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Quenby S, Booth K, Hiller L, Coomarasamy A, de Jong PG, Hamulyák EN, Scheres LJ, van Haaps TF, Ewington L, Tewary S, Goddijn M, Middeldorp S. Heparin for women with recurrent miscarriage and inherited thrombophilia (ALIFE2): an international open-label, randomised controlled trial. Lancet 2023; 402:54-61. [PMID: 37271152 DOI: 10.1016/s0140-6736(23)00693-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/09/2023] [Accepted: 03/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Anticoagulant therapy might reduce the number of miscarriages and adverse pregnancy outcomes in women with recurrent pregnancy loss and inherited thrombophilia. We aimed to assess use of low-molecular-weight heparin (LMWH) versus standard care in this population. METHODS The ALIFE2 trial was an international open-label, randomised controlled trial undertaken in hospitals in the UK (n=26), the Netherlands (n=10), the USA (n=2), Belgium (n=1), and Slovenia (n=1). Women aged 18-42 years who had two or more pregnancy losses and confirmed inherited thrombophilia, and who were trying to conceive or were already pregnant (≤7 weeks' gestation), were eligible for inclusion. Women were randomly assigned (1:1) to use low-dose LMWH or not (alongside standard care in both groups) once they had a positive urine pregnancy test. LMWH was started at or before 7 weeks' gestation and continued until the end of pregnancy. The primary outcome measure was livebirth rate, assessed in all women with available data. Safety outcomes included bleeding episodes, thrombocytopenia, and skin reactions, and were assessed in all randomly assigned women who reported a safety event. The trial was registered within the Dutch Trial Register (NTR3361) and EudraCT (UK: 2015-002357-35). FINDINGS Between Aug 1, 2012, and Jan 30, 2021, 10 625 women were assessed for eligibility, 428 were registered, and 326 conceived and were randomly assigned (164 to LMWH and 162 to standard care). 116 (72%) of 162 women with primary outcome data in the LMWH group and 112 (71%) of 158 in the standard care group had livebirths (adjusted odds ratio 1·08, 95% CI 0·65 to 1·78; absolute risk difference, 0·7%, 95% CI -9·2% to 10·6%). 39 (24%) of 164 women in the LMWH group and 37 (23%) of 162 women in the standard care group reported adverse events. INTERPRETATION LMWH did not result in higher livebirth rates in women who had two or more pregnancy losses and confirmed inherited thrombophilia. We do not advise use of LMWH in women with recurrent pregnancy loss and inherited thrombophilia, and we advise against screening for inherited thrombophilia in women with recurrent pregnancy loss. FUNDING National Institute for Health and Care Research and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Siobhan Quenby
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK; University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Katie Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Paulien G de Jong
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, Netherlands
| | - Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, Netherlands
| | - Luuk J Scheres
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs F van Haaps
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, Netherlands
| | - Lauren Ewington
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK; University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Shreeya Tewary
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK; University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mariëtte Goddijn
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, Netherlands.
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2
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Middeldorp S, Naue C, Köhler C. Thrombophilia, Thrombosis and Thromboprophylaxis in Pregnancy: For What and in Whom? Hamostaseologie 2022; 42:54-64. [PMID: 35196731 DOI: 10.1055/a-1717-7663] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Compared with nonpregnant women, pregnancy carries a four- to fivefold higher risk of venous thromboembolism (VTE). Despite increasing use of heparin prophylaxis in identified high-risk patients, pulmonary embolism still is the leading cause of maternal mortality in the western world. However, evidence on optimal use of thromboprophylaxis is scarce. Thrombophilia, the hereditary or acquired tendency to develop VTE, is also thought to be associated with complications in pregnancy, such as recurrent miscarriage and preeclampsia. In this review, the current evidence on optimal thromboprophylaxis in pregnancy is discussed, focusing primarily on VTE prevention strategies but also discussing the potential to prevent recurrent pregnancy complications with heparin in pregnant women with thrombophilia.
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Affiliation(s)
- Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiane Naue
- Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Christina Köhler
- Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
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Xiao S, Luo Y, Guo L, Zhang J, Mu L, Ye Z. Comparison of doses of heparin for venous thromboembolism and bleeding in pregnant women. J Investig Med 2021; 70:773-779. [PMID: 34921124 DOI: 10.1136/jim-2021-002050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/04/2022]
Abstract
The evaluation criteria for dosage of low-molecular-weight heparin (LMWH) for pregnant women at high risk of venous thromboembolism (VTE) remain unclear. A retrospective study was performed to investigate the relative appropriate LMWH administration strategy and dosage for pregnant women at risk of VTE. 219 pregnant women with perinatal and postpartum VTE were reviewed and divided into group A (fixed dose group: n=73, 5000 IU dalteparin daily for all women), group B (weight group: n=73, 2500 IU dalteparin daily for women less than 50 kg; 5000 IU dalteparin daily for women more than 50 kg), and group C (anti-factor Xa (FXa) + weight group: n=73, 5000 IU once daily for women less than 50 kg; 7500 IU once daily for women weighing 50-80 kg; 10,000 IU once daily for women weighing over 80 kg). Further dose administration was adjusted according to peak anti-FXa level, maintaining the peak at the 0.5-1.0 IU/mL range. Women in group C presented lower incidence of VTE and other pregnancy complications than group A and group B. Adjusting the dosage of LMWH according to both weight and anti-FXa level of pregnant women not only prevented VTE but also reduced the risk of postpartum hemorrhage induced by LMWH administration. In addition, adjusting the dose of LMWH according to anti-FXa level and body weight also affected the recurrence of VTE and the occurrence of postpartum hemorrhage in pregnant women.
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Affiliation(s)
- Sha Xiao
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Yuancai Luo
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Lu Guo
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Liping Mu
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Zhao Ye
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
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Han AR, Han JW, Lee SK. Inherited thrombophilia and anticoagulant therapy for women with reproductive failure. Am J Reprod Immunol 2020; 85:e13378. [DOI: 10.1111/aji.13378] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/09/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ae Ra Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Jae Won Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Sung Ki Lee
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
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Progress of the ALIFE2 study: A dynamic road towards more evidence. Thromb Res 2020; 190:39-44. [DOI: 10.1016/j.thromres.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/07/2020] [Accepted: 03/17/2020] [Indexed: 11/21/2022]
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Rao M, Zeng Z, Zhou F, Wang H, Liu J, Wang R, Wen Y, Yang Z, Su C, Su Z, Zhao S, Tang L. Effect of levothyroxine supplementation on pregnancy loss and preterm birth in women with subclinical hypothyroidism and thyroid autoimmunity: a systematic review and meta-analysis. Hum Reprod Update 2020; 25:344-361. [PMID: 30951172 DOI: 10.1093/humupd/dmz003] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 12/15/2018] [Accepted: 01/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCH) and thyroid autoimmunity (TAI) are associated with adverse pregnancy outcomes such as pregnancy loss and preterm birth. However, the ability of levothyroxine (LT4) supplementation to attenuate the risks of these outcomes remains controversial. OBJECTIVE AND RATIONALE This systematic review and meta-analysis was conducted to determine the effect of LT4 supplementation on pregnancy loss rate (PLR) and preterm birth rate (PBR) among pregnant women with SCH and TAI. SEARCH METHODS A systematic literature search of the PubMed, EMBASE, Web of Science and Cochrane Controlled Trials Register databases and Clinicaltrials.gov was performed to identify all relevant English studies published up to April 2018. The following terms were used for the search: [subclinical hypothyroidism OR thyroid autoimmunity OR thyroperoxidase antibody (TPO-Ab) OR thyroglobulin antibodies (Tg-Ab)] AND (levothyroxine OR euthyrox) AND [pregnancy outcome OR miscarriage OR abortion OR pregnancy loss OR preterm birth OR premature delivery OR early labo(u)r]. The reference lists of the relevant publications were also manually searched for related studies. Published manuscripts were included if they reported data on pregnancy loss, preterm birth or both. We separately analysed the pooled effects of LT4 supplementation on PLR and PBR in women with SCH and TAI. OUTCOMES Overall, 13 eligible studies including 7970 women were included in the meta-analysis. Eight and five of these studies were randomized controlled trials (RCTs) and retrospective studies, respectively. The pooled results indicated that LT4 supplementation significantly decreased the PLR [relative risk (RR) = 0.56, 95% confidence interval (CI): 0.42-0.75, I2 = 1%, 12 studies] and PBR (RR = 0.68, 95% CI: 0.51-0.91, I2 = 21%, eight studies) in women with SCH and/or TAI. We further found that LT4 supplementation significantly decreased the risk of pregnancy loss (RR = 0.43, 95% CI: 0.26-0.72, P = 0.001, I2 = 0%) but not of preterm birth (RR = 0.67, 95% CI: 0.41-1.12, P = 0.13, I2 = 0%) in women with SCH. Furthermore, LT4 supplementation significantly decreased the risks of both pregnancy loss (RR = 0.63, 95% CI: 0.45-0.89, P = 0.009, I2 = 0%) and preterm birth (RR = 0.68 95% CI: 0.48-0.98, P = 0.04, I2 = 46%) in women with TAI. These results were consistent when only RCTs were included in the analysis. Further, in women with SCH, LT4 supplementation reduced the risk of pregnancy loss in pregnancies achieved by assisted reproduction (RR = 0.27, 95% CI: 0.14-0.52, P < 0.001, I2 = 14%) but not in naturally conceived pregnancies (RR = 0.60, 95% CI: 0.28-1.30, P = 0.13, I2 = 0%). By contrast, in women with TAI, LT4 supplementation reduced the risks of both pregnancy loss (RR = 0.61, 95% CI: 0.39-0.96, P = 0.03, I2 = 0%) and preterm birth (RR = 0.49, 95% CI: 0.30-0.79, P = 0.003, I2 = 0%) in naturally conceived pregnancies but not in pregnancies achieved by assisted reproduction (RR = 0.68, 95% CI: 0.40-1.15, P = 0.15, I2 = 0% for pregnancy loss and RR = 1.20, 95% CI: 0.68-2.13, P = 0.53, I2 not applicable for preterm birth). WIDER IMPLICATIONS This meta-analysis confirmed the beneficial effects of LT4 supplementation, namely the reduced risks of pregnancy loss and preterm birth, among pregnant women with SCH and/or TAI. The different effects of LT4 supplementation on naturally conceived pregnancies and pregnancies achieved by assisted reproduction in women with SCH and/or TAI suggest that these women should be managed separately. Due to the limited number of studies included in this meta-analysis, especially in the subgroup analysis, further large RCTs and fundamental studies are warranted to confirm the conclusions and better clarify the molecular mechanism underlying these associations.
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Affiliation(s)
- Meng Rao
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Zhengyan Zeng
- Department of Neurology, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Fang Zhou
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hang Kong road, Wuhan, China
| | - Huawei Wang
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Jiang Liu
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Rui Wang
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Ya Wen
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Zexing Yang
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Cunmei Su
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Zhenfang Su
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Shuhua Zhao
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
| | - Li Tang
- Department of Reproduction and Genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, China
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Papadakis E, Pouliakis A, Aktypi Α, Christoforidou A, Kotsi P, Αnagnostou G, Foifa A, Grouzi E. Low molecular weight heparins use in pregnancy: a practice survey from Greece and a review of the literature. Thromb J 2019; 17:23. [PMID: 31827408 PMCID: PMC6894228 DOI: 10.1186/s12959-019-0213-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background Use of LMWH in pregnancy is not only limited to VTE management, but it extends, to the management of vascular gestational complications and the optimization of IVF pregnancies despite the lack of concrete scientific evidence. In this context, we conducted the present study aiming to gain insights regarding the use of LMWH during pregnancy and puerperium. We recorded indication for use, diagnostic work-up as well as the safety and efficacy of the treatment, trying to elucidate the clinical practice in our country. Methods We analyzed data regarding 818 pregnant women received LMWH during 2010-2015.Our cohort had a median age of 33.9 years and a BMI of 23.6.There were 4 groups: those with a history of VTE [Group-A: 76], those with pregnancy complications [Group-B: 445], those undergoing IVF [Group-C: 132] and those carrying prothrombotic tendency (thrombophilia, family history of VTE, other) [Group-D: 165]. Mean duration of LMWH administration was 8.6 ± 1.5 months. Out of the total number, 440 received LMWH in fixed prophylactic dose, 272 in higher prophylactic-weight adjusted dose and 106 in therapeutic dose. Moreover, 152 women received in addition low-dose acetylsalicylic acid (ASA). 93.8% of pregnancies were single and 6.2% were multiple ones. Live births occurred in 98.7% of pregnancies. Results Anticoagulation was efficacious and well tolerated. Seventeen VTE events were recorded; 7 of them antepartum and 10 postpartum. No major bleeding events were observed while 13 clinical relevant non-major bleeding events were recorded. Regarding gestational vascular complications, 28 IUGR events were recorded, as well as 48 cases of preterm labor of which 12 were concomitant with IUGR (25%). Six early pregnancy losses were recorded; there were 3 fetal deaths and 3 cases of pre-eclampsia/eclampsia. Conclusions LMWHs are used extensively during pregnancy and puerperium in Greece for VTE treatment and prophylaxis and for a variety of other indications as well. Although the drug has been shown to be both safe and efficacious, its use for some indications has no proven scientific evidence. In order to clearly define the role of LMWHs in pregnancy, beyond thromboprophylaxis, large prospective studies are required, which could be based on the conclusions of this study.
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Affiliation(s)
- E Papadakis
- 1Hemostasis Unit-Hematology Department Papageorgiou Hospital, Thessaloniki Ringroad 56403 Nea Efkarpia, Thessaloniki, Greece
| | - A Pouliakis
- 22nd Department of Pathology, National and Kapodistrian University of Athens, "ATTIKON" University Hospital, Rimini 1 Haidari, Athens, Greece
| | - Α Aktypi
- OLYMPION General Clinic, Volou-Patras, 26443 Patras, Greece
| | - A Christoforidou
- 4University Hospital of Alexandroupolis, Dragana Site 68100 Nea Chili, Alexandroupoli, Greece
| | - P Kotsi
- 5Blood Transfusion Unit, National Ref. Centre for Congenital Bleeding Disorders, Hemostasis Unit, Laiko General Hospital, Ag. Thoma, 17 11527 Athens, Greece
| | - G Αnagnostou
- 6Head of Transfusion Service and Clinical Haemostasis, Henry Dunant Hospital Center, Mesogion 107, 115 26 Athens, Greece
| | - A Foifa
- IASO, General Maternity and Gynecology Clinic, 37-39, Kifissias Avenue, 151 23 Maroussi, Athens, Greece
| | - E Grouzi
- "St Savvas" Oncology Hospital, Alexandras Avenue 171, 11522 Ambelikipoi, Athens, Greece
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Baek H, Yang H, Lee JH, Kang NH, Lee J, Bae H, Hwang DS. Prophylactic Effects of Bee Venom Phospholipase A2 in Lipopolysaccharide-Induced Pregnancy Loss. Toxins (Basel) 2019; 11:toxins11070404. [PMID: 31336883 PMCID: PMC6669565 DOI: 10.3390/toxins11070404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 11/23/2022] Open
Abstract
Spontaneous abortion represents a common form of embryonic loss caused by early pregnancy failure. In the present study, we investigated the prophylactic effects of bee venom phospholipase A2 (bvPLA2), a regulatory T cell (Treg) inducer, on a lipopolysaccharide (LPS)-induced abortion mouse model. Fetal loss, including viable implants, the fetal resorption rate, and the fetal weight, were measured after LPS and bvPLA2 treatment. The levels of serum and tissue inflammatory cytokines were determined. To investigate the involvement of the Treg population in bvPLA2-mediated protection against fetal loss, the effect of Treg depletion was evaluated following bvPLA2 and LPS treatment. The results clearly revealed that bvPLA2 can prevent fetal loss accompanied by growth restriction in the remaining viable fetus. When the LPS-induced abortion mice were treated with bvPLA2, Treg cells were significantly increased compared with those in the non-pregnant, PBS, and LPS groups. After LPS injection, the levels of proinflammatory cytokines were markedly increased compared with those in the PBS mouse group, while bvPLA2 treatment showed significantly decreased TNF-α and IFN-γ expression compared with that in the LPS group. The protective effects of bvPLA2 treatment were not detected in Treg-depleted abortion-prone mice. These findings suggest that bvPLA2 has protective effects in the LPS-induced abortion mouse model by regulating Treg populations.
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Affiliation(s)
- Hyunjung Baek
- Department of Physiology, College of Korean Medicine, Kyung Hee University, Seoul 02453, Korea
| | - HyeJin Yang
- Department of Physiology, College of Korean Medicine, Kyung Hee University, Seoul 02453, Korea
| | - Jong Hoon Lee
- Department of Physiology, College of Korean Medicine, Kyung Hee University, Seoul 02453, Korea
| | - Na-Hoon Kang
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul 02453, Korea
| | - Jinwook Lee
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul 02453, Korea
| | - Hyunsu Bae
- Department of Physiology, College of Korean Medicine, Kyung Hee University, Seoul 02453, Korea.
| | - Deok-Sang Hwang
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul 02453, Korea.
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Cavalcante MB, Sarno M, Cavalcante CTDMB, Araujo Júnior E, Barini R. Coagulation Biomarkers in Women with Recurrent Miscarriage and Polycystic Ovarian Syndrome: Systematic Review and Meta-Analysis. Geburtshilfe Frauenheilkd 2019; 79:697-704. [PMID: 31303657 PMCID: PMC6620176 DOI: 10.1055/a-0884-3212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/24/2022] Open
Abstract
Introduction Pregnant women with polycystic ovarian syndrome (PCOS) have high risk of pregnancy loss. Pathophysiological mechanisms appear to be associated with obesity, hormonal factors, or blood clotting disorders. Our aim is to perform a systematic review and meta-analysis on the relationship between coagulation disorders and risk of recurrent miscarriage (RM) in patients with PCOS and to identify coagulation biomarkers for this condition. Material and Methods PubMed and MEDLINE databases were searched for publications in English language. The search terms used included "RM", "polycystic ovary syndrome", "coagulation disorders", and "thrombophilia". Odds ratios (ORs) and 95% confidence intervals (CIs) for miscarriage in different RM groups (with and without PCOS). Results A total of 575 publications including the search terms were identified. Six studies were included for qualitative analysis, and five were included for quantitative analysis (meta-analysis). We found no association between RM and inherited thrombophilias in patients with PCOS: (1) Factor V Leiden (OR, 0.74; 95% CI, 0.38 - 1.45; p = 0.38); (2) C677T methylenetetrahydrofolate reductase polymorphism (MTHFR) (OR, 1.01; 95% CI, 0.64 - 1.59; p = 0.97); and (3) A1297C MTHFR polymorphism (OR, 1.08; 95% CI, 0.62 - 1.89; p = 0.77). Other potential biomarkers were identified, with emphasis on plasminogen activator inhibitor type 1. Conclusion Data available in the current literature revealed that there was no association between RM and inherited thrombophilias in patients with PCOS. RM patients with PCOS have a high risk of thromboembolic events.
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Affiliation(s)
| | - Manoel Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador-BA, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas-SP, Brazil
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Yoshihara H, Sugiura-Ogasawara M, Kitaori T, Katano K, Ozaki Y. Danaparoid is effective and safe for patients with obstetric antiphospholipid syndrome. Mod Rheumatol 2019; 30:332-337. [DOI: 10.1080/14397595.2019.1602241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hiroyuki Yoshihara
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Mayumi Sugiura-Ogasawara
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Tamao Kitaori
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Kinue Katano
- Obstetrics & Gynecology Katano Clinic, Kasugai, Japan
| | - Yasuhiko Ozaki
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
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11
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Scheres LJ, Bistervels IM, Middeldorp S. Everything the clinician needs to know about evidence-based anticoagulation in pregnancy. Blood Rev 2019; 33:82-97. [DOI: 10.1016/j.blre.2018.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/25/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
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12
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Toth B, Würfel W, Bohlmann M, Zschocke J, Rudnik-Schöneborn S, Nawroth F, Schleußner E, Rogenhofer N, Wischmann T, von Wolff M, Hancke K, von Otte S, Kuon R, Feil K, Tempfer C. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/050). Geburtshilfe Frauenheilkd 2018; 78:364-381. [PMID: 29720743 PMCID: PMC5925690 DOI: 10.1055/a-0586-4568] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Official guideline of the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (ÖGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). The aim of this guideline was to standardize the diagnosis and treatment of couples with recurrent miscarriage (RM). Recommendations were based on the current literature and the views of the involved committee members. Methods Based on the current literature, the committee members developed the statements and recommendations of this guideline in a formalized process which included DELPHI rounds and a formal consensus meeting. Recommendations Recommendations for the diagnosis and treatment of patients with RM were compiled based on the international literature. Specific established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders were taken into consideration.
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Affiliation(s)
- Bettina Toth
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | | | | | - Johannes Zschocke
- Zentrum für Medizinische Genetik, Universität Innsbruck, Innsbruck, Austria
| | | | | | | | - Nina Rogenhofer
- Klinikum der Universität München - Frauenklinik Maistraße, München, Germany
| | - Tewes Wischmann
- Institut für Medizinische Psychologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael von Wolff
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Bern, Switzerland
| | - Katharina Hancke
- Klinik für Frauenheilkunde, Universitätsklinikum Ulm, Ulm, Germany
| | - Sören von Otte
- Kinderwunschzentrum, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Ruben Kuon
- Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Katharina Feil
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Clemens Tempfer
- Universitätsfrauenklinik, Ruhr-Universität Bochum, Bochum, Germany
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Sano T, Terai Y, Daimon A, Nunode M, Nagayasu Y, Okamoto A, Fujita D, Hayashi M, Ohmichi M. Recombinant human soluble thrombomodulin as an anticoagulation therapy improves recurrent miscarriage and fetal growth restriction due to placental insufficiency - The leading cause of preeclampsia. Placenta 2018; 65:1-6. [PMID: 29908636 DOI: 10.1016/j.placenta.2018.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/11/2018] [Accepted: 03/23/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Placental insufficiency is one of the major risk factors for growth restriction and preeclampsia. The aim of this study is to investigate whether recombinant human Thrombomodulin(r-TM) improves fetal conditions and physiological outcomes. METHODS We used CBA/J × BALB/C mice as a control and CBA/J × DBA/2 mice - a well-studied model of recurrent spontaneous miscarriage. Pregnant mice received daily subcutaneous injections of r-TM or saline from day 0-15. The fetal resorption rate, fetal weight, and litter size were calculated at day 15. Additionally, we analyzed the mRNA expression of angiogenic factors and the concentration of soluble Flt-1 (sFlt-1) using the ELISA kit. RESULTS The rate of fetal resorption in CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with mice without r-TM treatment. Additionally, fetal weight and litter size were also significantly higher in the r-TM treated mice. Fibrinogen deposition in the labyrinth area of the CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with deposits in the mice untreated with r-TM. As well, r-TM significantly increased the gene expression level of VEGF and Flt-1 mRNA in the placentas of the CBA/J × DBA/2 mice. r-TM treatment also significantly decreased the production of sFlt-1 protein in the placentas of preeclampsia-like diseased mice. CONCLUSION r-TM as an anticoagulation therapy has the potential for the medical treatment of recurrent miscarriage and fetal growth restriction due to improved angiogenic factors. Additionally, r-TM treatment has the potential for the recovery of preeclampsia.
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Affiliation(s)
- Takumi Sano
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan.
| | - Atsushi Daimon
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Misa Nunode
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Yoko Nagayasu
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Atsuko Okamoto
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Masami Hayashi
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology, Osaka Medical College, Takatsuki-city, Osaka, Japan
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Rottenstreich A, Amsalem H, Kleinstern G, Kalish Y. Outcomes of threatened abortions after anticoagulation treatment to prevent recurrent pregnancy loss. Reprod Biomed Online 2017; 35:461-467. [PMID: 28756129 DOI: 10.1016/j.rbmo.2017.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
We aimed to determine the outcome of threatened abortion in women treated with low-molecular weight heparin (LMWH) for recurrent pregnancy loss (RPL). Data of women with RPL who experienced threatened abortion while taking LMWH between 2007 and 2016 were retrospectively reviewed. All patients received the LMWH, enoxaparin (40 mg). Thrombophilia was present in 38 (33.3%) women, including 11 (9.6%) with antiphospholipid syndrome (APLS). The overall live birth rate was 58.8% (67/114). Live birth rates were 87.2% (41/47 patients) and 38.8% (26/67 patients) among those who discontinued versus those who continued LMWH treatment, respectively (P < 0.0001). Among APLS patients, live births resulted in eight of the nine women who continued LMWH. In multivariate analysis, discontinuation of LMWH was the only significant predictor of live birth outcome (P < 0.0001). Thrombophilia, presence of subchorionic haematoma, and severity of bleeding were not found to be associated with live birth outcomes. For women with threatened abortions, continuation of LMWH indicated to prevent RPL was negatively associated with live birth rates. Therefore, we support its discontinuation in this setting. Among women with APLS, LMWH continuation resulted in a relatively high live birth rate; we advocate against its withdrawal in this subset of patients.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Hematology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel
| | - Hagai Amsalem
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel
| | - Geffen Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, POB 12000, Jerusalem 91120, Israel; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
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15
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Middeldorp S. Inherited thrombophilia: a double-edged sword. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:1-9. [PMID: 27913455 PMCID: PMC6142488 DOI: 10.1182/asheducation-2016.1.1] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Inherited thrombophilia is a blood coagulation disorder that increases the risk for venous thromboembolism (VTE). During the last decades, the practice of testing has evolved from testing selected populations, leading to high perceived risks, to broad testing for various conditions that included VTE, arterial thrombosis, and pregnancy complications. Because results of such tests usually do not guide treatment decisions, not testing patients with VTE for inherited thrombophilia is on the "Choosing Wisely" list endorsed by multiple specialty societies, including ASH. Inherited thrombophilia can be regarded a double-edged sword, as despite the rationale not to test, it is still being performed frequently. Another way of seeing inherited thrombophilia as a double-edged sword lies in its 2-sided association with reproduction, both in men and in women. Current areas of research are whether women with inherited thrombophilia and pregnancy complications benefit from anticoagulant therapy with regard to improving the chance of a successful pregnancy. Potential effects of inherited thrombophilia, most notably factor V Leiden, on improved embryo implantation in women and sperm counts in men are intriguing, but are currently poorly understood.
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Affiliation(s)
- Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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16
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Shen MC, Wu WJ, Cheng PJ, Ma GC, Li WC, Liou JD, Chang CS, Lin WH, Chen M. Low-molecular-weight-heparin can benefit women with recurrent pregnancy loss and sole protein S deficiency: a historical control cohort study from Taiwan. Thromb J 2016; 14:44. [PMID: 27799851 PMCID: PMC5084381 DOI: 10.1186/s12959-016-0118-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 10/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heritable thrombophilias are assumed important etiologies for recurrent pregnancy loss. Unlike in the Caucasian populations, protein S and protein C deficiencies, instead of Factor V Lieden and Prothrombin mutations, are relatively common in the Han Chinese population. In this study we aimed to investigate the therapeutic effect of low molecular weight heparin upon women with recurrent pregnancy loss and documented protein S deficiency. METHODS During 2011-2016, 68 women with recurrent pregnancy loss (RPL) and protein S deficiency (both the free antigen and function of protein S were reduced) were initially enrolled. All the women must have experienced at least three recurrent miscarriages. After excluding those carrying balanced translocation, medical condition such as diabetes mellitus, chronic hypertension, and autoimmune disorders (including systemic lupus erythematosus and anti-phospholipid syndrome), coexisting thrombophilias other than persistent protein S deficiency (including transient low protein S level, protein C deficiency, and antithrombin III), only 51 women with RPL and sole protein S deficiency were enrolled. Initially they were prescribed low dose Aspirin (ASA: 100 mg/day) and unfortunately there were still 39 women ended up again with early pregnancy loss (12 livebirths were achieved though). Low-molecular-weight-heparin (LMWH) was given for the 39 women in a dose of 1 mg/Kg every 12 h from the day when the next clinical pregnancy was confirmed to the timing at least 24 h before delivery. The perinatal outcomes were assessed. RESULTS Of 50 treatment subjects performed for the 39 women (i.e. 11 women enrolled twice for two pregnancies), 46 singletons and one twin achieved livebirths. The successful live-birth rate in the whole series was 94 % (47/50). Nineteen livebirths delivered vaginally whereas 28 delivered by cesarean section. The cesarean delivery rate is thus 59.57 %. Emergent deliveries occurred in 3 but no postpartum hemorrhage had been noted. CONCLUSIONS Our pilot study in Taiwan, an East Asian population, indicated anti-coagulation therapy is of benefit to women with recurrent pregnancy loss who had documented sole protein S deficiency. TRIAL REGISTRATION ISRCTN64574169. Retrospectively registered 29 Jun 2016.
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Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wan-Ju Wu
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang-Gung Memorial Hospital Linkou Medical Center and Chang-Gung University, Taoyuan, Taiwan
| | - Gwo-Chin Ma
- Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Wen-Chu Li
- Department of Obstetrics and Gynecology, Puli Christian Hospital, Nantou, Taiwan
| | - Jui-Der Liou
- Department of Obstetrics and Gynecology, Taipei Chang-Gung Memorial Hospital, Taipei, Taiwan
| | - Cheng-Shyong Chang
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Hsiang Lin
- Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan
| | - Ming Chen
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Genomic Medicine, Changhua Christian Hospital, 500 Changhua, Taiwan.,Department of Obstetrics and Gynecology, and Department of Medical Genetics, College of Medicine, and Hospital, National Taiwan University, Taipei, Taiwan.,Department of Life Science, Tunghai University, Taichung, Taiwan
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17
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Etiologic characteristics and index pregnancy outcomes of recurrent pregnancy losses in Korean women. Obstet Gynecol Sci 2016; 59:379-87. [PMID: 27668201 PMCID: PMC5028645 DOI: 10.5468/ogs.2016.59.5.379] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The goal of this study was to evaluate the etiologies and clinical outcomes of Korean recurrent pregnancy loss (RPL) patients. And also, we investigated the differences between primary and secondary RPL patients, between two and three or more pregnancy losses. METHODS One hundred seventy eight women diagnosed as RPL were enrolled. We performed chromosomal analysis, thyroid stimulating hormone, prolactin, blood glucose, plasminogen activator inhibitor-1, natural killer cell proportion, anticardiolipin antibodies, antiphospholipid antibodies, lupus anticoagulant, anti-β2glycoprotein-1 antibodies, antinuclear antibody, protein C, protein S, antithrombin III, homocysteine, MTFHR gene, factor V Leiden mutation, and hysterosalphingography/hysteroscopic evaluation. RESULTS The mean age was 34.03±4.30 years, and mean number of miscarriages was 2.69±1.11 (range, 2 to 11). Anatomical cause (13.5%), chromosomal abnormalities (5.6%), and endocrine disorders (34.3%) were observed in RPL women. Elevated natural killer cell and antiphospholipid antibodies were observed in 43.3% and 7.3% each. Among of 178 women, 77 women were pregnant. After management of those women, live birth rate was 84.4% and mean gestational weeks was 37.63±5.12. Women with three or more RPL compared with women with two RPL had more common anatomical cause such as intrauterine adhesions and lower rates of spontaneous pregnancy. Compare with secondary RPL women, immunological abnormalities were more common in primary RPL. However, miscarriage rates were not different. CONCLUSION Immunological factor including autoimmune and alloimmune disorders was most common etiology of RPL. Inherited thrombophilia showed different patterns with other ethnic countries. Miscarriage rates were not different between primary and secondary RPL, or between two and three or more miscarriages group.
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18
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Dixon SG, Bruce CT, Glueck CJ, Sisk RA, Hutchins RK, Jetty V, Wang P. Retinal vascular occlusion: a window to diagnosis of familial and acquired thrombophilia and hypofibrinolysis, with important ramifications for pregnancy outcomes. Clin Ophthalmol 2016; 10:1479-86. [PMID: 27563233 PMCID: PMC4984829 DOI: 10.2147/opth.s106969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim Our specific aim was to document the pathoetiologic importance of thrombophilia among females presenting with severe ischemic retinal vein (RVO) or retinal artery (RAO) occlusion, without typical risk factors, and to emphasize that the ophthalmologists’ diagnosis of thrombophilia has important diagnostic and therapeutic downstream ramifications for nonocular thrombosis, including reproductive outcomes. Methods We evaluated familial and acquired thrombophilia in 60 females with RVO (central RVO, n=52; branch RVO, n=8) and 16 with RAO (central RAO, n=11; branch RAO, n=5). They were referred by retinologists, without typical risk factors for RVO/RAO and/or severe ocular ischemic presentation. We focused on extraocular thrombotic events, particularly pregnancy complications, including unexplained spontaneous abortion, pre-eclampsia–eclampsia. Thrombophilia measurements in the 76 females were compared with 62 healthy normal females without ocular vascular occlusions (OVOs). Results The 76 females with OVO were more likely than 62 normal female controls to have high homocysteine (24% vs 0%, P<0.0001), high anticardiolipin antibody (immunoglobulin M, 17% vs 3%, P=0.012), high (>150%) factor VIII (42% vs 11%, P<0.0001), and high (>150%) factor XI (22% vs 4%, P=0.004). Of the 76 females, 26 (34%) had ≥1 spontaneous abortion; 17 (22%) had ≥2 spontaneous abortions and/or pre-eclampsia–eclampsia. Compared to 62 healthy female controls, these 17 females with pregnancy complications had high homocysteine (29% vs 0%, P=0.0003), high anticardiolipin antibody immunoglobulin M (24% vs 3%, P=0.02), high factor VIII (38% vs 11%, P=0.02), and were marginally more likely to be heterozygous for the factor V Leiden mutation (19% vs 3%, P=0.058). Conclusion In females lacking typical risk factors for retinal vascular occlusion or severely ischemic presentation, by diagnosing thrombophilia as an etiology for OVO, the ophthalmologist opens a window to family screening and preventive therapy, with particular relevance to pregnancy outcomes and venous thromboembolism.
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Affiliation(s)
- Stephan G Dixon
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Carl T Bruce
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Charles J Glueck
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Robert A Sisk
- Cincinnati Eye Institute; Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert K Hutchins
- Cincinnati Eye Institute; Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vybhav Jetty
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
| | - Ping Wang
- Cholesterol, Metabolism, and Thrombosis Center, Jewish Hospital of Cincinnati
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19
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Shinozaki N, Ebina Y, Deguchi M, Tanimura K, Morizane M, Yamada H. Protein S deficiency complicated pregnancy in women with recurrent pregnancy loss. Gynecol Endocrinol 2016; 32:672-674. [PMID: 26941215 DOI: 10.3109/09513590.2016.1152239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This prospective study aimed to evaluate pregnancy outcome and complications in women with recurrent pregnancy loss (RPL) and protein S (PS) deficiency, who received low dose aspirin (LDA) or LDA plus heparin (LDA/H) therapies. Clinical characteristics, pregnancy outcome and complications of 38 women with two or more RPL and <60% of plasma free PS antigen were compared among three groups: antiphospholipid antibody (aPL)-negative women who received LDA (group A), aPL-negative women who received LDA/H (group B) and aPL-positive women who received LDA/H (group C). Gestational weeks (GW) at delivery in group C (median 32 GW) were earlier than 40 GW in group A and 38.5 GW in group B (p < 0.05). The birth weight in group C (median 1794 g) was less than 2855 g in group B (p < 0.05). The incidences of fetal growth restriction (37.5%), pregnancy-induced hypertension (37.5%), and preterm delivery (62.5%) in group C were higher than those (4.5%, 0%, and 4.5%, respectively) in group B (p<0.05). Women with RPL, PS deficiency, and positive aPL had high risks for adverse pregnancy outcome and complications, even when they received LDA/H therapy. Among women with RPL, PS, and negative aPL, there was no difference in these risks between LDA alone and LDA/H therapies.
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Affiliation(s)
- Nanae Shinozaki
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Yasuhiko Ebina
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Masashi Deguchi
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Kenji Tanimura
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Mayumi Morizane
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Hideto Yamada
- a Department of Obstetrics and Gynecology , Kobe University Graduate School of Medicine , Kobe , Japan
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Luna RL, Vasconcelos AG, Nunes AKS, de Oliveira WH, Barbosa KPDS, Peixoto CA. Effects of Sildenafil Citrate and Heparin Treatments on Placental Cell Morphology in a Murine Model of Pregnancy Loss. Cells Tissues Organs 2016; 201:193-202. [PMID: 26978649 DOI: 10.1159/000444123] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 11/19/2022] Open
Abstract
Lipopolysaccharide (LPS) injections during pregnancy are well established as models for pregnancy complications, including fetal growth restriction (FGR), thrombophilia, preterm labor and abortion. Indeed, inflammation, as induced by LPS injection has been described as a pivotal factor in cases of miscarriage related to placental tissue damage. The phosphodiesterase-5 inhibitor sildenafil (Viagra®) is currently used to treat FGR cases in women, while low-molecular weight heparin (Fragmin®) is a standard treatment for recurrent miscarriage (RM). However, the pathways and cellular dynamics involved in RM are not completely understood. The aim of this study was to evaluate the protective effect of sildenafil and dalteparin in a mouse model of LPS-induced abortion. Histopathology, ultrastructural analysis and immunofluorescence for P-selectin were studied in two different placental cell types: trophoblast cells and labyrinth endothelial cells. Treatment with sildenafil either alone or in combination with heparin showed the best response against LPS-induced injury during pregnancy. In conclusion, our results support the use of these drugs as future therapeutic agents that may protect the placenta against inflammatory injury in RM events. Analyses of the ultrastructure and placental immunophysiology are important to understand the mechanism underlying RM. These findings may spark future studies and aid in the development of new therapies in cases of RM.
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Affiliation(s)
- Rayana Leal Luna
- Ultrastructure Laboratory, Aggeu Magalhx00E3;es Research Center, Oswaldo Cruz Foundation, Recife, Brazil
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21
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Toth B, Würfel W, Bohlmann MK, Gillessen-Kaesbach G, Nawroth F, Rogenhofer N, Tempfer C, Wischmann T, von Wolff M. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG (S1-Level, AWMF Registry No. 015/050, December 2013). Geburtshilfe Frauenheilkd 2015; 75:1117-1129. [PMID: 26997666 DOI: 10.1055/s-0035-1558299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Purpose: Official guideline coordinated and published by the German Society of Gynecology and Obstetrics (DGGG). Aim of the guideline was to standardize the diagnosis and treatment of patients with recurrent miscarriage (RM). Recommendations were proposed, based on the current national and international literature and the experience of the involved physicians. Consistent definitions, objective assessments and standardized therapy were applied. Methods: Members of the different involved societies developed a consensus in an informal process based on the current literature. The consensus was subsequently approved by the heads of the scientific societies. Recommendations: Recommendations for the diagnosis and treatment of patients with RM were compiled which took the importance of established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders into consideration.
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Affiliation(s)
- B Toth
- Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Universitätsfrauenklinik Heidelberg, Heidelberg
| | - W Würfel
- Kinderwunsch Centrum München-Pasing, München
| | - M K Bohlmann
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Mannheim, Mannheim
| | | | - F Nawroth
- Facharzt-Zentrum für Kinderwunsch, Pränatale Medizin, Endokrinologie und Osteologie, Hamburg
| | - N Rogenhofer
- Hormon und Kinderwunschzentrum der Ludwig-Maximilians-Universität München, München
| | - C Tempfer
- Universitätsfrauenklinik der Ruhr-Universität Bochum, Marienhospital Herne, Herne
| | - T Wischmann
- Institut für Medizinische Psychologie im Zentrum für Psychosoziale Medizin des Universitätsklinikums Heidelberg, Heidelberg
| | - M von Wolff
- Inselspital, Universitätsfrauenklinik, Abteilung Gynäkologische Endokrinologie und Reproduktionsmedizin, Bern, Switzerland
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Shomer E, Katzenell S, Zipori Y, Rebibo-Sabbah A, Brenner B, Aharon A. Microvesicles of pregnant women receiving low molecular weight heparin improve trophoblast function. Thromb Res 2015; 137:141-147. [PMID: 26639203 DOI: 10.1016/j.thromres.2015.11.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/16/2015] [Accepted: 11/18/2015] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Microvesicles including exosomes and microparticles, participate in the placental-maternal crosstalk in normal pregnancies and gestational vascular complications (GVC). Low molecular weight heparin (LMWH) is known to reduce the risk of placenta-mediated pregnancy complications. This study was aimed to characterize microvesicles of pregnant women receiving LMWH and explore microvesicle involvement in trophoblast and endothelial cell function. MATERIALS AND METHODS Microvesicles were isolated from blood samples obtained from non-pregnant women, healthy pregnant women (HP) and pregnant woman treated with LMWH. Microvesicle protein contents were assessed by protein array and ELISA. Microvesicle effects on early stage trophoblasts, term trophoblasts and endothelial cell migration, angiogenesis and apoptosis were evaluated. RESULTS Microvesicles derived from the group treated with LMWH contained higher levels of several proangiogenic proteins compared to those of HP women. Exposure of endothelial cells to circulating microvesicles derived from HP and LMWH treated groups induced significantly higher cell migration and branch tube formation compared to untreated cells. The effect of microvesicles from HP- and LMWH groups on early-stage trophoblast migration was similar. Microvesicles derived from these two study groups significantly decreased early-stage trophoblast apoptosis, while microvesicles derived from the HP-group (but not from the LMWH-group) significantly increased the term trophoblast apoptosis (TUNEL assay) compared to untreated cells. CONCLUSION Therapy with LMWH affects patients' microvesicle content, leading to normalization of invasion, angiogenesis activity and survival of endothelial and trophoblast cells in vitro. The effects of LMWH on microvesicles may point to an additional mechanism of heparin action in high-risk pregnancy.
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Affiliation(s)
- Einat Shomer
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Rambam Health Care Campus, Haifa, Israel
| | - Sarah Katzenell
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Rambam Health Care Campus, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Annie Rebibo-Sabbah
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Benjamin Brenner
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Anat Aharon
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel.
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Sildenafil (Viagra®) blocks inflammatory injury in LPS-induced mouse abortion: A potential prophylactic treatment against acute pregnancy loss? Placenta 2015; 36:1122-9. [PMID: 26303758 DOI: 10.1016/j.placenta.2015.07.133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/24/2015] [Accepted: 07/30/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Recurrent pregnancy losses (RPL) are common women's health issues. Inflammatory and thrombotic events have been associated with RPL including excessive production of cytokines, in particular TNF-α. However, mechanisms behind gestational losses are not yet fully understood. Sildenafil inhibits phosphodiesterase Type-5 (PDE5). This drug increases intracellular cyclic guanosine monophosphate, having vasodilatory and, more recently described, anti-inflammatory properties. PDE5 is present in murine and human uterus and placenta. Sildenafil is already used clinically for treatment of human fetal growth restriction (FGR). Our objective was to determine if Sildenafil alone or in combination with Heparin had protective effects in pregnant Swiss albino challenged to abort by lipopolysaccharide (LPS). METHODS Treatments (Sildenafil (50 mg/kg/day), Heparin (500 IU/Kg/day) or Sildenafil + Heparin at the same doses) were initiated the morning of copulation plug detection (gestational day (gd0)). On the 15th day of pregnancy, an intra-peritoneal injection of LPS (100 μg/kg) was administered. Untreated, pregnant mice challenged by LPS served as controls. RESULTS Assessments at 48 h after LPS revealed that Sildenafil + Heparin prevented fetal loss. Early assessments at 2 h after LPS indicated that the pretreatments prevented induction of inflammatory cytokine production (TNF-α, IL-1β/NF-κβ) and preserved placental histopathology. DISCUSSION Combined Sildenafil + Heparin therapy was superior to either treatment alone in most analyses. The known safety of Sildenafil and Heparin in human pregnancy suggests that usage of these combined agents may be of value for treatment of patients with impending pregnancy loss or prophylactically in women with a history of recurrent miscarriages.
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de Jong PG, Quenby S, Bloemenkamp KWM, Braams-Lisman BAM, de Bruin JP, Coomarasamy A, David M, DeSancho MT, van der Heijden OWH, Hoek A, Hutten BA, Jochmans K, Koks CAM, Kuchenbecker WKM, Mol BWJ, Torrance HL, Scheepers HCJ, Stephenson MD, Verhoeve HR, Visser J, de Vries JIP, Goddijn M, Middeldorp S. ALIFE2 study: low-molecular-weight heparin for women with recurrent miscarriage and inherited thrombophilia--study protocol for a randomized controlled trial. Trials 2015; 16:208. [PMID: 25947329 PMCID: PMC4453290 DOI: 10.1186/s13063-015-0719-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A large number of studies have shown an association between inherited thrombophilia and recurrent miscarriage. It has been hypothesized that anticoagulant therapy might reduce the number of miscarriages and stillbirth in these women. In the absence of randomized controlled trials evaluating the efficacy of anticoagulant therapy in women with inherited thrombophilia and recurrent miscarriage, a randomized trial with adequate power that addresses this question is needed. The objective of the ALIFE2 study is therefore to evaluate the efficacy of low-molecular-weight heparin (LMWH) in women with inherited thrombophilia and recurrent miscarriage, with live birth as the primary outcome. METHODS/DESIGN Randomized study of LMWH plus standard pregnancy surveillance versus standard pregnancy surveillance alone. STUDY POPULATION pregnant women of less than 7 weeks' gestation, and confirmed inherited thrombophilia with a history of 2 or more miscarriages or intra-uterine fetal deaths, or both. SETTING multi-center study in centers from the Dutch Consortium of Fertility studies; centers outside the Netherlands are currently preparing to participate. INTERVENTION LMWH enoxaparin 40 mg subcutaneously once daily started prior to 7 weeks gestational age plus standard pregnancy surveillance or standard pregnancy surveillance alone. Main study parameters/endpoints: the primary efficacy outcome is live birth. Secondary efficacy outcomes include adverse pregnancy outcomes, such as miscarriage, pre-eclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP syndrome), fetal growth restriction, placental abruption, premature delivery and congenital malformations. Safety outcomes include bleeding episodes, thrombocytopenia and skin reactions. DISCUSSION After an initial period of slow recruitment, the recruitment rate for the study has increased. Improved awareness of the study and acknowledgement of the need for evidence are thought to be contributing to the improved recruitment rates. We aim to increase the number of recruiting centers in order to increase enrollment into the ALIFE2 study. The study website can be accessed via www.ALIFE2study.org. TRIAL REGISTRATION The ALIFE2 study was registered on 19 March 2012 under registration number NTR3361.
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Affiliation(s)
- Paulien G de Jong
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Siobhan Quenby
- Division of Reproductive Health, Warwick Medical School, The University of Warwick, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Kitty W M Bloemenkamp
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Babette A M Braams-Lisman
- Division Woman, Mother and Child, Tergooiziekenhuis, Rijksstraatweg 1, 1261 AN, Blaricum, the Netherlands.
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Ziekenhuis, Henri Dunantstraat 1, 5223, GZ s-Hertogenbosch, the Netherlands.
| | - Arri Coomarasamy
- Department of Gynaecology, Birmingham Women's Hospital and School of Clinical and Experimental Medicine, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK.
| | - Michele David
- Division of Hematology, CHU Ste-Justine, University of Montreal, 3175 Cote Ste-Catherine, Montreal, H3T 1C5, , QC, Canada.
| | - Maria T DeSancho
- Hematology - Medical Oncology Division, Department of Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, 1305 York Avenue 7th Floor Room 51, New York, NY, 10021, USA.
| | - Olivier W H van der Heijden
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Annemieke Hoek
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Kristin Jochmans
- Department of Hematology and Hemostasis, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Carolien A M Koks
- Department of Obstetrics and Gynecology, Máxima Medical Center, De Run 4600, Postbus 7777, 5500MB, Veldhoven, the Netherlands.
| | - Walter K M Kuchenbecker
- Department of Obstetrics and Gynecology, Isala Klinieken, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands.
| | - Ben Willem J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, 5000, , SA, Australia.
| | - Helen L Torrance
- Division Woman & Baby, University Medical Center Utrecht, Postbus 85090, 3508 AB, Utrecht, the Netherlands.
| | - Hubertina C J Scheepers
- Department of Gynecology and Obstetrics at Maastricht University Medical Centre, P Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - Mary D Stephenson
- Department of Obstetrics and Gynecology, University of Illinois College of Medicine, 820 S Wood Street, M/C 808, Chicago, IL, USA.
| | - Harold R Verhoeve
- Department of Obstetrics & Gynecology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands.
| | - Jantien Visser
- Department of Obstetrics, Gynecology and Reproductive Medicine, Amphia Hospital, Langendijk 75, 4819EV, Breda, the Netherlands.
| | - Johanna I P de Vries
- Department of Obstetrics, Vrije Universiteit Medical Center, PO Box 7057, , 1007 MB, Amsterdam, the Netherlands.
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Garrido-Gimenez C, Alijotas-Reig J. Recurrent miscarriage: causes, evaluation and management. Postgrad Med J 2015; 91:151-62. [DOI: 10.1136/postgradmedj-2014-132672] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Several aspects of the diagnostic and therapeutic management of women with venous thrombosis are uncertain, because of the absence of adequately sized observational or intervention studies. Here, I will discuss the rationale and design of two currently ongoing investigator-initiated, international, randomized controlled trials of LMWHin pregnancy. The Highlow study (www.highlowstudy.org; NCT Clinicaltrials.gov) 01828697) investigates two doses of low-molecular-weight heparin to prevent recurrent venous thromboembolism (VTE) in pregnant women with a history of VTE. The ALIFE2 study (www.alife2study.org; www.trialregister.nl, NTR 3361) investigates the effect of LMWH on live birth in women with inherited thrombophilia and two or more miscarriages.
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Affiliation(s)
- Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Abstract
Human reproduction is remarkably inefficient; nearly 70% of human conceptions do not survive to live birth. Spontaneous fetal aneuploidy is the most common cause for spontaneous loss, particularly in the first trimester of pregnancy. Although losses owing to de novo fetal aneuploidy occur at similar frequencies among women with sporadic and recurrent losses, some couples with recurrent pregnancy loss have additional associated genetic factors and some have nongenetic etiologies. Genetic testing of the products of conception from couples experiencing two or more losses may aid in defining the underlying etiology and in counseling patients about prognosis in a subsequent pregnancy. Parental karyotyping of couples who have experienced recurrent pregnancy loss (RPL) will detect some couples with an increased likelihood of recurrent fetal aneuploidy; this may direct interventions. The utility of preimplantation genetic analysis in couples with RPL is unproven, but new approaches to this testing show great promise.
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Affiliation(s)
- Kassie J Hyde
- University of Missouri School of Medicine, Columbia, Missouri 65201
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri School of Medicine, Columbia, Missouri 65201
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Di Ciaula A, Bilancia M. Relationships between mild PM10 and ozone urban air levels and spontaneous abortion: clues for primary prevention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2015; 25:640-55. [PMID: 25609560 DOI: 10.1080/09603123.2014.1003041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The effects of environmental pollution on spontaneous abortion (SAB) are still unclear. Records of SAB were collected from five cities (514,996 residents) and correlated with PM10, NO(2) and ozone levels. Median pollutant concentrations were below legal limits. Monthly SABs positively correlated with PM10 and ozone levels but not with NO(2) levels. The mean monthly SAB rate increase was estimated equal to 19.7 and 33.6 % per 10 μg/m(3) increase in PM10 or ozone concentration, respectively. Higher values of PM10 and SABs were evident in cities with- than in those without pollutant industries, with a number of SABs twofolds higher in the former group. In conclusion, SAB occurrence is affected by PM10 (particularly if industrial areas are present) and ozone concentrations, also at levels below the legal limits. Thus, SAB might be considered, at least in part, a preventable condition.
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Affiliation(s)
- Agostino Di Ciaula
- a Division of Internal Medicine, Hospital of Bisceglie (ASL BAT), International Society of Doctors for Environment (ISDE) , Italy
| | - Massimo Bilancia
- b Ionic Department in Legal and Economic System of Mediterranean: Society, Environment, Culture , University of Bari Aldo Moro , Bari , Italy
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Middeldorp S. Anticoagulation in pregnancy complications. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:393-399. [PMID: 25696884 DOI: 10.1182/asheducation-2014.1.393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Women with acquired and inherited thrombophilia are thought to be at increased risk for pregnancy complications, including recurrent pregnancy loss and, depending on the type of thrombophilia, severe preeclampsia. This review discusses the associations between the types of thrombophilia and types of complications, as well as the currently available clinical trial evidence regarding the use of aspirin and heparin to prevent these pregnancy complications. In women with antiphospholipid syndrome, guidelines recommend prescribing aspirin and heparin to women with recurrent miscarriage. The same regimen is suggested for late pregnancy complications by some, but not all, experts. Aspirin or low-molecular-weight heparin to improve pregnancy outcome in women with unexplained recurrent miscarriage has no benefit and should not be prescribed. Whether anticoagulant therapy prevents recurrent miscarriage in women with inherited thrombophilia or in women with severe pregnancy complications remains controversial because of inconsistent results from trials. Aspirin modestly decreases the risk of severe preeclampsia in women at high risk.
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Affiliation(s)
- Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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de Jesus GR, Agmon-Levin N, Andrade CA, Andreoli L, Chighizola CB, Porter TF, Salmon J, Silver RM, Tincani A, Branch DW. 14th International Congress on Antiphospholipid Antibodies Task Force report on obstetric antiphospholipid syndrome. Autoimmun Rev 2014; 13:795-813. [PMID: 24650941 DOI: 10.1016/j.autrev.2014.02.003] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/17/2014] [Indexed: 01/12/2023]
Abstract
Pregnancy morbidity is one of the clinical manifestations used for classification criteria of antiphospholipid syndrome (APS). During the 14th International Congress on Antiphospholipid Antibodies (aPL), a Task Force with internationally-known experts was created to carry out a critical appraisal of the literature available regarding the association of aPL with obstetric manifestations present in actual classification criteria (recurrent early miscarriage, fetal death, preeclampsia and placental insufficiency) and the quality of the evidence that treatment(s) provide benefit in terms of avoiding recurrent adverse obstetric outcomes. The association of infertility with aPL and the effectiveness of the treatment of patients with infertility and positive aPL was also investigated. This report presents current knowledge and limitations of published studies regarding pregnancy morbidity, infertility and aPL, identifying areas that need better investigative efforts and proposing how critical flaws could be avoided in future studies, as suggested by participants of the Task Force. Except for fetal death, there are limitations in the quality of the data supporting the association of aPL with obstetric complications included in the current APS classification criteria. Recommended treatments for all pregnancy morbidity associated to APS also lack well-designed studies to confirm its efficacy. APL does not seem to be associated with infertility and treatment does not improve the outcomes in infertile patients with aPL. In another section of the Task Force, Dr. Jane Salmon reviewed complement-mediated inflammation in reproductive failure in APS, considering new therapeutic targets to obstetric APS (Ob APS).
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Affiliation(s)
- Guilherme R de Jesus
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carlos A Andrade
- Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Immunorheumatological Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - T Flint Porter
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA; Intermountain Healthcare, Salt Lake City, USA
| | - Jane Salmon
- Hospital For Special Surgery, Weill Cornell Medical College, NY, USA; Kirkland Center for Lupus Research, NY, USA; Lupus and APS Center of Excellence, NY, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of UT, Salt Lake City, USA; Intermountain Healthcare, Salt Lake City, USA
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