest morbidity in all groups, whereas colectomy and ileorectal anastomosis carried no mortality and little morbidity.

The effect of vitamin D treatment on decreased levels of ATP and energy charge in the thoracic aorta of uraemic rats

The contents of ATP, ADP, AMP and calcium in the thoracic aorta were determined in rats with moderate uraemia, and in rats with the same degree of uraemia following treatment with 1,25-dihydroxycholecalciferol (1,25-DHCC). The contents of ATP, ADP and total nucleotides were decreased in the thoracic aorta in the uraemic rats but not in uraemic rats following 1,25-DHCC treatment. The content of calcium in the aorta increased substantially in uraemic rats given 1,25-DHCC. The results indicate that the development of arterial calcifications in uraemic rats following vitamin D treatment is dissociated from an impaired energy metabolism, since vitamin D may simultaneously restore impaired energy metabolism and accumulate calcium in the aortic wall.

Tissue calcium in uraemia

The content of calcium in the thoracic aorta, the heart and the kidney was determined in rats with moderate renal failure treated with 1.25-dihydroxycholecalciferol (1.25-DHCC) 100 ng/kg/day and Verapamil 20 mg/kg/day. In the aorta the content of calcium was significantly increased in uraemic rats and this increase was significantly augmented after administration of 1.25-DHCC. In the kidney no increase in calcium was seen in rats with uraemia, but treatment with 1.25-DHCC increased the calcium content significantly. This increase was not correlated to the serum calcium x phosphate product, which was almost normal. In the heart no changes in the content of calcium were observed. Verapamil did not influence the effect of 1.25-DHCC. It is concluded that administration of 1.25-DHCC per se may increase the content of calcium in the aorta and kidney in rats with moderate uraemia and possibly in this way sensitize the tissue to the development of tissue calcification.

Implantable drug delivery systems in computed tomography and magnetic resonance imaging--a comparison between titanium and stainless steel

The effect of implantable drug delivery systems on computed tomography (CT) and magnetic resonance imaging (MRI) was investigated in a phantom and in two patients. The implantable systems of identical construction consisted either of medical grade titanium alloy or stainless steel. Images of a phantom showed artefacts of the stainless steel port in both CT and MRI. These artefacts were substantially reduced in images of the titanium port. Similar results were found in situ in two patients.

Uraemic and 1-alpha-hydroxycholecalciferol induced aortic lesions

Aortic alterations in uraemic rats were studied ultrastructurally. The main changes consisted of degeneration and necrosis of smooth muscle cells and occurrence of extracellular calcifications. These alterations were aggravated when 1-alpha-hydroxycholecalciferol (1-alpha-OH-D3) was given in a slightly hypercalcaemic dose. Parathyroidectomy prevented, to some degree, the development of ultrastructurally demonstrable changes; this effect was abolished when 1-alpha-OH-D3 was given. The influence of 1-alpha-OH-D3 and parathyroidectomy on the aorta in uraemia was not solely a function of their effect on the serum calcium X phosphate product. Bodies composed of concentrically arranged (target-like) ring formations (1,200-6,000 A in diameter), possibly originating from degenerated smooth myocytes, were observed in the aortae of uraemic rats. These bodies may represent the matrix for initial calcification in the ground substance. The calcium salt deposits in the target-like bodies disappears when the tissues are stored in glutaraldehyde solutions for a long period of time. Calcifications were normally only found extracellularly, and it is proposed that the target-like bodies may locally initiate the calcification process.

Tissue calcification and alkaline phosphatase activity in uraemic rats

The activity and localization of alkaline phosphatase activity (AP) in aorta and heart, and the incidence of calcifications in aorta, heart and kidney as well as cardial fibrosis were studied in uraemic rats treated with 1,25-dihydroxycholecalciferol (1,25-DCHH) and Nifedipine. 1,25-DHCC treatment elevated the serum Ca x P product and aggravated the development of renal and aortic calcifications and cardial fibrosis. Nifedipine did not protect against calcifications, but decreased the incidence of cardial fibrosis. The activity of AP was increased in the thoracic aorta in uraemia independent of 1,25-DHCC or Nifedipine treatment or presence of calcification. No changes of the AP activity were found in the heart.

Reflux esophagitis: assessment of therapy effects and observer variation by video documentation of endoscopy findings

Twenty-eight patients with endoscopically confirmed erosive or ulcerative esophagitis completed an 8-week placebo-controlled trial evaluating the symptomatic and endoscopic improvement obtained with ranitidine, 150 mg twice daily. Twice daily the patients recorded the number of episodes of retrosternal pain, regurgitation, and pyrosis on a diary card during a trial period of 1 week and during the 1st and 5th study week. Video documentation of endoscopy findings was undertaken before and at the end of the trial. The symptomatic relief obtained with ranitidine was significantly better than that obtained with placebo. The videotapes were assessed blindly and independently by three experienced fiberoptic endoscopists. The tapes were also recoded and reassessed by the same endoscopist. No systematic difference between different observers, either before or after treatment, could be detected. The interobserver variation, expressed as Kendall's tau b correlation coefficient, was 0.44 to 0.74. This coefficient was higher in intra-observer variation (0.63 to 0.91). Corresponding kappa-values for inter- and intra-observer variations were 0.12 to 0.30 and 0.27 to 0.85, respectively. The esophagitis, as judged by all observers, improved more in the ranitidine group than in the placebo group, but the difference did not reach statistical significance.

Hexokinase and adenylate kinase activities in aorta, heart muscle and skeletal muscle from uraemic rats

The effect of parathyroidectomy and/or vitamin D on the development of arterial and myocardial lesions was studied in rats with moderate uraemia. The activities of hexokinase and adenylate kinase in the aorta, myocardium and skeletal muscle were measured and the incidence of aortic calcification and muscle cell necrosis determined. There was a decreased hexokinase activity in the aorta, myocardium and skeletal muscle from uraemic rats. Adenylate kinase showed an increased activity in the same tissues. Parathyroidectomy as well as I-alpha-hydroxycholecalciferol in a dose of 3 ng/100 g b.w. normalized these activities to a great extent. This effect did not occur when 10 ng/100 g b.w. was given. Parathyroidectomy in combination with a low dose of I-alpha-OH-D3 reduced the incidence of myocardial necrosis. Aortic calcifications were found in uraemic animals given 10 ng/100 g b.w. of I-alpha-hydroxycholecalciferol. In this group increased activity of adenylate kinase was found in calcified aortae but not in non-calcified aortae. The study shows that uraemia causes metabolic changes in the aorta, myocardium, and skeletal muscle which may partly be prevented by parathyroidectomy and by low doses of vitamin D. It also indicates some parallelism between these metabolic changes and the development of histologically demonstrable lesions in the aorta.

Enzyme activities and adenine nucleotide content in aorta, heart muscle and skeletal muscle from uraemic rats

A prominent feature of arterial and myocardial lesions in uraemia is necrosis of the smooth muscle cells. In this study the possibility of detecting metabolic disturbances before necroses appear was investigated. The investigation was made on rats with moderate uraemia (mean serum creatinine 165 mumol/l) of 12 weeks duration. Enzyme activities and concentrations of adenine nucleotides were measured in aorta, heart and skeletal muscles. Histological examination disclosed no changes in these organs. Hexokinase, an important glycolytic enzyme, showed decreased activity in the skeletal muscle and aorta, whereas the hexosemonophosphate shunt enzyme glucose-6-phosphate dehydrogenase remained unchanged. The aspartate aminotransferase was increased in the skeletal muscle. Fat metabolism was not disturbed as reflected by unchanged activity of hydroxyacyl-CoA-dehydrogenase. Adenylatekinase which is important for the energy supply showed markedly increased activities in all tissues examined from the uraemic rats. Decreased ATP levels were found in the heart muscle and the aorta of the uraemic animals, whereas the total pool of adenosine phosphates remained unchanged in all tissues. The animal model described offers a useful means of detecting early changes in uraemia and should be useful for studying the effects of different treatments of uraemic complications.

The aortic content of glycosaminoglycans, hydroxyproline and calcium in experimental uraemia with special reference to parathyroidectomy and vitamin-D treatment

The contents of the various glycosaminoglycan (GAG) fractions, hydroxyproline and calcium in the thoracic aorta from the rat were studied. The effect on these contents of induced uraemia (3/4 kidney resection) combined with parathyroidectomy and/or 1-alpha-hydroxycholecalciferol (1-alpha-OH-D3) treatment was evaluated. Confirming earlier results increased levels of GAGs (predominately of chondroitin and dermatan sulphate) were found in the aortae of uraemic rats. The present study showed that parathyroidectomy or treatment with 1-alpha-OH-D3 did not significantly further alter the aortic content of GAGs in uraemic rats. Arteriosclerotic changes (calcifying medial necrosis) were only found in non-parathyroidectomized uraemic rats given 1-alpha-OH-D3. The aorta from these rats had a lower total content of GAGs, mainly due to a decrease in hyaluronic acid, than that from uraemic rats without calcifications. The aortic content of calcium was lowest in uraemic parathyroidectomized rats. Treatment with 1-alpha-OH-D3 increased this content, which was augmented 100-200-fold when calcifications were present. No correlation between the aortic contents of calcium and GAGs was found. There was a statistically significant correlation between the aortic content of calcium and the serum calcium X phosphate product. A significantly lower content of hydroxyproline was found in uraemic non-parathyroidectomized rats given 1-alpha-OH-D3, especially in those with arteriosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial calcifications in uraemic rats treated with 1-alpha-hydroxycholecalciferol and parathyroidectomy

The effect of 1-alpha-hydroxycholecalciferol (1-alpha-OH-D3) on the incidence of arterial calcifications, and the influence of parathyroidectomy on the effect of this vitamin D treatment, were studied in uraemic rats. Uraemia was induced by 3/4 kidney resection, and parathyroidectomy was achieved by electrocoagulation. 1-alpha-OH-D3 in a dose of 3, 10 or 125 ng/100 g body weight (b.w.) was given in the drinking water. The animals were killed after 12 or 16 weeks. Aorta and small arteries in the heart and in anterior tibial muscle were studied by light microscopy. Arterial lesions were frequently found in uraemic rats and were characterized by medial necrosis and calcifications. Following a 1-alpha-OH-D3 dose of 125 ng/100 g b.w. in uraemic rats both serum calcium and serum phosphate were increased and there was a high incidence of arterial calcifications both in the aorta and the small arteries. In uraemic rats receiving 10 ng/100 g b.w. of 1-alpha-OH-D3 serum calcium was only slightly elevated although the incidence of arterial calcifications (mainly in the aorta) was such higher than in uraemic rats without vitamin-D treatment. A dose of 3 ng/100 g b.w. of 1-alpha-OH-D3 given to uraemic rats did not result in any serum calcium increase, nor did it alter the incidence of arterial calcifications. Parathyroidectomy prevented arterial calcifications. Parathyroidectomy prevented arterial calcification in uraemic rats, but this effect was abolished by 1-alpha-OH-D3 in a dose of 10 ng/100 g b.w. which only raised the serum calcium to a subnormal value. In uraemia, treatment with 1-alpha-OH-D3 may increase the serum calcium X phosphate product, but this cannot fully explain the increased incidence of arterial calcifications. It is therefore suggested that vitamin D causes changes in the arterial wall which increase its susceptibility to the development of calcifications.

Scintigraphic assessment of biliary reflux into the residual stomach after subtotal gastrectomy and gastrojejunostomy

A method is described for evaluating biliary reflux into the gastric remnant after subtotal gastrectomy, avoiding naso- or orogastric intubation. Gamma camera detection and continuous recording of the distribution and possible gastric reflux of 99Tcm-HIDA after intravenous injection was employed, before and after stimulation of bile flow by a fatty meal. The technique is simple and specific, but further clinical evaluation is needed.