Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identified within 21 days of conception

Medical nutritional therapy in pregnant women with pregestational diabetes mellitus

OBJECTIVE

Diabetic women now can have the same chances as nondiabetic women to have a healthy infant. The reduction of risk associated with pregnancies complicated by diabetes can only be assured if normoglycemia is achieved before and during pregnancy. This review is intended to provide guidelines and scientific evidence for the optimal diet for the Type 1 or Type 2 diabetic woman.

METHODS

The literature over the past 10 years is presented. Those diets which achieved the best outcome of pregnancies complicated by diabetes (as evidenced by term delivery of a healthy, normal weight infant) are then outlined.

RESULTS

Diets which provide adequate calories without causing postprandial hyperglycemia or premeal ketosis are found to be based on body weight and gestational week of the pregnancy. Quantity of carbohydrate in the meal plan emerges as the most important component in achieving and maintaining glucose control.

CONCLUSIONS

The medical nutritional therapy for the Type 1 and Type 2 diabetic woman is a necessary component of the overall strategy to achieve and maintain normoglycemia and thus achieve the best outcome of pregnancy.

A population-based survey of frequencies of self-reported spontaneous and induced abortions in Danish women with Type 1 diabetes mellitus. Danish IDDM Epidemiology and Genetics Group

AIMS

Whether pregnant women with Type 1 diabetes mellitus (Type 1 DM) have an increased risk of abortions is controversial. The aim of the present Danish population-based study of 33% of the Danish population was to describe the pattern of self-reported miscarriage and stillbirths from 1304 women with Type 1 DM.

METHODS

Data were obtained by questionnaire. The current age of the women was 20-65 years and their age at diabetes onset was 30 years or less.

RESULTS

The frequency of spontaneous abortions (SA) and induced abortions (IA) reported from women diagnosed with Type 1 DM prior to pregnancy was 17.5% (95% CI 15.5-19.9%) and 18.0%. (95% CI 16.0-20.0%), respectively. No significant differences in abortion frequencies before or after 1980 were reported. Previous findings of a decreasing stillbirth-rate in diabetic pregnancies during the last decades were supported.

CONCLUSIONS

The reported SA frequency of 17.5% (95% CI 15.5-19.9%) in pregnant women with Type 1 DM is higher than previously reported SA rates of 10-12% in Danish nondiabetic women and the SA rate is more than twice the SA rate found in a previous Danish study from a highly specialized obstetrical centre for diabetic women. These data suggest an urgent need for further improvement in the general management of Danish pregnant women with Type 1 DM.

Temporal trends in spontaneous abortion associated with Type 1 diabetes

The objective of this study was to investigate temporal changes in the reported rates of spontaneous abortion associated with Type 1 diabetes. Individuals from the Children's Hospital of Pittsburgh Type 1 Diabetes Registry for 1950-1964 (n=495) completed a self-report reproductive history questionnaire in 1981 that was updated in 1990. Data from both surveys, which proved to be valid and reliable, were utilized for this report. More spontaneous abortions (26.8 vs. 7.7%, P<0.001), stillbirths (4.7 vs. 1.2%, P<0.001) and induced abortions (7.0 vs. 0.9%, P<0.001) were reported for Type 1 diabetic women than for the non-diabetic partners of Type 1 diabetic men. A significant temporal decline in the rates of spontaneous abortion for Type 1 diabetic women was observed (< or = 1969: 26.4%; 1970-1979: 31.0%; 1980-1989: 15.7%; P<0.05). No differences were apparent for the non-diabetic partners of Type 1 diabetic men (< or = 1969: 4.2%; 1970-1979: 9.5%; 1980-1989: 5.7%; P>0.05). Temporal changes in medical care for women with diabetes (i.e. self-monitoring of glycemic control) may have contributed to a recent reduction in spontaneous abortions associated with maternal Type 1 diabetes.

Factors affecting pregnancy outcome resulting from assisted reproductive technology (ART)

OBJECTIVE

A retrospective, observational study of pregnancy outcome was performed on variables maintained in an ART database to determine factors that might affect miscarriage rate in pregnancies resulting from assisted reproduction technologies (ART).

METHODS

Previously infertile couples, where conception was achieved after ART, were included. Seven hundred and ninety-four consecutive clinical pregnancies, diagnosed by ultrasound documentation of the gestation sac in the first trimester were divided into 2 groups: 'miscarriage' and 'term birth'. Differences between the groups were analysed using crosstable regression analyses or t-test in second yearly cohorts.

RESULTS

A statistically significant positive relationship was seen between age and spontaneous abortion rate (p = 0.008) with a major increase after the age of 38 years. There was no significant difference in the mean number of oocytes retrieved between groups (p = 0.17). While there was a significant negative correlation between maternal age and the total number of oocytes collected (p < 0.001), there was no statistical difference between those women who miscarried or delivered a live infant. No relationships were found with any other variables analysed.

CONCLUSION

Maternal age is probably the most important factor in pregnancy outcome in ART. This survey could not determine any other variables as being major prognostic determinant for miscarriage once pregnancy was attained.

Clinical effect of immunochemotherapy for a patient with advanced gallbladder cancer: report of a case

A 56-year-old woman was admitted presenting with a sensation of abdominal fullness. She was diagnosed to have advanced gallbladder cancer with carcinomatous peritonitis, as well as lymph node and liver metastases. We obtained highly purified tumor cells and tumor-infiltrating lymphocytes (TIL) from extirpated cervical lymph nodes and peritoneal effusion, and the chemosensitivity of these cells was tested with an MTT assay. Intensive chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5-FU) was then performed according to the results of the MTT assay. Thereafter, cytotoxic T-lymphocytes (CTL) were induced in mixed cultures of autologous tumor cells and peripheral blood lymphocytes, and adoptive immunotherapy was performed with TIL and CTL. The malignant ascites and metastatic lesions disappeared after the intraperitoneal administration of CDDP and the transfer of TIL and CTL, and subsequently the patient's quality of life improved. This patient could return to work; however, liver metastasis was later observed, and she died 14 months after the initial diagnosis. Combination therapy with anticancer drugs and activated killer cells was thus found to be effective in a patient with advanced gallbladder cancer.

Maternal hyperglycemia alters glucose transport and utilization in mouse preimplantation embryos

Glucose utilization was studied in preimplantation embryos from normal and diabetic mice. With use of ultramicrofluorometric enzyme assays, intraembryonic free glucose in single embryos recovered from control and streptozotocin-induced hyperglycemic mice was measured at 24, 48, 72, and 96 h after mating. Free glucose concentrations dropped significantly in diabetics at 48 and 96 h, corresponding to the two-cell and blastocyst stages (48 h: diabetic 0.23 +/- 0.09 vs. control 2.30 +/- 0.43 mmol/kg wet wt; P < 0.001; 96 h: diabetic 0.31 +/- 0.29 vs. control 5.12 +/- 0.17 mmol/kg wet wt; P < 0.001). Hexokinase activity was not significantly different in the same groups. Transport was then compared using nonradioactive 2-deoxyglucose uptake and microfluorometric enzyme assays. The 2-deoxyglucose uptake was significantly lower at both 48 and 96 h in embryos from diabetic vs. control mice (48 h diabetic, 0.037 +/- 0. 003; control, 0.091 +/- 0.021 mmol . kg wet wt-1 . 10 min-1, P < 0. 05; 96 h diabetic, 0.249 +/- 0.008; control, 0.389 +/- 0.007 mmol . kg wet wt-1 . 10 min-1, P < 0.02). When competitive quantitative reverse transcription-polymerase chain reaction was used, there was 44 and 68% reduction in the GLUT-1 mRNA at 48 h (P < 0.001) and 96 h (P < 0.05), respectively, in diabetic vs. control mice. GLUT-2 and GLUT-3 mRNA values were decreased 63 and 77%, respectively (P < 0.01, P < 0.01) at 96 h. Quantitative immunofluorescence microscopy demonstrated 49 +/- 6 and 66 +/- 4% less GLUT-1 protein at 48 and 96 h and 90 +/- 5 and 84 +/- 6% less GLUT-2 and -3 protein, respectively, at 96 h in diabetic embryos. These findings suggest that, in response to a maternal diabetic state, preimplantation mouse embryos experience a decrease in glucose utilization directly related to a decrease in glucose transport at both the mRNA and protein levels.

Lack of association between antiphospholipid antibodies and first-trimester spontaneous abortion: prospective study of pregnancies detected within 21 days of conception

OBJECTIVE

To determine the role of antiphospholipid antibodies and anticardiolipin antibodies in first-trimester losses, addressing experimental pitfalls that preclude excluding the possibility that these antibodies reflect merely the selection bias of studying couples only after they have already experienced losses.

DESIGN

Given that retrospective studies cannot exclude the possibility that such antibodies arise as a result of the fetal death, blood samples were obtained either before pregnancy or very early in pregnancy. Sera were obtained within 21 days of conception.

SETTING

Multicenter university-based hospitals (National Institute of Child Health and Human Development collaborative study).

PATIENT(S)

Subjects for the current study were 93 women who later experienced pregnancy loss (48 diabetic; 45 nondiabetic), matched 2:1 with 190 controls (93 diabetic and 97 nondiabetic) who subsequently had normal live-born offspring.

INTERVENTION(S)

Sera from these 283 women were analyzed for antiphospholipid antibodies by enzyme immunoassay. In 260 of the 283 women (87 with pregnancy losses; 173 with live-born infants), sera were also available to perform assays for anticardiolipin antibodies by enzyme immunoassay.

MAIN OUTCOME MEASURE(S)

Pregnancy losses.

RESULT(S)

No association was observed between pregnancy loss and the presence of antiphospholipid antibodies or anticardiolipin antibodies. Levels of antiphospholipid antibodies were 6-19 PL/mL in 62.4% of the pregnancies that ended in losses and > or = 20 PL/mL in 5.4%; among pregnancies resulting in live-born infants, the percentages were 56.8% and 6.8%, respectively. Of the pregnancies that ended in a loss, 5.7% had anticardiolipin antibodies > or = 16 GPL/mL, compared with 5.2% of those ending in a live birth.

CONCLUSION(S)

This prospective study suggests that anticardiolipin antibodies and antiphospholipid antibodies are not associated with an increased risk for first-trimester pregnancy loss.

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus. Putting evidence into practice

PURPOSE

To summarise current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of preventions, screening, and treatment, all of which are focused on office practice.

METHODS

Review of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search.

MAIN RESULTS

An algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus.

Clinical biochemistry of pregnancy

Major adaptations in maternal physiology and metabolism are required for successful pregnancy outcome. Hormonal changes initiated even before conception significantly alter maternal biochemistry early in pregnancy. Steroid hormones, peptide hormones, and prostaglandins interact to expand blood and plasma volume and modulate the maternal capacity to supply energy and nutrients to the fetoplacental unit. As gestation progresses, reference ranges for the concentration of many biochemical parameters change significantly from those found in the nonpregnant state. Gestation-specific reference ranges are essential for correct interpretation of tests used in screening, diagnosis, and monitoring during pregnancy. The use of clinical laboratory tests in the management of high-risk pregnancy are discussed from the perspective of testing before conception and during pregnancy.

Teratogenic effects of diabetes mellitus in the rat. Prevention by vitamin E

We wanted to determine whether administration of vitamin E could reduce the production of free radicals which could play a role in the teratogenic effects of diabetes mellitus. Diabetes was induced in Wistar rats by the intravenous administration of streptozotocin. The animals were divided into six groups: one with no supplement (D) and two, supplemented during pregnancy either with oral vitamin E (150 mg/day) (D + E) or with a placebo (safflower oil) (D + O). Three other groups were kept under the same conditions, but were treated with insulin: D + I, D + I + E and D + I + O. There were three groups of matched controls: C, C + E and C + O. All animals were killed on day 11.5 of pregnancy. In C animals the percentages of reabsorptions and malformations were 1.3 and 2%, respectively, compared with 23.6, 24.3, 6.2 and 13.2%, respectively in D and D + I groups. The crown-rump length, number of somites, and protein and DNA content were higher in C animals than in the diabetic rats, independent of insulin treatment. When vitamin E was administered no changes in these parameters were observed in C and D + I animals; however, in the D mothers it reduced the rate of embryo malformations to 4.6% and increased the crown-rump length and the number of somites. However, vitamin E did not modify the protein and DNA content and the percentage of reabsorptions. In conclusion, administration of vitamin E to diabetic animals decreases the rate of embryo malformations and increases their size and maturation, supporting a role for free radicals in the teratogenic effects of diabetes.

Prospective study showing that antisperm antibodies are not associated with pregnancy losses

OBJECTIVE

To obtain prospective data on the relationship between presence of antisperm antibodies in maternal sera and first trimester pregnancy losses.

DESIGN

First trimester sera obtained from diabetic and nondiabetic women recruited within 21 days of conception were analyzed using the indirect immunobead test for immunoglobulin (Ig)G, IgA, and IgM antisperm antibodies. Regional binding also was considered: sperm head, midpiece, and sperm tail. Results were correlated with pregnancy outcome.

SETTING

Five university centers.

PATIENTS

One hundred eleven women who experienced pregnancy loss (55 diabetic; 56 nondiabetic) were matched 2:1 with 104 diabetic and 116 nondiabetic women (controls) who subsequently had a normal liveborn infant.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Pregnancy outcome (spontaneous abortion, liveborn) correlated with presence or absence of antisperm antibodies.

RESULTS

Analyzing samples without knowledge of clinical status, no differences were observed with respect to IgG, IgA, and IgM binding when a positive test was defined as 50% of sperm showing antibody binding. Likewise, no association was found for IgG and IgM antisperm antibodies at 20% binding. The only positive finding was observed for IgA antisperm antibodies at 20% binding (Fisher's Exact test). This one positive finding merely could reflect multiple comparisons. No significant differences between groups were observed when analysis was stratified according to location of antibody binding (head, midpiece, tail tip, entire sperm). When the sample was stratified into those having and not having a prior loss, a relationship between antisperm antibodies and pregnancy loss still was not evident.

CONCLUSION

Further work is necessary to determine whether IgA antisperm antibodies truly are associated with pregnancy loss or whether antisperm antibodies play any role in repetitive aborters. Findings in this study suggest that antisperm antibodies do not play a major role in pregnancy loss.

Pregnancy outcomes in the Diabetes Control and Complications Trial

OBJECTIVE

Our purpose was to examine the maternal and fetal outcomes of the 180 women with insulin-dependent diabetes mellitus who became pregnant during the Diabetes Control and Complications Trial.

STUDY DESIGN

The Diabetes Control and Complications Trial was a multicenter controlled clinical trial that compared intensive with conventional therapy in insulin-dependent diabetes mellitus. Intensive therapy, with the aim of achieving normal glycemic control, was initiated in women originally assigned to conventional therapy who actively sought to become pregnant or who became pregnant.

RESULTS

A total of 180 women completed 270 pregnancies between 1983 and 1993, with 191 total live births. The mean glycosylated hemoglobin level was significantly different between the treatment groups at conception (7.4% +/- 1.3% in intensive vs. 8.1% +/- 1.7% in conventional therapy, p = 0.0001) but was similar during gestation (6.6% +/- 0.8% and 6.6% +/- 1.3%). Nine congenital malformations were identified (4.7%), eight of which occurred in women originally assigned to conventional therapy (p = 0.06). There were 32 spontaneous abortions, 13.3% in the intensive and 10.4% in the women originally assigned to conventional treatment (not significant). There were no significant differences in outcome between the women with conventional treatment who initiated intensive therapy preconception and those who began it after conception.

CONCLUSIONS

Timely institution of intensive therapy is associated with rates of spontaneous abortion and congenital malformation similar to those in the nondiabetic population.

The Art and Science of Maintenance of Normoglycemia in Pregnancies complicated by Insulin-Dependent Diabetes Mellitus

OBJECTIVE

To provide a "how-to" manual for achieving and maintaining normoglycemia in pregnant women with insulin-dependent diabetes.

METHODS

We describe a detailed program that has successfully maintained normoglycemia before, during, and after diabetes-complicated pregnancies. Insulin and glucose requirements throughout pregnancy, during labor, and in the postpartum period are outlined.

RESULTS

With preconception planning and careful dietary and blood glucose management during pregnancy, complications can be minimized and an optimal outcome of pregnancy can be achieved in women with diabetes.

CONCLUSION

Women with type I, insulin-dependent diabetes can now have the same chances as women without diabetes to have a healthy infant. The reduction of risks associated with pregnancies complicated by diabetes can be ensured if normoglycemia is achieved before and during the pregnancy.

Diabetes

There is now strengthening evidence that meticulous control of maternal carbohydrate and fat metabolism before and during pregnancy in women with diabetes mellitus had positive benefits for the offspring, not only by reducing the incidence of congenital malformations, but also by diminishing fetal loss, reducing immediate neonatal complications and, in the long term, reducing unnecessary obesity, improving neuropsychological development and reducing the emergence of diabetes in the offspring at a relatively early age. Women who develop GDM are at a significant risk of developing NIDDM, and prevention of obesity, consumption of a high-fibre diet and possibly prophylactic hypoglycaemic therapy may reduce this otherwise inevitable progression, which will affect at least 50%.

Deformations in infants of diabetic and control pregnancies

Severe and mild deformations in newborn infants of insulin dependent diabetic mothers (IDDMs) and control mothers were evaluated with respect to the types of anomalies and previously hypothesized constraint factors. Factors evaluated were gestational length, birth weight, corrected birth weight for gestation (weight ratio), maternal height and parity, and severe deformations. Newborn infants from 81 control and 133 insulin dependent diabetic pregnancies were recruited periconceptually as part of a larger study of diabetes in early pregnancy. Examinations were done at 48 to 72 hours of life by one examiner blinded to maternal status using a checklist of major and minor deformations and malformations. Mild deformations were found to be common and were present in 84% of newborn infants. Severe deformations occurred in three (1.4%) IDMs, with two of three newborn infants having major malformations involving the CNS and/or musculoskeletal system which affected fetal movement. There was no significant difference between IDMs and control newborn infants with respect to the number with deformations; however, fetal macrosomia was not present in study participants. Using the entire cohort, a significantly greater number of deformations were present in newborn infants with a gestation > 36 weeks (P < 0.001), birth weight > 3,000 g (P < 0.001), and weight ratio > or = 1.2 (P = 0.05). There was no significant association with primiparous mothers or women with a height < 165 cm and the presence of deformations. For gestational age and birth weight, mild deformations were apparent only after 33 weeks gestation (P << 0.001) and/or birth weights of 2.0 kg or more (P << 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of diabetic pregnancy and glucose intolerance in pregnancy: an audit of fetal loss in Newcastle General Hospital 1977-1990

The outcome of pregnancy complicated by established diabetes or gestational glucose intolerance (diabetes mellitus or impaired glucose tolerance) is compared with the outcome of non-diabetic pregnancy. Between 1977 and 1990, 169 pregnancies in women with established diabetes and 61 pregnancies in women with gestational glucose intolerance were referred to the Newcastle General Hospital. The perinatal mortality (PNM) in women with established diabetes was 8.2/1000 and the viable fetal loss (sum of PNM, neonatal and infant loss) was 41/1000. The PNM in women with gestational glucose intolerance was 49.2/1000 and the viable fetal loss was 82/1000. The PNM in the background population was 11.6/1000. The fetal malformation rate was 17.3% for established diabetes, 9.8% in gestational glucose intolerance and 2.2% in the background population. Fetal abnormality remains the major cause of viable fetal loss in both established diabetes and gestational glucose intolerance.

Risk factors for spontaneous abortion: a preliminary study on Saudi women

A preliminary case-control study was conducted on Saudi women to detect possible risk factors for spontaneous abortion (SA). Two hundred and twenty six consecutive women hospitalised for SA and 226 women admitted for normal delivery and used as controls, were studied. Women with SA were significantly older at menarche (Relative Risk (RR) = 3.2), more frequently married to blood-related husbands (RR = 2.1) and husbands older than 50 years (RR = 2.4). Number of previous abortions related linearly to the risk of aborting spontaneously in the next pregnancy. Compared to primigravidas, the RR was 3.2 if the outcome of the most recent pregnancy was SA, and 0.8 if it was a livebirth. A family history of SA was more common among cases (RR = 4.6). Spontaneous abortion was also associated with daily consumption of more than 150 mg of caffeine, abdominal trauma, infection and fever during pregnancy. No significant association, however, emerged with maternal age, social class, education, exposure to video display terminals, parity, use of contraception, diabetes or obesity. The application of these data in clinical practice and future research needs are discussed.

Long-term developmental follow-up of infants of diabetic mothers

The neurodevelopmental consequences of maternal insulin-dependent diabetes were studied in 109 infants of diabetic mothers and 90 control infants. The infants born to diabetic mothers included 70 "early entry" subjects and 39 "late entry" subjects. Maternal diabetes control during pregnancy was significantly better in "early entry" mothers than in late-entry mothers, as determined by glycosylated hemoglobin levels. Infants were examined by a psychologist and a developmental pediatrician unaware of group status at 6, 12, 24, and 36 months of age; 71% of the subjects completed the 3-year-study. Neurodevelopment of early-entry subjects was similar to that of control subjects, whereas late-entry subjects scored less well on language measures. Mean head size in late-entry subjects was significantly less (p = 0.03) than in either control subjects or early-entry subjects at age 3 years, and correlated negatively with glycosylated hemoglobin levels during all three trimesters. Less optimal intellectual development was associated with reduced head circumference. In addition, the presence of major congenital malformations was associated with reduced developmental performance through age 2 years. Our results indicate that mothers with insulin-dependent diabetes who maintain good control during pregnancy can expect to have infants who are neurodevelopmentally normal; mothers whose diabetes is less well controlled may have infants with less optimal neurodevelopment.

Gynecologic manifestations of Sjögren's syndrome

OBJECTIVE

Sjögren's syndrome is a chronic, inflammatory autoimmune disease in which the salivary and lacrimal glands are progressively destroyed by lymphocytes and plasma cells. Because women are affected 10 times more often than men, we studied gynecologic manifestations of Sjögren's syndrome.

STUDY DESIGN

One thousand questionnaires were sent to women with Sjögren's syndrome in New York, New Jersey, Connecticut, and Pennsylvania. Five hundred thirty-nine women responded.

RESULTS

Women with Sjögren's syndrome reported significant vaginal dryness. There was no relationship of Sjögren's syndrome to either the incidence of infertility or miscarriage, although the 4% incidence of congenital anomalies in offspring was relatively high. Of the congenital anomalies, nine of 19 (47%) were cardiac. A long menstrual cycle (> 35 days) was associated with infertility and neuropathy.

CONCLUSIONS

The vaginal dryness in women with Sjögren's syndrome is not surprising, because the nasal and esophageal mucosae are also dry in this disorder. The relationship of infertility to a long menstrual cycle may simply indicate the presence of ovulatory dysfunction or inadequate luteal phase unrelated to Sjögren's syndrome. The relationship of neuropathy to a long menstrual cycle may be related to repeated, prolonged estrogen or progesterone exposure during the long cycles or to involvement of hypothalamic-pituitary-ovarian function.

Metabolic interactions of diabetes and pregnancy

Many of the embryonic and fetal abnormalities that occur in pregnancies complicated by maternal diabetes are the result of development in a metabolically abnormal environment. Diabetic embryopathy (birth defects and spontaneous abortions) results from maternal metabolic abnormalities during the first 6-7 weeks of gestation. The embryopathy appears to be multifactorial in origin, and the resulting defects remain important causes of morbidity and mortality in diabetic pregnancies. Diabetic fetopathy (predominantly macrosomia and neonatal hypoglycemia) results from fetal overnutrition and hyperinsulinemia during the second and third trimesters. Fetopathy may cause significant morbidity not only in the perinatal period, but also in later life as overweight infants grow up to be overweight children and young adults. Careful regulation of maternal metabolism from the preconceptional period onward can reduce greatly or even eliminate the excess risks that have been incurred by infants of diabetic mothers in the past. Successful management of maternal diabetes requires knowledge of the alterations in intermediary metabolism that normally occur during pregnancy, as discussed in this chapter.

Association of anticardiolipin antibodies and pregnancy loss in women with systemic lupus erythematosus

OBJECTIVE

To analyze the pregnancy history in relation to the presence or absence of anticardiolipin antibodies in women who had been diagnosed with systemic lupus erythematosus (SLE).

DESIGN

One-hundred twenty-five women of reproductive age who were diagnosed with SLE and attended the Lupus Clinic at Parkland Memorial Hospital or Southwestern Medical Center were selected for this study. A retrospective review of patient histories, including anticardiolipin antibody test results and pregnancy histories, was conducted. Women who had therapeutic pregnancy terminations were excluded from this study. A chi 2 analysis was used to evaluate the significance of the data.

RESULTS

In women with SLE of childbearing age with anticardiolipin antibodies, a 39% pregnancy loss rate occurred, compared with an 11% loss rate in anticardiolipin antibody-negative women. In women with at least two pregnancies who had anticardiolipin antibodies, 27% experienced two or more losses, whereas only 3% of antibody-negative women had recurrent pregnancy loss.

CONCLUSION

We conclude that women with SLE and the presence of anticardiolipin antibodies are at increased risk for pregnancy loss.

An estrogen receptor genetic polymorphism and a history of spontaneous abortion--correlation in women with estrogen receptor positive breast cancer but not in women with estrogen receptor negative breast cancer or in women without cancer

We previously identified a polymorphism in the human estrogen receptor gene. In a preliminary study on women with estrogen receptor positive (ER+) breast tumors, we found that the presence of the rarer of the two alleles, the B' allele, is correlated with a history of spontaneous abortion. Because that study evaluated only women with estrogen receptor positive (ER+) breast cancer, it was unknown whether the observed correlation was restricted to the cancer group or was independent of breast cancer. We have now extended our analysis to include not only additional women with ER+ breast cancer, but also those with estrogen receptor negative (ER-) breast cancer and women without cancer. Results of the current study continue to show an association between the B' allele and a history of spontaneous abortion in the ER+ breast cancer group. There was no such correlation either in the ER- breast cancer group or in the group without cancer. Also, we continue to observe, in the ER+ breast cancer group, a significantly higher concentration of ER protein in tumors from homozygous wild type women (genotype BB), than in the tumors from women who are heterozygous for the rarer allele (genotype BB'). We conclude that the combination of spontaneous abortion and the BB' ER genotype may be a marker for breast cancer susceptibility.

Mechanism of recurrent spontaneous abortion. I. Ultrasonographic findings

OBJECTIVES

Our objective was to study the mechanisms of early pregnancy loss with ultrasonographic findings in pregnancies that terminated in repeat abortion in women with recurrent spontaneous abortion compared with patients with spontaneous abortion with no previous spontaneous abortion and with women with recurrent spontaneous abortion who had viable pregnancies.

STUDY DESIGN

A prospective, unselected study of 83 pregnancies followed from 4 to 12 weeks of gestation. Weekly transvaginal ultrasonography.among 43 pregnancies terminating in abortion were compared with 40 pregnancies ending in live birth with the Fisher exact test with a p value of significance assigned at less than 0.05.

RESULT

A significant difference in the presence of fetal heart activity was observed at 6 weeks +/- 5 days among women who subsequently aborted when recurrent spontaneous abortions were compared with no history of abortion (55% and 14%, p less than 0.02). Fetal pole size was small in 86% of pregnancies lost after fetal heart activity.

CONCLUSION

Ultrasonographic examination at 6 weeks can diagnose impending abortion with a sensitivity of 85%, specificity of 93%, positive predictive value of 92%, and negative predictive value of 87% among women with recurrent spontaneous abortion.

Infertility and pregnancy outcome in an unselected group of women with insulin-dependent diabetes mellitus

OBJECTIVES

The null hypothesis of this study is that infertility and pregnancy outcomes in women with insulin-dependent diabetes are identical to those of nondiabetic control subjects.

STUDY DESIGN

A questionnaire survey comprising an unselected population of 18- to 49-year-old diabetic women and a comparable control group was performed. Reply rates were 94% (n = 245) and 88% (n = 253), respectively.

RESULTS

Cumulative rates of pregnancies and involuntary infertility (17%) did not differ between the two groups. Diabetic women had significantly fewer pregnancies (1.4 vs 1.7) and fewer births per pregnancy than controls, and more diabetic women were nulliparous (48% vs 38%). Half of all diabetic pregnancies were planned. Diabetic women reported that their diabetes had a negative influence on their attitude toward having children.

CONCLUSION

In insulin-dependent diabetic women the ability to conceive is normal, but diabetic women have fewer pregnancies and fewer births per pregnancy than controls.

Update on immunotherapy for recurrent pregnancy loss

Results of recent, randomized, placebo-controlled clinical trials have raised questions about the efficacy of immunotherapy for recurrent spontaneous abortion (RSA). Most of the clinical trials have shown a 70% successful pregnancy rate with immunotherapy. The controversy comes from variations in success rates in the control populations, which have ranged from 29% to 76%. Explanations for these variations includes small sample sizes and heterogeneity by the populations studied as well as cointervention by the placebo. A meta-analysis has been proposed to investigate these explanations. Because the trials have largely used husband's leukocytes for immunization, alternative forms of immunotherapy have been sought. Two treatments that have been proposed but have not completed testing a randomized, placebo-controlled trials are intravenous immunoglobulin (IVIG) and immunization with seminal plasma. A safe and efficacious method is needed to treat recurrent spontaneous abortion; it is hoped that results of proposed studies will answer this controversy.

The Diabetes in Early Pregnancy Study: changes in cholesterol, triglycerides, body weight, and blood pressure. The National Institute of Child Health and Human Development--the Diabetes in Early Pregnancy Study

This study examined changes in cholesterol, triglycerides, body weight, and blood pressure during pregnancy in 312 diabetic and 356 control women recruited within 21 days after conception. Cholesterol values rose in both groups but were significantly lower in diabetic women at each time point (166 vs 178 mg/dl at week 12, p = 0.0004). Triglyceride values also rose in both groups. Triglyceride levels did not differ between groups up to week 8 of gestation, but by weeks 10 to 12 they were significantly lower in diabetic women than in controls (75 vs 89 mg/dl at week 12, p = 0.0004). Although they were no heavier at entry, diabetic women gained significantly more weight between weeks 6 and 8 (p less than 0.001), resulting in a mean difference between groups of 1 kg. Systolic blood pressure increased steadily and significantly in the diabetic but not the control women (115.8 +/- 16.2 SD vs 109.3 +/- 11.8 mm Hg, p = 0.0006 at term). Diastolic blood pressure was higher in diabetic women on entry (70.7 vs 67.3 mm Hg, p = 0.0006) and throughout gestation. Significant correlations were found in the diabetic group between maternal blood pressure and lipids and infant birth weight. These newly found differences in cholesterol and triglyceride levels, weight gain, and blood pressure between type I diabetic and control women during gestation may have long-term cardiovascular implications.

Epidemiology of recurrent spontaneous abortion

With recent scientific advances leading to better understanding of the immunobiology of recurrent spontaneous abortion (RSA), interest has now focused upon the epidemiology of RSA. A cohort of 214 couples with a history of two or more consecutive abortions were studied for the prevalence of etiologic factors and association with other reproductive failures. The prevalence of causes of RSA in this cohort was compared with etiologic factors among 179 couples with a history of three or more consecutive abortions. The obstetrical histories of 214 women with RSA were analyzed for the total number of pregnancies, live births, stillbirths, spontaneous abortions, ectopic pregnancies, and hydatidiform moles. These numbers were compared with the expected frequency of each in the general population. The prevalence of etiologies among 214 with RSA were as follows: chromosomal-6%, anatomic-1%, hormonal-5%, immunologic-65%, and unexplained-23%. No differences in the prevalence of etiologic factors exist when couples with a history of two or more abortions are compared with three or more abortions. When the number of ectopic pregnancies, molar pregnancies, and stillbirths among 214 women with RSA were compared with the expected numbers, the odds ratios were 2.2 for ectopic pregnancies, 6.0 for molar pregnancies, and 2.3 for stillbirths. These data indicate that no difference in the prevalence of etiologies of RSA exist when couples with two or more abortions are compared with three or more and a comorbidity between RSA and other types of reproductive failure exists.

In vitro effects of glucose and growth factors on limb bud and mandibular arch chondrocytes maintained at various serum concentrations

In human and experimental diabetic pregnancy there is an increased risk of congenital malformation in the offspring. Some malformations involve growth retardation and altered chondrocyte differentiation, suggesting that a diabetic milieu may modify embryonic cell replication and the development of (pre)chondrocytes. The aim of the present work was to study the effects of a diabetes-like environment in vitro on the growth and differentiation of rat chondrocytes in the presence of specific growth factors and different concentrations of serum. This was performed with a modified micromass culture system of embryonic (pre)chondrocytes from the limb bud and mandibular arch areas using medium supplemented with different glucose concentrations and with serum from diabetic rats. An elevated ambient glucose concentration inhibited the growth of mature chondrocytes in vitro, and this effect was diminished in a serum-rich culture milieu. The (pre)chondrocytes exhibited a marked dependence on the serum level in the culture medium for optimal in vitro development. Diabetic rat serum had the lowest stimulatory capacity of the three different types tested (at similar glucose concentrations), suggesting a deficiency of growth-stimulating factor(s) rather than the presence of inhibiting factor(s) in this type of serum. One of the deficient factor(s) in diabetic rat serum may be similar to IGF-II, but a combined deficiency of several growth-stimulating agents is likely to be present. Chondrocytes originating from the mandibular arch in general appeared more sensitive to MSA and IGF-II than those from the limb buds. The present observations support the notion that while diabetes-induced hyperglycemia in the conceptus contributes to severe growth retardation of the mandibular arch, additional factors also play a role.

Spontaneous abortion and congenital malformations in diabetes

The first few weeks after conception are a critical period for the embryo of a diabetic mother. If the mother is in good glycaemic control during this time, the risk of spontaneous abortion or major congenital malformation is low. Otherwise, the risk increases in proportion to the degree of blood glucose elevation. Glycohaemoglobin determination in the first trimester can be useful in retrospectively evaluating the degree of glycaemic control present around the time of conception and in roughly estimating the risk of spontaneous abortion or major malformation. For women with high risk, early prenatal diagnosis of congenital anomalies is warranted using detailed ultrasound examination, fetal echocardiography and alpha-fetoprotein determinations. Encouraging diabetic women to achieve strict control prior to conception should virtually eliminate the excess risk of spontaneous abortion or major malformation.

Occurrence of other reproductive failures among women with recurrent spontaneous abortion

We have previously reported an association between recurrent spontaneous abortion and ectopic pregnancy. We now report that not only ectopic pregnancy, but also other reproductive failures including hydatidiform moles, preterm births, and stillbirths are also associated with recurrent spontaneous abortion. The obstetrical histories of 455 women who had experienced two or more consecutive spontaneous abortions were studied for the occurrence of term births, preterm births, stillbirths, spontaneous abortions, ectopic pregnancies, and hydatidiform moles. The observed frequencies of these reproductive outcomes were compared with the expected frequencies of 920 term births, 80 preterm births, five stillbirths, 150 spontaneous abortions, 14.5 ectopic pregnancies and 0.5 molar pregnancies per 1,000 livebirths. The 455 women had experienced 1,968 pregnancies of which 184 were term births, 30 were preterm births, 16 were stillbirths, 1,669 were spontaneous abortions, 63 were ectopic pregnancies, and six were molar pregnancies. The ratio of observed to expected values was term births 0.1, preterm births 1.6, stillbirths 14.0, spontaneous abortion 6.6, ectopic pregnancy 2.6, and molar pregnancy 7.1. The gravid specific proportions of reproductive outcomes were constant suggesting comorbidity or common cause(s). The commonality that links these types of reproductive failure will provide insight into the mechanisms of reproductive wastage.

Statistical analysis of outcomes from repeated pregnancies: effects of HLA sharing on fetal loss rates

As part of our ongoing studies of genetic markers of reproductive outcome in the Hutterites, we have been analyzing potential risk factors for pregnancy outcomes. In particular, we are interested in the effects of HLA sharing between parents on fetal loss rates. Pregnancy outcome data such as these have two characteristics that create statistical challenges, i.e., repeated observations per couple and between-couple heterogeneity in risk. We critically examine four approaches based on the logistic model for the analysis of this and similar data: 1) unconditional likelihood analysis with and without fixed cluster effects; 2) conditional likelihood analysis; 3) mixed-effects analysis with random cluster effects; and 4) the robust generalized estimating equation (GEE) procedure. Of these approaches, the GEE method of Liang and Zeger would be best suited for the analysis of our data when the question of interest concerns a variable that is constant over all pregnancies, such as HLA sharing. If the question concerns a couple's risk associated with a changing variable such as maternal age, the mixed-effects analysis is the more appropriate.