Fondaparinux Results in Similar Pregnancy Outcomes with Lower Adverse Reaction Rates Compared to Low Molecular Weight Heparin in Chinese Recurrent Miscarriage Women

Fondaparinux inhibits thrombin generation by inactivating factor Xa, which has the potential to treat recurrent miscarriage (RM). However, more clinical evidence is required to support its application in Chinese women with RM. This research aimed to compare the live birth rate, gestational weeks at delivery, birth weight, Apgar score of newborns, and adverse reaction rates between fondaparinux and low molecular weight heparin (LMWH) in Chinese women with RM. Totally, 132 women with RM treated with fondaparinux or LMWH were included in this retrospective study. According to the corresponding treatment, women with RM were divided into the fondaparinux cohort (N = 45) and LMWH cohort (N = 87). The live birth rate was 68.9% in the fondaparinux cohort and 56.3% in the LMWH cohort, which was not different between the two cohorts (P = 0.161). Multivariable logistics regression analysis suggested that only previous miscarriage times (≥ 4 times vs. < 4 times) were independently related to a lower possibility of live birth in women with RM (odds ratio = 0.431, P = 0.036). It was also observed that gestational weeks at delivery (38.1 ± 1.4 vs. 37.7 ± 1.7 weeks) (P = 0.258), birth weight (2,923.7 ± 355.0 vs. 2,807.8 ± 334.0 g) (P = 0.144), and Apgar score of newborns (9.8 ± 0.5 vs. 9.6 ± 0.8) (P = 0.175) were not different between the fondaparinux cohort and LMWH cohort. Inspiringly, the total adverse reaction rate was reduced in the fondaparinux cohort vs. the LMWH cohort (20.0% vs. 37.9%) (P = 0.036). Fondaparinux results in similar pregnancy outcomes with lower adverse reaction rates compared to LMWH in Chinese women with RM.

Environmental BPDE induced human trophoblast cell apoptosis by up-regulating lnc-HZ01/p53 positive feedback loop

Human trophoblast cell apoptosis may induce miscarriage. Trophoblast cells are sensitive to environmental BaP-7,8-dihydrodiol-9,10-epoxide (BPDE). However, how BPDE induces human trophoblast cell apoptosis is still largely elusive. In this work, we used BPDE-treated human trophoblast cells and villous tissues collected from recurrent miscarriage and health control groups to explore the underlying mechanism of BPDE-induced human trophoblast cell apoptosis. Continued with our recent work, we found that lncRNA HZ01 (lnc-HZ01) could induce human trophoblast cell apoptosis. In mechanism, lnc-HZ01 up-regulated p53 expression level by suppressing its MDM2-mediated proteasomal degradation. Meanwhile, we found that p53 acted as lnc-HZ01 transcription factor and promoted lnc-HZ01 transcription. Thus, lnc-HZ01 and p53 composed a positive feedback loop in human trophoblast cells. In normal trophoblast cells, relatively low levels of lnc-HZ01 and p53 suppressed p53/caspase-3 apoptosis pathway, giving normal pregnancy. Upon BPDE exposure, BPDE up-regulated the expression levels of lnc-HZ01 and p53, triggered this positive feedback loop, activated the p53/caspase-3 apoptosis pathway, and then induced miscarriage. Collectively, we discovered new mechanism by which lnc-HZ01 regulated BPDE-induced human trophoblast cell apoptosis, providing scientific basis for the diagnosis and treatment of unexplained recurrent miscarriage.

Levothyroxine in euthyroid thyroid peroxidase antibody positive women with recurrent pregnancy loss (T4LIFE trial): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

Women positive for thyroid peroxidase antibodies (TPO-Ab) have a higher risk of recurrent pregnancy loss. Evidence on whether levothyroxine treatment improves pregnancy outcomes in women who are TPO-Ab positive women with recurrent pregnancy loss is scarce. The aim of this study was to determine if levothyroxine increases live birth rates in women who were TPO-Ab positive with recurrent pregnancy loss and normal thyroid function.

METHODS

The T4LIFE trial was an international, double-blind, placebo-controlled, phase 3 study done in 13 secondary and tertiary hospitals in the Netherlands, one tertiary hospital in Belgium, and one tertiary hospital in Denmark. Women (18-42 years) who were TPO-Ab positive, had two or more pregnancy losses, and had a thyroid stimulating hormone (TSH) concentration within the institutional reference range were eligible for inclusion. Women were excluded if they had antiphospholipid syndrome (lupus anticoagulant, anticardiolipin IgG or IgM antibodies, or β2-glycoprotein-I IgG or IgM antibodies), other autoimmune diseases, thyroid disease, previous enrolment in this trial, or contraindications for levothyroxine use. Before conception, women were randomly assigned (1:1) to receive either levothyroxine or placebo orally once daily. The daily dose of levothyroxine was based on preconception TSH concentration and ranged from 0·5-1·0 μg/kg bodyweight. Levothyroxine or placebo was continued until the end of pregnancy. The primary outcome was live birth, defined as the birth of a living child beyond 24 weeks of gestation measured in the intention-to-treat population. The trial was registered within the Netherlands Trial Register, NTR3364 and with EudraCT, 2011-001820-39.

RESULTS

Between Jan 1, 2013, and Sept 19, 2019, 187 women were included in the study: 94 (50%) were assigned to the levothyroxine group and 93 (50%) were assigned to the placebo group. The trial was prematurely stopped when 187 (78%) of the 240 predefined patients had been included because of slow recruitment. 47 (50%) women in the levothyroxine group and 45 (48%) women in the placebo group had live births (risk ratio 1·03 [95% CI 0·77 to 1·38]; absolute risk difference 1·6% [95% CI -12·7 to 15·9]). Seven (7%) women in the levothyroxine group and seven (8%) in the placebo group reported adverse events, none of them were directly related to the study procedure.

INTERPRETATION

Compared with placebo, levothyroxine treatment did not result in higher live birth rates in euthyroid women with recurrent pregnancy loss who were positive for TPO-Ab. On the basis of our findings, we do not advise routine use of levothyroxine in women who are TPO-Ab positive with recurrent pregnancy loss and normal thyroid function.

FUNDING

Dutch Organization for Health Research and Development, Fonds NutsOhra, Dutch Patient Organization of Thyroid Disorders, the Jan Dekkerstichting and Dr Ludgardine Bouwmanstichting, and a personal donation through the Dutch Patient Organization of Thyroid Disorders.

Environmental exposure to bisphenol analogues and unexplained recurrent miscarriage: A case-control study

The use of bisphenol A (BPA) has been substantially limited since 2010 due to its toxicity to human health. A group of bisphenol analogues that are structurally similar to BPA have been developed as the alternatives and used widely. The reproductive toxicity of these emerging chemicals has caused substantial concerns in recent years. Whether bisphenol analogues affect miscarriage, especially unexplained recurrent miscarriage (URM), remains to be explored. We conducted a hospital-based, case-control study with 1180 URM cases and 571 controls in China from 2014 to 2016. Concentrations of six bisphenol analogues (BPA, BPAF, BPAP, BPB, BPP and BPS) were measured in the urine samples collected at median intervals of 7.6 months after last miscarriage (interquartile ranges: 4.8, 14.7 months). Multiple logistic regression, Bayesian kernel machine regression (BKMR) and quantile g-computation (q-gcomp) were used to assess the relationship of bisphenol analogues with URM risk. We observed significantly higher levels of all urinary bisphenols in the cases than the controls. After controlling for potential confounders, bisphenol analogues were significantly associated with increased odds of URM in varying degrees. A dose-response pattern was observed for the associations of BPAF, BPAP and BPB quartiles with URM. The mixed exposure of six bisphenol analogues was positively associated with the risk of URM (adjusted odds ratio (aOR) = 1.25; 1.11-1.42), which was mainly driven by BPAP (60.1%), BPAF (25.1%) and BPA (14.8%). After age stratification, the risks tended to be higher in women aged 30 years or older, compared to women <30 years. Our large case-control study indicates that environmental exposure to bisphenol analogues is associated with an increased risk of URM. Older women may be more vulnerable to the insult.

Women's risk of repeat abortions is strongly associated with alcohol consumption: a longitudinal analysis of a Russian national panel study, 1994-2009

Abortion rates in Russia, particularly repeat abortions, are among the highest in the world, and abortion complications make a substantial contribution to the country's high maternal mortality rate. Russia also has a very high rate of hazardous alcohol use. However, the association between alcohol use and abortion in Russia remains unexplored. We investigated the longitudinal predictors of first and repeat abortion, focussing on women's alcohol use as a risk factor. Follow-up data from 2,623 women of reproductive age (16–44 years) was extracted from 14 waves of the Russian Longitudinal Monitoring Survey (RLMS), a nationally representative panel study covering the period 1994–2009. We used discrete time hazard models to estimate the probability of having a first and repeat abortion by social, demographic and health characteristics at the preceding study wave. Having a first abortion was associated with demographic factors such as age and parity, whereas repeat abortions were associated with low education and alcohol use. After adjustment for demographic and socioeconomic factors, the risk of having a repeat abortion increased significantly as women's drinking frequency increased (P<0.001), and binge drinking women were significantly more likely to have a repeat abortion than non-drinkers (OR 2.28, 95% CI 1.62–3.20). This association was not accounted for by contraceptive use or a higher risk of pregnancy. Therefore the determinants of first and repeat abortion in Russia between 1994–2009 were different. Women who had repeat abortions were distinguished by their heavier and more frequent alcohol use. The mechanism for the association is not well understood but could be explained by unmeasured personality factors, such as risk taking, or social non-conformity increasing the risk of unplanned pregnancy. Heavy or frequent drinkers constitute a particularly high risk group for repeat abortion, who could be targeted in prevention efforts.

Analysis of sperm karyotypes in a patient treated with griseofulvin

Griseofulvin is known to interfere with chromosome segregation by binding to microtubule-associated proteins. Studies in mouse germ cells have demonstrated that griseofulvin can induce aneuploidy (numerical chromosome abnormalities) at therapeutic concentrations. The aim of this study was to determine if chronic griseofulvin treatment led to an increased frequency of sperm chromosome abnormalities in one male subject. We analyzed 290 full sperm karyotypes using the human sperm-hamster oocyte fusion system. The frequency of X- and Y-bearing sperm was equal. There was no increase in the frequency of numerical (1.7%) or structural (9.3%) abnormalities in the subject compared to unexposed controls. Although reassuring, this is the first report on this subject and future studies are needed to assess the risk of griseofulvin.

Caffeine intake, CYP1A2 polymorphism and the risk of recurrent pregnancy loss

Some case-control studies have demonstrated that caffeine intake and high CYP1A2 activity increase risks of recurrent pregnancy loss (RPL) but the multifactorial effect is obscure. To investigate whether susceptible women who have more caffeine intake are at high risk of RPL, a case-control study of 58 cases with two or more RPL and fertile 147 controls was performed. The association between daily caffeine intake together with CYP1A21F (AA versus CA and CC) genotype and RPL was assessed. Without consideration of the genotype, there were no significant differences of the RPL risk in proportion to daily caffeine intake [less than 100 mg (reference); 100-299 mg: odds ratio (OR), 1.29; 95% confidence interval (CI), 0.66-2.50; 300 mg or more: OR, 1.82; 95% CI, 0.72-4.58; P for trend, 0.20]. However, the RPL risk significantly increased only among women who had homozygous CYP1A21F alleles with a dosage effect of daily caffeine intake [less than 100 mg (reference); 100-299 mg: OR, 1.94; 95% CI, 0.57-6.66; 300 mg or more: OR, 5.23; 95% CI, 1.05-25.9; P for trend, 0.03]. It was demonstrated for the first time that an increase in caffeine intake deteriorates the fecundity among susceptible women.

Exposure to bisphenol A is associated with recurrent miscarriage

BACKGROUND

Little is known about the influence of high exposure to bisphenol A on recurrent miscarriage and immunoendocrine abnormalities.

METHODS

Serum bisphenol A, antiphospholipid antibodies (aPLs), antinuclear antibodies (ANAs), natural killer cell (NK) activity, prolactin, progesterone, thyroid-stimulating hormone (TSH) and free T4 were examined in 45 patients with a history of three or more (3-11) consecutive first-trimester miscarriages and 32 healthy women with no history of live birth and infertility. Subsequent pregnancy outcome and embryonic karyotype of abortuses were examined prospectively.

RESULTS

The mean+/-SD values for bisphenol A in patients were 2.59+/-5.23 ng/ml, significantly higher than the 0.77+/-0.38 ng/ml found for control women (P=0.024). High exposure to bisphenol A was associated with the presence of ANAs but not hypothyroidism, hyperprolactinaemia, luteal phase defects, NK cell activity or aPLs. A high level of bisphenol A in itself did not predict subsequent miscarriage.

CONCLUSION

Exposure to bisphenol A is associated with recurrent miscarriage.

PCBs, Hexachlorobenzene and DDE are not Associated with Recurrent Miscarriage

PROBLEM

A case-control study was designed to evaluate any associations between high exposure to polychlorinated biphenyls (PCB), hexachlorobenzene (HCB) and the 1,1,1,-trichloro-2,2-bis (p-chlorophenyl) ethane (DDT) metabolite 1,1-dichloro-2,2-bis (p-chlorophenyl) ethylene (DDE) and recurrent miscarriage and immunoendocrine abnormalities.

METHODS OF STUDY

A total of 18 kinds of co-planer PCBs, HCB, DDE, natural killer cell (NK) activity, antiphospholipid antibodies, antinuclear antibody, prolactin, progesterone, thyroid-stimulating hormone (TSH) and free T4 were examined in 45 patients with a history of three or more (3-11) consecutive first-trimester miscarriages and 30 healthy women with no history of live birth and infertility.

RESULTS

There were no differences in mean +/- S.D. values in serum samples for PCBs, HCB and DDE between patients and controls. Hypothyroidism, hyperprolactinemia, luteal phase defects, NK cell activity and the presence of autoantibodies were also not associated with levels of any of the compounds in the patients.

CONCLUSION

PCBs, HCB and DDE are not associated with miscarriage and immunoendocrine abnormalities in patients with a history of recurrent miscarriage.

Environmental toxins associated with recurrent pregnancy loss

Couples experiencing recurrent pregnancy loss are often concerned that toxins within the environment have contributed to their reproductive difficulty. Questions posed by these couples to their health care providers are difficult to answer because scientifically accurate information regarding the reproductive impact of potential environmental toxins and other teratogens is not readily available. Heavy metals such as lead and mercury, organic solvents, alcohol, and ionizing radiation are confirmed environmental teratogens, and exposure could contribute to pregnancy loss. Caffeine, cigarette smoking, and hyperthermia are suspected teratogens, and the teratogenic impact of pesticides remains unknown. The teratogenic potential of multiple other environmental factors has been studied and is reviewed. Before definitive conclusions can be drawn regarding the teratogenicity of environmental exposures, several clinical factors need to be addressed, including gestational age at the time of exposure, the amount of toxin reaching the conceptus, the duration of exposure, the impact of other factors or agents to which the mother or her conceptus is simultaneously exposed, and the physiological status of the mother and conceptus. In addition, in a given population, the interrelationship between frequency of exposures,frequency of effects, and recognizability of adverse outcomes, such as spontaneous abortion, should be considered.

[Toxic pollutants and fertility disorders. Solvents and pesticides]

It is demonstrated by means of extensive reference studies, as well as own results, that organic solvents and pesticides can be accountable for intoxications and various complications during pregnancy (e.g. abortion, stillbirth, intrauterine growth retardation). An initial stimulation of the adrenal cortex (hyperandrogenaemia) can result in partial insufficiency of the adrenal cortex with symptoms like alopecia and feeling of sickness. Consequences can be hypo- and hyperthyroidism. The immunological system is affected (e.g. abortion, susceptibility to infections). Neurovegetative and neuropsychological concomitant symptoms are numerous. Toxic contaminants affect men at different levels of the semen producing organs (e.g. oligospermia, azoospermia). Indications regarding diagnosis of toxic substances related illnesses as well as therapeutic and prophylactic potentialities are presented.

Dioxins--a commentary on gynaecological aspects of recent research

Dioxins are very toxic chemical compounds which are most likely carcinogenic and immunosuppressant in humans. Reproductive toxicity may occur at lower dose levels. Dioxins have been detected in mothers milk and fetal tissue. Experimental data suggest that placental function could be compromised by dioxins. Further research into the biological effects of this group of environmental contaminants is needed.

Fetal and neonatal outcome of exposure to anticoagulants during pregnancy

We studied fetal and neonatal outcome of women maintained on anticoagulants (warfarin and/or heparin) during pregnancy. Among 22 Chinese families, 13 mothers (59%) had a history of recurrent abortion or stillbirth while being maintained on warfarin treatment. Twenty-nine liveborn children (17 boys, 12 girls), ages 0.6-11.3 years at follow-up, were analysed for evidence of embryopathy. These were subdivided into 2 groups. Group 1 consisted of 18 children (12 boys, 6 girls) whose mothers were only given warfarin during pregnancy. Five were small for gestational age, and 12 had features of warfarin embryopathy such as nasal hypoplasia. One had subependymal intraventricular hemorrhage shown on neonatal ultrasonography. Group 2 consisted of 11 children (5 boys, 6 girls) whose mothers were maintained on warfarin and heparin during pregnancy. Three were premature deliveries, and 4 had nasal hypoplasia. One had cleft lip, cleft palate, cataract, microphthalmia, intraventricular hemorrhage, and hydrocephalus. We found that despite the high risk of fetal wastage, there was a relative lower risk of major complications, except for some minor cosmetic defects such as nasal hypoplasia. This might lead to readjustment of advice concerning contraception given to pregnant women who were maintained on anticoagulant therapy.

Health effects associated with exposure to anaesthetic gases in Ontario hospital personnel

In a retrospective study (by questionnaire) of 8032 personnel exposed to anaesthetic gases in operating and recovery rooms in Ontario hospitals, and 2525 non-exposed hospital staff, the response was 78.8% for the exposed and 87.2% for the unexposed personnel during the period 1981-5. Logistic regression analysis, with age and smoking standardised, showed that women in the exposed group had significantly increased frequencies of spontaneous abortion and their children had significantly more congenital abnormalities (p less than 0.05). No chronic disease was significantly associated with the exposed group. These findings, together with similar ones from other studies, suggest that it is prudent to minimise exposure to waste anaesthetic gases.

Spontaneous abortions, stillbirths, and birth defects in families of agricultural pilots

Families engaged in Agricultural Aviation (314) and cooperating sibling families, not occupationally exposed to pesticides (178) provided information, in response to a questionnaire, on their general health status and pregnancy outcomes. These two groups were comparable in age, height, weight, and years of education. Statistical evaluation confirmed the null hypothesis with respect to total pregnancies, number of male or female children, spontaneous abortions, and birth defects.