Seroprevalence and risk factors of Toxoplasma gondii infection in women with recurrent fetal loss from the province of Khyber Pakhtunkhwa, Pakistan

BACKGROUND

In women with a bad obstetric history (BOH), infection is an established cause of recurrent fetal loss. A common infecting agent is the protozoan parasite Toxoplasma gondii (T. gondii). The aim of this study was to measure the prevalence of toxoplasmosis in women with recurrent fetal loss from the Khyber Pakhtunkhwa province of Pakistan.

METHODS

The study included 360 females aged 16-40 years, of which 180 had a bad obstetric history (study group) and the other 180 had no such history (control group). Blood serum samples were tested for toxoplasma IgM antibodies by Enzyme Linked Immunosorbent Assay and for toxoplasma IgG antibodies using an Immunochromatographic technique.

RESULTS

The overall seroprevalence of toxoplasma infection in study group females was 40.6% and in control group females it was 7.2%. Specifically, IgM prevalence was 12.8% in the study group and 1.1% in the control group. IgG prevalence was 23.9% in the study group and 6.1% in the control group. IgM and IgG combined prevalence was 3.9% in the study group cases. There is a statistically significant association between BOH and seropositivity for T. gondii (p < 0.0001, Chi square test). Various risk factors associated with T. gondii seroprevalence in study and control groups were analyzed.

CONCLUSION

The seroprevalence of toxoplasmosis was significantly higher in women with a bad obstetric history compared to those with no such history. Associated risk factors had no significant effects on the results.

Neutrophil migration into the placenta: Good, bad or deadly?

Almost 2 decades have passed since the discovery that pregnancy is associated with a basal inflammatory state involving neutrophil activation, and that this is more overt in cases with preeclampsia, than in instances with sepsis. This pivotal observation paved the way for our report, made almost a decade ago, describing the first involvement of neutrophil extracellular traps (NETs) in a non-infectious human pathology, namely preeclampsia, where an abundance of these structures were detected directly in the placental intervillous space.

Despite these remarkable findings, there remains a paucity of interest among reproductive biologists in further exploring the role or involvement of neutrophils in pregnancy and related pathologies. In this review we attempt to redress this deficit by highlighting novel recent findings including the discovery of a novel neutrophil subset in the decidua, the interaction of placental protein 13 (PP13) and neutrophils in modulating spiral artery modification, as well as the use of animal model systems to elucidate neutrophil function in implantation, gestation and parturition. These model systems have been particularly useful in identifying key components implicated in recurrent fetal loss, preeclampsia or new signaling molecules such as sphingolipids. Finally, the recent discovery that anti-phospolipid antibodies can trigger NETosis, supports our hypothesis that these structures may contribute to placental dysfunction in pertinent cases with recurrent fetal loss.

Neutrophil NETs in reproduction: from infertility to preeclampsia and the possibility of fetal loss

The intention of this review is to provide an overview of the potential role of neutrophil extracellular traps (NETs) in mammalian reproduction. Neutrophil NETs appear to be involved in various stages of the reproductive cycle, starting with fertility and possibly ending with fetal loss. The first suggestion that NETs may play a role in pregnancy-related disorders was in preeclampsia, where vast numbers were detected in the intervillous space of affected placentae. The induction of NETosis involved an auto-inflammatory component, mediated by the increased release of placental micro-debris in preeclampsia. This report was the first indicating that NETs may be associated with a human pathology not involving infection. Subsequently, NETs have since then been implicated in bovine or equine infertility, in that semen may become entrapped in the female reproductive tract during their passage to the oocyte. In this instance interesting species-specific differences are apparent, in that equine sperm evade entrapment via expression of a DNAse-like molecule, whereas highly motile bovine sperm, once free from seminal plasma (SP) that promotes interaction with neutrophils, appear impervious to NETs entrapment. Although still in the realm of speculation it is plausible that NETs may be involved in recurrent fetal loss mediated by anti-phospholipid antibodies, or perhaps even in fetal abortion triggered by infections with microorganisms such as L. monocytogenes or B. abortus.

Lupus anticoagulant (LA) in pregnant women with history of recurrent fetal loss

The frequency of LA in 50 women with intact pregnancy, age range 26 to 39 years, but with past history of at least 2 lost pregnancies, was determined using coagulation-based assays. Most (68%) of the pregnant women were in the first trimester. Venous blood (4.5 mL) carefully collected from each of the subjects and also the controls (normal relative donors) was put in 0.5 mL of 3.8% citrate (ratio 9:1). The blood was quickly centrifuged at 1500 g; platelet-poor plasma was separated and frozen at -30°C until analyzed. The control plasma was pooled and dispensed in 2 mL aliquots. Partial thromboplastin time with kaolin (PTT(k)) (against the control samples for comparison) and kaolin clotting time (KCT) were determined on each of the test samples using standard laboratory procedures. Prolonged PTT(k) was obtained in 36 patients (72%). KCT was obtained through mixtures of patients' plasma with pooled control plasma (P:C) at 100:0; 0.8:0.2; 0.6:0.4; 0.5:0.5; 0.4:0.6; 0.2:0.8; 0:100; and lin-lin graph paper was used to plot out each of these dilutions against their respective clotting time in seconds. The interpreted graph showed that 12 (24%) had LA, while 3 (6%) had LA with cofactor. This high frequency necessitates regular screening for LA in pregnant women with a history of recurrent fetal loss at any gestational age.

The role of d-dimer as first marker of thrombophilia in women affected by sterility: implications in pathophysiology and diagnosis of thrombophilia induced sterility

BACKGROUND: D-dimer is considered a marker of hypercoagulable state and of endogenous fibrinolysis, so increased d-dimer is detectable in patients affected by thrombosis. Yet, several studies showed that also infertility, in particular secondary infertility due to recurrent fetal losses, has been often related to thrombotic events, in particular in women carrying thrombotic risk factors such as inherited thrombophilia (MTHFRC677T, PTHRA20210G, Factor V Leiden polimorphisms and/or inhAfter this screening we selected 39erited protein C, protein S, AT III deficiency) or acquired thrombophilia (primary antiphospholipid syndrome, acquired protein C, protein S, AT III deficiency, drugs induced thrombophilia). However, because its high predictive negative value in case of suspected thrombosis, increased d-dimer has been often associated to subclinical thrombophilia. The aim of this study is to investigate the role of d-dimer as first marker of thrombophilia in women affected by unexplained infertility and subsequently to search the cause of increased d-dimer, such as inherited and/or acquired thrombophilia. PATIENTS AND METHODS: We selected 79 patients with unexplained primary or secondary infertility. We excluded 40 patients affected by hydrosalpinx, uterine fibroids, uterine malformations, endocrinological and immunological diseases, luteal insufficiency, cytogenetical alterations. All remaining 39 patients were tested for d-dimer and divided in two groups: the patients of group A (25 patients) showed increased plasma d-dimer, in group B were included 14 patients with normal plasma level of d-dimer. After this step all 39 patients were screened for MTHFRC677T, PTHRA20210G, Factor V Leiden polimorphisms, protein C, protein S, AT III, anticardiolipin IgM and IgG, lupus anticoagulant. In the control group were included 15 age matched women without sterility problems referred to our outpatient's section of vascular medicine for suspected deep venous thrombosis.Statistical analysis was based on chi2 test, differences were considered to be significant if p < 0.05. RESULTS: D-dimer was increased in 25/39 and 20/25 showed inherited/acquired thrombophilia while patients with normal d-dimer showed inherited/acquired thrombophilia in 7/14 (p: < 0.05, s). DISCUSSION: D-dimer is a well known marker of hypercoagulable state, in particular its high predictive negative value in case of suspected thrombosis has been recognised by several reports. Yet, increased d-dimer has been identified also for subclinical thrombophilia besides for vascular thrombosis. Our data, in fact, for the first time suggest an interesting role of d-dimer to identify women affected by unexplained primary or secondary infertility and thrombophilia. So, probably there is a role for d-dimer in these subjects for its predictive positive value. Of course, further data on large based population are needed to confirm our results, because these findings may speed up a diagnostic screening in these patients also for a good cost/effectiveness of this test.