Reproductive Outcomes Following Recurrent First Trimester Miscarriage: A Retrospective Cohort Study

STUDY QUESTION

What are the subsequent reproductive outcomes (livebirths, miscarriages or other adverse pregnancy outcomes or no further pregnancy) of women with recurrent miscarriage (RM) attending a dedicated clinic?

SUMMARY ANSWER

Of women with RM, 77% had a subsequent pregnancy, and among these pregnancies, the livebirth rate was 63%.

WHAT IS KNOWN ALREADY

RM affects ∼1–3% of women of reproductive age. RM has known associations with advanced maternal age, obesity, diabetes, inherited thrombophilias, thyroid dysfunction, endometriosis and parental balanced translocations. However, ∼ 50% of women or couples will be left without an explanation for their pregnancy loss, even after completing investigations. RM is also associated with secondary infertility and adverse pregnancy outcomes including preterm birth and perinatal death.

STUDY DESIGN, SIZE, DURATION

We undertook a retrospective cohort study to identify subsequent pregnancy outcomes in women with RM, defined as three consecutive first-trimester miscarriages. Women attending the RM clinic at a tertiary university hospital in the Republic of Ireland over 12 years (2008–2020) with a confirmed diagnosis of primary or secondary first-trimester RM were eligible for inclusion. In total, 923 charts were identified for review against the eligibility criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with non-consecutive first-trimester miscarriages or ectopic pregnancy were excluded. Epidemiological and clinical information regarding medical history, investigation and management was gathered from paper and electronic medical records. Data were analysed using SPSS (Version 27). Associations between maternal characteristics and outcomes were explored using the χ² test, with significance set at P < 0.05. Multinomial regression analysis was performed using a stepwise approach.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 748 women who were included; 332 (44%) had primary RM and 416 (56%) had secondary RM. The median age was 36 years (range 19–47). Foetal aneuploidy was the most common investigative finding (15%; n = 111/748); 60% had unexplained RM. In addition to supportive care, most women were prescribed aspirin (96%) and folic acid (75%). Of the 748 women, 573 had a subsequent pregnancy (77%) and 359 (48% of all women; 63% of pregnancies) had a livebirth, while 208 had a further pregnancy loss (28% of all women; 36% of pregnancies) and 6 were still pregnant at the end of the study. Women aged 35–39 years were more likely to have a livebirth than no further pregnancy (relative risk ratio (RRR): 2.29 (95% CI: 1.51–5.30)). Women aged 30–34 years were more likely to have a livebirth (RRR: 3.74 (95% CI: 1.80–7.79)) or a miscarriage (RRR: 2.32 (95% CI: 1.07–4.96)) than no further pregnancy. Smokers were less likely to have a livebirth (RRR: 0.37 (95% CI: 0.20–0.69)) or a miscarriage (RRR: 0.45 (95% CI: 0.22–0.90)) than no further pregnancy. Couples with an abnormal parental karyotype were less likely to have a miscarriage than no further pregnancy (RRR: 0.09 (95% CI: 0.01–0.79)). Including successive pregnancies conceived over the study period, the overall livebirth rate was 63% (n = 466/742), but this was reduced to 44% in women aged ≥40 years and 54% in women with infertility.

LIMITATIONS, REASONS FOR CAUTION

This work covers 13 years; however, those included in the later years have a shorter follow-up time. Although electronic health records have improved data availability, data collection in this cohort remains hampered by the absence of a formal booking visit for women presenting with miscarriage and a national miscarriage database or register.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings are largely reassuring as most women with RM and hoping to conceive achieved a livebirth. In addition to older age, smoking and parental balanced translocations were associated with a reduced likelihood of further pregnancy. No investigation or treatment was associated with pregnancy outcome, reiterating the importance of the supportive aspects of care for women and their partners after RM and counselling regarding individual risk factors. This contributes to the limited international data on the investigative findings and treatment of women with RM. The high rate of prescribed medications merits greater scrutiny, in conjunction with other pregnancy outcomes, and reiterates the need for a national guideline on RM.

STUDY FUNDING/COMPETING INTEREST(S)

L.A.L. is a PhD scholar funded through the Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. M.H. and C.F. are Postdoctoral Researchers on a project funded by the Health Research Board Ireland [ILP-HSR-2019-011] and led by K.O.D., titled: ‘Study of the impact of dedicated recurrent miscarriage clinics in the Republic of Ireland’. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

P-393 The care experiences of women and men who have received recurrent miscarriage care in Ireland: a national survey

Study question

What are the care experiences of women and men who have received recurrent miscarriage (RM) care in the Republic of Ireland?

Summary answer

Of the participants, 24% rated a poor experience of RM care (n = 32), while 36% said the care they received was much worse than expected (n = 48).

What is known already

International guidelines suggest that couples who experience RM should be referred for specialist investigations, support and, if possible, treatment. Providing individualised care, respect for women’s opinions, and appropriate clinical information is imperative to those experiencing RM. However, currently, there is no national standard for the management, investigation, or follow-up of those who experience RM in Ireland. Research on patient-centred early pregnancy care concluded that it is essential for healthcare professionals (HCPs) to realise that women undergoing miscarriage experience a significant life event and recommended that future studies explore potential targets for improving RM care and patients’ perspectives.

Study design, size, duration

A cross-sectional study of women and men who have experienced RM was conducted. An anonymous web-based national survey was used to examine the experience of those who have interacted with the maternity services following RM. The survey was distributed online using Qualtrics between September – November 2021. The survey was shared through emails, websites, newsletters, and social media accounts as well as the Pregnancy Loss Research Group and the Miscarriage Association of Ireland among others.

Participants/materials, setting, methods

Women and men over 18 who have experienced two≥ first trimester miscarriages in the last ten years and who have received care for RM in the Republic of Ireland were invited to participate in the survey. The survey was purposefully designed using relevant literature, including questions on key areas such as sociodemographic information, pregnancy and pregnancy loss history, investigation and treatment for RM. Descriptive statistics and subgroup analysis are ongoing using Stata.

Main results and the role of chance

In total, 213 participants completed the survey (some did not experience a consecutive RM or receive care between 2011-2021 (n = 65)). Therefore, 147 participants were eligible (97% female, n = 135). Of the female participants, 79% were aged 35-44 years (n = 106), 95% were white Irish (n = 128) and 84% were married (n = 114). Women were educated, with 38% having postgraduate degrees (n = 53) or a university degree (27%, n = 36). 57% had experienced two consecutive RM (n = 77) and 25% three consecutive RM (n = 34). Of the 135 women, 53% had investigations for RM (n = 71), with 45% having investigations after two RM (n = 32) or 27% after three RM (26). When asked if their HCP did everything to investigate their RM, 49% said no. Of those who had investigations (n = 71), 83% always had confidence and trust in their HCP (n = 59), and 42% felt treated with dignity and respect (n = 30). However, 44% did not have a HCP to talk to about their worries and fears (n = 31). 24% of women rated a poor experience when receiving RM care (n = 32), 36% said the care they received was much worse than expected (n = 48), with 60% of women saying that HCPs in different places did not work well together during their RM care (n = 81).

Limitations, reasons for caution

Despite an open call to recruit women and men, only four men participated. Therefore, further research needs to include strategies to recruit men to provide a complete picture of RM care experiences. There is also the potential for recall bias as some women received care several years ago.

Wider implications of the findings

This study demonstrates that the overall experience for RM care is poor, providing areas for improvements such as communication and better care coordination between HCPs across hospitals/units. These results provide a better understanding of the drivers shaping care experiences to help inform and improve RM care in Ireland.

Trial registration number

not applicable

P-376 Estimating the costs associated with the implementation of a best practice model of care for recurrent miscarriage clinics in Ireland: a cost analysis

Study question

What are the potential costs to the Irish healthcare system of implementing a ‘best practice’ model of care for recurrent miscarriage clinics?

Summary answer

Total cost for RM patients ranges from €1,634.19 to €4,817.87 for a pregnancy outcome and from €1,245.77 to €4,317.87 for women who do not conceive.

What is known already

Recurrent miscarriage (RM) affects 1% -5% of the reproductive age population. It is recognised that the best care for RM is offered in a dedicated recurrent miscarriage clinic (RMC). While RM represents a significant burden to couples, the setup of RMCs involves substantial resource costs. This study reports on the cost impact to the Irish healthcare system of implementing a ‘best practice’ model of care for RMCs. Evidence from cost analysis plays an important role in informing the cost-effectiveness of interventions ensuring that those available resources are used efficiently, as health policymakers plan for future healthcare services.

Study design, size, duration

A micro-costing approach was employed using a range of data sources to identify, measure, and value the resources required to implement the proposed model of care. Data was collected from March – September 2021. The cost analysis was calculated using the following components: 1. The initial set up costs of a best practice RMC, 2. The ongoing implementation costs of delivering a best practice RMC, and 3. The subsequent and related care pathway costs.

Participants/materials, setting, methods

Per patient costs were estimated within a best practice RMC using two scenarios (a typical versus a complex RM case). The cost estimates were extrapolated to estimate the cost impact to the Irish healthcare care system over a 1-year period using population data and published prevalence rates for RM. A sensitivity analysis was performed to control for the uncertainty in each of the parameters.

Main results and the role of chance

The total cost to set up a best practice RMC is €37,321. The yearly on-going delivery cost is €6,212.25. The total cost for a RM patient who has another pregnancy after receiving investigations, treatment and reassurance scans ranges between €1,634.19 (typical) and €4,817.87 (complex). For a RM patient who does not conceive again, costs range from €1,245.77 (typical) to €4,317.87 (complex). Using population estimates, the total budget impact to the health service for women who experience ≥2 losses costs €61,927,630 (typical) /€20,336,229 (complex) for a pregnancy outcome and €22,480,630 (typical)/€7,78,437 (complex) for women who do not conceive. Sensitivity analysis identified RM investigations and treatments costs as the main cost drivers for per-patient costs.

Limitations, reasons for caution

With only six RMCs operating in Ireland, calculating costs savings was not possible. A fixed number of investigations and treatments for patient scenarios were applied. In a real-world setting, investigations and treatments will vary significantly by patient need, risk factors and previous history of loss, directly impacting the costs reported.

Wider implications of the findings

This study proposes a model of care for RMCs in Ireland, providing cost estimates at the patient and healthcare system level. While future studies should consider the cost-effectiveness of this model of care, this analysis provides a valuable first step in providing a breakdown of the resources and costs.

Trial registration number

Not applicable

46, XX Male Disorder of Sexual Development

Presentation A 47-year-old male was referred to endocrinology with a 9-year history of primary hypogonadism. Baseline testosterone was 4.3 nmol/L (RR 8-30) with an elevated follicle stimulating hormone (17.5 IU/L) and luteinizing hormone (15.2 mIU/ml). He had a short stature with bilateral small pre-pubertal testicles. Diagnosis Karyotyping showed 46 XX, making a diagnosis of 46, XX male disorder of sexual development. Fluorescence in situ hybridization analysis identified the presence of a translocated sex-determining region Y gene. Treatment Testosterone replacement therapy (testogel). Monitoring blood markers affected by testosterone therapy and metabolic risk factors. Conclusion Primary hypogonadism in males can be divided into congenital and acquired causes. 46, XX male disorder of sexual development is a rare congenital cause, with an incidence of approximately 1 in 20,000 newborn males. This case report highlights the value of karyotyping in the workup for primary hypogonadism.

Enablers and barriers to physical activity in overweight and obese pregnant women: an analysis informed by the theoretical domains framework and COM-B model

Background

Obesity during pregnancy is associated with increased risk of gestational diabetes mellitus (GDM) and other complications. Physical activity is a modifiable lifestyle factor that may help to prevent these complications but many women reduce their physical activity levels during pregnancy. Interventions targeting physical activity in pregnancy are on-going but few identify the underlying behaviour change mechanisms by which the intervention is expected to work. To enhance intervention effectiveness, recent tools in behavioural science such as the Theoretical Domains Framework (TDF) and COM-B model (capability, opportunity, motivation and behaviour) have been employed to understand behaviours for intervention development. Using these behaviour change methods, this study aimed to identify the enablers and barriers to physical activity in overweight and obese pregnant women.

Methods

Semi-structured interviews were conducted with a purposive sample of overweight and obese women at different stages of pregnancy attending a public antenatal clinic in a large academic maternity hospital in Cork, Ireland. Interviews were recorded and transcribed into NVivo V.10 software. Data analysis followed the framework approach, drawing on the TDF and the COM-B model.

Results

Twenty one themes were identified and these mapped directly on to the COM-B model of behaviour change and ten of the TDF domains. Having the social opportunity to engage in physical activity was identified as an enabler; pregnant women suggested being active was easier when supported by their partners. Knowledge was a commonly reported barrier with women lacking information on safe activities during pregnancy and describing the information received from their midwife as ‘limited’. Having the physical capability and physical opportunity to carry out physical activity were also identified as barriers; experiencing pain, a lack of time, having other children, and working prevented women from being active.

Conclusion

A wide range of barriers and enablers were identified which influenced women’s capability, motivation and opportunity to engage in physical activity with “knowledge” as the most commonly reported barrier. This study is a theoretical starting point in making a ‘behavioural diagnoses’ and the results will be used to inform the development of an intervention to increase physical activity levels among overweight and obese pregnant women.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1816-z) contains supplementary material, which is available to authorized users.

Investigating the Perceived Benefits, Barriers and Beliefs towards Physical Activity in Pregnancy among Women with Gestational Diabetes Mellitus

Gestational Diabetes Mellitus (GDM) is a growing concern and poses serious health risks to both mother and child1. The current study explores the psychological determinants of exercise behaviour in a sample of pregnant women with GDM. A cross-sectional survey design was employed to examine exercise behaviour, illness perceptions, perceived barriers and benefits, exercise beliefs, and exercise self-efficacy using validated questionnaires. A sample of 46 pregnant women was recruited from University College Hospital Galway, Letterkenny General Hospital, Cork University Hospital and Mayo General Hospital in Castlebar. Participant's varied; age (22-44 years), body mass index (19-41). High mean scores for Personal Control (24.5) and Treatment Control (30.2) subscales indicated strongly held positive beliefs in relation to controllability of the illness. Total MET-min/week score was not related to any psychological variables. Analysis of the IPQ-R data revealed 'diet' (n=37, 80.4%) as the most referred to cause of diabetes. Exercise belief data identified "managing weight gain" (n= 21, 45.7%), and "losing baby weight" (n= 31, 67.4%) as the most frequent beliefs for engaging in physical activity during pregnancy and post pregnancy. Further research on the psychological determinants of physical activity behaviour among this population group is needed in order to create successful intervention strategies.

Knockdown of the gene encoding Drosophila tribbles homologue 3 (Trib3) improves insulin sensitivity through peroxisome proliferator-activated receptor-γ (PPAR-γ) activation in a rat model of insulin resistance

AIMS/HYPOTHESIS

Insulin action is purportedly modulated by Drosophila tribbles homologue 3 (TRIB3), which in vitro prevents thymoma viral proto-oncogene (AKT) and peroxisome proliferator-activated receptor-γ (PPAR-γ) activation. However, the physiological impact of TRIB3 action in vivo remains controversial.

METHODS

We investigated the role of TRIB3 in rats treated with either a control or Trib3 antisense oligonucleotide (ASO). Tissue-specific insulin sensitivity was assessed in vivo using a euglycaemic-hyperinsulinaemic clamp. A separate group was treated with the PPAR-γ antagonist bisphenol-A-diglycidyl ether (BADGE) to assess the role of PPAR-γ in mediating the response to Trib3 ASO.

RESULTS

Trib3 ASO treatment specifically reduced Trib3 expression by 70% to 80% in liver and white adipose tissue. Fasting plasma glucose, insulin concentrations and basal rate of endogenous glucose production were unchanged. However, Trib3 ASO increased insulin-stimulated whole-body glucose uptake by ~50% during the euglycaemic-hyperinsulinaemic clamp. This was attributable to improved skeletal muscle glucose uptake. Despite the reduction of Trib3 expression, AKT2 activity was not increased. Trib3 ASO increased white adipose tissue mass by 70% and expression of Ppar-γ and its key target genes, raising the possibility that Trib3 ASO improves insulin sensitivity primarily in a PPAR-γ-dependent manner. Co-treatment with BADGE blunted the expansion of white adipose tissue and abrogated the insulin-sensitising effects of Trib3 ASO. Finally, Trib3 ASO also increased plasma HDL-cholesterol, a change that persisted with BADGE co-treatment.

CONCLUSIONS/INTERPRETATION

These data suggest that TRIB3 inhibition improves insulin sensitivity in vivo primarily in a PPAR-γ-dependent manner and without any change in AKT2 activity.

Variability in the G3 domain content of bovine aggrecan from cartilage extracts and chondrocyte cultures

The content of the globular domains G1, G2 and G3 on the core protein of high-density (A1D1) aggrecan isolated from newborn and mature bovine cartilage and from cultures of bovine chondrocytes was examined. Quantitation based on the 220 nm absorbance of tryptic marker peptides from each domain isolated by reversed-phase HPLC showed that while the content of G1 and G2 was essentially the same for all samples, the content of G3 varied markedly. The molar yield of G3 and G1 marker peptides indicated that approximately 55% of the G1-bearing aggrecan from immature cartilage carried the G3 domain, while for mature cartilage this figure was markedly reduced, at about 35%. Aggrecan prepared from the cell layer matrix of calf chondrocyte cultures had an apparent G3 content similar to newborn cartilage (55%), whereas aggrecan prepared from the medium of these cultures had a markedly higher G3 content, at about 80%. The high content of G3 in cell medium samples compared to cartilage extracts was supported by electron microscopic analysis of A1D1 preparations. The G3 content of the two subpopulations of aggrecan present in mature cartilage and separable by flat bed agarose gel electrophoresis was also determined at about 45% (Band I) and 20% (Band II) respectively. These results are discussed in terms of the likely origin of the marked variability in the G3 domain content of aggrecan.

Suicide in later life: psychological autopsy findings

The authors report preliminary data from a psychological autopsy study of completed suicide in late life. Sixteen of 18 victims had diagnosable psychopathology, most commonly major depression of late onset. Symptoms manifest prior to death are described and directions for future investigation discussed. The psychological autopsy is shown to be a viable method for studying suicide in the elderly.