Consecutive Miscarriages Research Articles

Impact of Vitamin D deficiency on immunological and metabolic responses in women with recurrent pregnancy loss: focus on VDBP/HLA-G1/CTLA-4/ENTPD1/adenosine-fetal-maternal conflict crosstalk

Background and aimRecurrent pregnancy loss (RPL), also known as recurrent implantation failure (RIF), is a distressing condition affecting women characterized by two or more consecutive miscarriages or the inability to carry a pregnancy beyond 20 weeks. Immunological factors and genetic variations, particularly in Vit D Binding Protein (VDBP), have gained attention as potential contributors to RPL. This study aimed to provide insight into the immunological, genetic, and metabolic networks underlying RPL, placing a particular emphasis on the interactions between VDBP, HLA-G1, CTLA-4, ENTPD1, and adenosine-fetal-maternal conflict crosstalk.MethodsA retrospective study included 198 women with three or more consecutive spontaneous abortions. Exclusion criteria comprised uterine abnormalities, endocrine disorders, parental chromosomal abnormalities, infectious factors, autoimmune diseases, or connective tissue diseases. Immunological interplay was investigated in 162 female participants, divided into two groups based on their Vit D levels: normal Vit D-RPL and low Vit D-RPL. Various laboratory techniques were employed, including LC/MS/MS for Vit D measurement, ELISA for protein detection, flow cytometry for immune function analysis, and molecular docking for protein–ligand interaction assessment.ResultsGeneral characteristics between groups were significant regarding Vit D and glucose levels. Low Vit D levels were associated with decreased NK cell activity and downregulation of HLA-G1 and HLA-G5 proteins, while CTLA-4 revealed upregulation. VDBP was significantly downregulated in the low Vit D group. Our findings highlight the intricate relationship between Vit D status and adenosine metabolism by the downregulation of SGLT1, and NT5E, key components of adenosine metabolism, suggests that Vit D deficiency may disrupt the regulation of adenosine levels, leading to an impaired reproductive outcome. HNF1β, a negative regulator of VDBP, was upregulated, while HNF1α, a positive regulator, was downregulated in low Vit D women after RPL. Molecular docking analysis revealed crucial residues involved in the interaction between Vit D and HNF1β.ConclusionCollectively, these findings underscore the importance of Vit D in modulating immune function and molecular pathways relevant to pregnancy maintenance, highlighting the need for further research to elucidate the mechanisms and potential therapeutic interventions for improving pregnancy outcomes in individuals with Vit D deficiency and RPL.

KLF4 regulates trophoblast function and associates with unexplained recurrent spontaneous abortion

BackgroundRecurrent spontaneous abortion (RSA) is defined as two or more consecutive spontaneous abortions before 20 weeks with the same spouse [1]. However, approximately 50% of RSA cases of unknown cause are classified as unexplained recurrent spontaneous abortion (URSA). Potential factors include decreased trophoblast cell migration and invasion, leading to impaired placental implantation and maintenance of the normal maternal-fetal interface. However, the mechanism of this pathogenesis remains unknown. In this study, we investigated the potential role and mechanism of KLF4 in regulating URSA by influencing the invasion and migration ability of trophoblast cells.MethodsWe firstly identified 817 differentially expressed genes by performing a difference analysis of the dataset GSE121950 [2] related to recurrent abortion, and intersected the top 10 genes obtained respectively by the three algorithms: DMNC, MNC, and EPC using Venn Diagram.To detect the expression levels of core genes, villi samples were obtained from normal pregnant women and patients with URSA. RT-qPCR analysis revealed a significant difference in KLF4 mRNA expression and KLF4 was then analyzed. Trophoblast cell lines HTR8 and JEG3 were used to investigate the effect of KLF4 on trophoblastic function. Wound healing and transwell assays was performed to detect the invasion and migration of trophoblast cells. The expression of epithelial-mesenchymal transition(EMT) molecules were detected by RT-qPCR and western blot. Promoter detection and epigenetic modification were detected by chromatin immunoprecipitation (ChIP) assay. Molecular nuclear localization was detected by immunofluorescence and subcellular fractionation. Miscarried mice model was used to study the effects of KLF4 on URSA induced by reduced trophoblast invasion and migration.ResultsKLF4 is highly expressed in the villi of patients with URSA. KLF4 inhibits the expression level of H3R2ME2a in trophoblast cells by regulating the transcriptional level and nuclear translocation of PRMT6, thereby inhibiting the possible regulatory mechanism of trophoblastic invasion and providing a potential treatment strategy for URSA in vivo.ConclusionsThe KLF4/PRMT6/H3R2ME2a axis regulates mechanisms associated with unexplained recurrent spontaneous abortion by regulating trophoblast function.

Prospective Observational Study Of Hyperhomocysteinemia In Patients With Recurrent Pregnancy Loss In Teaching Hospital

Background: Spontaneous pregnancy loss can be physically and emotionally taxing for couples, especially when faced with recurrent losses. Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period . RPL is also defined by two or more failed consecutive pregnancies. It is estimated that fewer than 5% of women will experience two consecutive miscarriages and only 1% experience three or more. At present, there exists a small number of accepted etiologies for RPL. Most of the diagnosed etiologies include endocrine abnormalities, autoimmune disorders, uterine anomalies, and genetic factors. After evaluation for these causes, approximately half of all cases will still remain unexplained. Hence the present study was taken up to investigate the association between hyperhomocysteinemia and recurrent pregnancy loss, evaluating prevalence, potential mechanisms and implications for management. Materials and Methods: The prospective observational study was conducted on 50 patients in the Department of OBG in Dr. B. R. Ambedkar Medical College and Hospital for a period of 18 months. Prior to the initiation of the study, Ethical and Research Committee clearance was obtained from Institutional Ethical Committee. Results: The majority of participants in both groups were aged 35 to 40 years (32.35% in Group A and 37.5% in Group B).Statistically significant differences were observed between the groups regarding hypertensive disorders of pregnancy, co-morbidities, adverse pregnancy outcomes, the nature of abortion (primary vs. secondary), fetal outcomes, APGAR scores at 1 and 5 minutes, neonatal birth weight, and NICU admissions, with p-values of 0.001 across these measures.Group B (with hyperhomocysteinemia) showed higher instances of hypertensive disorders, co-morbidities, adverse pregnancy and fetal outcomes, abnormal APGAR scores at 1 and 5 minutes, lower neonatal birth weight, and NICU admissions.The mean homocysteine levels were 13.28 ± 1.8 µmol/L in Group A and 73.98 ± 5.1 µmol/L in Group B, with a highly significant difference (p: 0.0001).Most subjects in Group B had intermediately severe hyperhomocysteinemia (50%), with 37.5% experiencing moderately severe hyperhomocysteinemia and 12.5% with severe hyperhomocysteinemia. All abortions in Group A were primary, whereas Group B had 60% primary and 40% secondary abortions. Conclusion: Hyperhomocysteinemia is a risk factor for recurrent pregnancy loss. About 1 in 3 patients of RPL have hyperhomocysteinemia and therefore as a routine workup for RPL serum homocysteine measurement should also be included. Treatment of hyperhomocysteinemia with folic acid and vitamin B12 decreases homocysteine levels significantly.

Fluorescent, pH, and UCST Responsive Polymer Nanomaterials for Treatment of Recurrent Miscarriage.

Recurrent miscarriage (RM), defined as three or more consecutive spontaneous miscarriages, affects many women of childbearing age. The pathological basis of RM is an imbalance in apoptosis, with the MDM2-p53 pathway playing a crucial role. In this study, we synthesized poly(6-acetoxyl-ε-caprolactone)-graft-(4-amino-benzimidazole) (PCCL-4-ABI) by modifying poly(6-acetoxyl-ε-caprolactone) (PCCL) with 4-amino-benzimidazole (4-ABI). The introduction of carboxyl and 4-ABI groups endowed the PCL backbone with fluorescence, pH responsiveness, and UCST responsiveness. The temperature-dependent release behavior of compound 1-loaded PCCL-4-ABI nanofluorescent materials was attributed to UCST transition. We successfully developed a novel nanofluorescent polymer drug delivery platform, PCCL-4-ABI@1, and evaluated its regulatory effects on p53 and MDM2 in trophoblast cells (HTR-8/SVneo). The results showed that the system loaded with low molecular weight heparin increased MDM2 and decreased p53 expression in a dose-dependent manner, thereby inhibiting trophoblast cell apoptosis. This study developed a biodegradable poly(ε-caprolactone) with UCST behavior, significant for the advancement of thermoresponsive fluorescent nanoparticle systems.

O-317 Recurrent miscarriage and infertility : a qualitative study of views and experiences of services in the republic of Ireland

Abstract Study question How do women with recurrent miscarriage (RM) and infertility and healthcare professionals view and experience services and supports? Summary answer RM and infertility is a complex experience, intensified by divisions within the Irish healthcare system and a lack of knowledge and awareness around reproductive health What is known already While services for recurrent miscarriage (RM) are gradually improving with increasing awareness, women with RM and infertility have received limited attention in research and clinical guidance internationally. RM and infertility are separately associated with psychological distress and adverse pregnancy outcomes. Moreover, the dual experience is devastating for women and couples, and the optimal supports remain unidentified. Identifying the needs of this cohort is especially pertinent in the Republic of Ireland as public fertility care expands to include assisted reproductive technologies, previously only available through private or not-for-profit fertility clinics. Study design, size, duration We undertook a qualitative semi-structured interview study using a Reflexive Thematic Analysis approach. Thirty-three interviews were conducted, virtually on MIcrosoft Teams and in-person, between Dec 2022 and May 2023. These were audio-recorded, and data transcribed to NVivo12 for subsequent analysis. Participants/materials, setting, methods We recruited healthcare professionals delivering RM and/or fertility services, and women who experienced two or more consecutive miscarriages in the last four years and had undergone fertility care, through our professional networks and social media. Purposive sampling was used to include diverse perspectives across disciplines, public and private sectors, lived experiences and geographical locations. Interviews were audio-recorded, and data transcribed for subsequent reflexive thematic analysis. Main results and the role of chance We interviewed 16 healthcare professionals and 17 women with lived experience. Women were aged 35-47 and had experienced two to nine miscarriages. All received fertility care in ROI, with some additional care abroad. Healthcare professionals included four Clinical Midwifery Specialists in Bereavement eight Consultants and four Clinical Nurse Specialists in Fertility. We actively generated four themes during data analysis. (1) “Exploring all avenues”- women sought the best care and information, but their search was hindered by stigmatisation, definitions of RM and misinformation. (2) “Exhausting all resources” - women wanted to ensure they had tried everything to have a baby, investing all physical, emotional and financial reserves (3) “Separateness” - women feel remote from others who have not experienced RM or infertility and removed from both maternity and fertility services, as well as caught between public and private systems. (4) “No woman is an island” - supports come from multiple sources in their lives and in various guises but are limited, especially psychological supports. Limitations, reasons for caution This was a sample of white, educated, professional women with access to private fertility services. While a diverse group of HCPs were interviewed with current and past clinical experiences of private fertility services, there was limited engagement from fertility care providers. Wider implications of the findings This study identifies areas for improvement, such as access to investigations and supports, as well as the experiences and specific care and support needs of women/couples experiencing RM and infertility. Issues such as women’s awareness of their reproductive health, and equity in services, are applicable to all maternity service users. Trial registration number N/A

Management of PCOS Infertility then implementation of Garbhini Parichaya till Full Term by Ayurveda - Case Study

Primary Infertility associated with recurrent pregnancy loss because of Viral infections like TORCH and Polycystic Ovarian Syndrome (PCOS) is a worrisome issue nowadays. In modern medicine, antiviral drugs are the main treatment for TORCH, causing various side effects. Ayurveda being preventive and curative medicinal branch, has good positive outcome in the treatment of TORCH induced BOH and infertility. The Garbhini Paricharya refers to the care given to pregnant lady. It has to be started as soon as the signs and symptoms of pregnancy are seen. The rate of abortions can be prevented by following proper antenatal care detailed in Ayurveda. Presenting a case report of 32-year-old female came to Govt. Ayurvedic college and hospital, Varanasi with 11 years of married life and history of two consecutive spontaneous abortions and wasn’t able to conceive since then. She was detected with PCOS and Positive TORCH infection. Her last USG findings dated 17/01/2023 was right ovarian- PCOS morphology & left ovarian- hemorrhagic cyst 54x60mm + subserosal uterine fibroid 20x27mm in fundal region with complaints of inability to conceive with complaints of delayed menses at interval of 2-6 months with prolonged bleeding with clots for 10-15 days for 7 years (after last abortion). Treatment protocol was based upon Samprapti Vighatan & focused on Prakriti of patient, Dosha Pradhanya Lakshana & Dosha Dushya Sammurchana. She was treated with Jalkumbhi Kshar with Varunadi Kwath for her fibroid and Pushpadhanva Rasa, Kanchanar Guggulu, Ashokarishta etc along with Nasya, Matra Basti and Uttar Basti. After 4 months of treatment, patient was treated successfully with Ayurvedic intervention and Garbhini paricharya with conception and delivery of a full-term healthy baby boy.

Sub-Septate Uterus: An Incidental Radiological Finding in a Woman with History of Recurrent Miscarriage. A Case Report

Background: The septate uterus, which is the most common Mullerian duct anomaly, results from the abnormal fusion of the Mullerian duct during embryonic life, and it is usually associated with poor obstetric outcomes such as recurrent spontaneous abortions, subfertility, preterm labour, and reproductive failure. A large proportion of the patients that are affected remain asymptomatic owing to lack of indication for abdominal ultrasound before conception, and the problems are mainly detected after several pregnancy losses. The exact aetiology of the septate uterus is unknown but is caused by incomplete resorption of the uterovaginal septum after fusion of the Mullerian duct during embryogenesis. Case Presentation: We present a 32-year-old Para 0+3 woman referred to the radiology department for ultrasonography and hysterosalpingography (HSG) on account of recurrent miscarriage, which occurs within the first trimester of gestation. She has had three (3) consecutive miscarriages within the last 4 years, of pregnancies which were achieved spontaneously and were lost between the gestational ages of 9-12 weeks. She was investigated with ultrasonography, which demonstrated a bulky uterine appearance with two endometrial cavities that is connected to one cervical canal. Hysterosalpingography (HSG) showed a contrast-filled partly divided uterus with inter-cornual angles of 34º and intercornual distance of 1.92cm. The patient had hysteroscopic septum resection with a satisfactory outcome given addressing other medical problems that could militate against conception and has been on monthly follow-up. Conclusion: Radiological investigation of patients with recurrent miscarriages is indispensable for optimal evaluation to achieve accurate diagnosis and identify women whose problems are amenable to specialized treatments.

Hysteroembryoscopy in repeated early pregnancy loss due to suspected thrombophilia

Introduction: The cause of a 1st trimester repeated pregnancy loss (RPL) under treatment with aspirin and /or heparin due to suspected thrombophilia was investigated. Using hystero-embryoscopy (HEpy) and embryo genetic analysis the embryo development was correlated to its karyotype. Patients and methods: Seventeen first trimester pregnant women recruited in the study. They all had a history of at least 2 consecutive 1st trimester recurrent miscarriages, underwent an investigation for the cause of RPL and diagnosed to suffer from hypercoagulation. Thromboprophylaxis was administrated in all 17 pregnant women during their next pregnancy, postulating that their past cause of miscarriage was due to a hypercoagulability state. Twelve patients had positive Anticardiolipin and /or Antiphospholipid antibodies and 5 patients had MTHFR high titers. Embryo autopsy was performed by hysteroscopy technique using 2.9mm – 5mm hysteroscopes, 5Fr graspers and scissors and normal saline as distending medium. The embryo morphology results were correlated with the genetic results and compared with the patients’ diagnosis and treatment during the last miscarriage. Results: HEpy revealed that in 11 out of 17 cases embryos had chromosomal abnormalities ensuring patients that the problem of their loss was not the followed treatment. In all 4 cases with decidua haematoma and umbilical cord defect patients received aspirin and LWMH, raising the possibility of anticoagulation overtreatment. Conclusion: In-situ autopsy of a miscarriage embryo can provide useful information regarding the morphology of the embryo, ruling out anatomical defects and collecting the embryo under direct vision anticipating an accurate embryo karyotyping. Embryoscopy results may assist to change the management of the next pregnancy in RPL cases and patients with hypercoagulability state.

Patterns of Cytogenomic Findings from a Case Series of Recurrent Pregnancy Loss Provide Insight into the Extent of Genetic Defects Causing Miscarriages.

Background A retrospective study was performed to evaluate the patterns of cytogenomic findings detected from a case series of products of conception (POC) in recurrent pregnancy loss (RPL) over a 16-year period from 2007 to 2023. Results This case series of RPL was divided into a single analysis (SA) group of 266 women and a consecutive analysis (CA) group of 225 women with two to three miscarriages analyzed. Of the 269 POC from the SA group and the 469 POC from the CA group, a spectrum of cytogenomic abnormalities of simple aneuploidies, compound aneuploidies, polyploidies, and structural rearrangements/pathogenic copy number variants (pCNVs) were detected in 109 (41%) and 160 cases (34%), five (2%) and 11 cases (2%), 35 (13%) and 36 cases (8%), and 10 (4%) and 19 cases (4%), respectively. Patterns with recurrent normal karyotypes, alternating normal and abnormal karyotypes, and recurrent abnormal karyotypes were detected in 74 (33%), 71 (32%), and 80 (35%) of consecutive miscarriages, respectively. Repeat aneuploidies of monosomy X and trisomy 16, triploidy, and tetraploidy were detected in nine women. Conclusions A comparable spectrum of cytogenomic abnormalities was noted in the SA and CA groups of RPL. A skewed likelihood of 2/3 for recurrent normal and abnormal karyotypes and 1/3 for alternating normal and abnormal karyotypes in consecutive miscarriages was observed. Routine cytogenetic analysis should be performed for consecutive miscarriages. Further genomic sequencing to search for detrimental and embryonic lethal variants causing miscarriages and pathogenic variants inducing aneuploidies and polyploidies should be considered for RPL with recurrent normal and abnormal karyotypes.

Untargeted metabolomics analysis reveals the metabolic disturbances and exacerbation of oxidative stress in recurrent spontaneous abortion.

Recurrent spontaneous abortion (RSA) is characterized by the occurrence of two or more consecutive spontaneous abortions, with a rising prevalence among pregnant women and significant implications for their physical and mental well-being. The multifaceted etiology of RSA has posed challenges in unraveling the molecular mechanisms underlying that underlie its pathogenesis. Oxidative stress and immune response have been identified as pivotal factors in the development of its condition. Eleven serum samples from healthy pregnant women and 17 from RSA were subjected to liquid chromatography/mass spectrometry (LC-MS) analysis. Multivariate statistical analysis was employed to excavate system-level characterization of the serum metabolome. The measurement of seven oxidative stress products, namely superoxide dismutase (SOD), catalase (CAT), malonaldehyde (MDA), glutathione (GPx), glutathione peroxidase (GSH), oxidized glutathione (GSSG), heme oxygenase (HO-1), was carried out using ELISA. Through the monitoring of metabolic and lipid alternations during RSA events, we have identified 816 biomarkers that were implicated in various metabolic pathways, including glutathione metabolism, phosphonate and phosphinate metabolism, nucleotide metabolism, sphingolipid metabolism, lysine degradation and purine metabolism, etc. These pathways have been found to be closely associated with the progression of the disease. Our finding indicated that the levels of MDA and HO-1 were elevated in the RSA group compared to the control group, whereas SOD, CAT and GPx exhibited a contrary pattern. However, no slight difference was observed in GSH and GSSG levels between the RSA group and the control group. The manifestation of RSA elicited discernible temporal alternations in the serum metabolome and biochemical markers linked to the metabolic pathways of oxidative stress and immune response. Our investigation furnished a more comprehensive analytical framework encompassing metabolites and enzymes associated with oxidative stress. This inquiry furnished a more nuanced comprehension of the pathogenesis of RSA and established the ground work for prognostication and prophylaxis.

Oxidative/nitrosative stress increased the risk of recurrent pregnancy loss–Taiwan Recurrent Pregnancy Loss and Environmental Study (TREPLES)

ObjectiveOxidative stress biomarkers (OSBs) may be strongly associated with disease progression and recurrent pregnancy loss (RPL). However, the research on associations of most OSBs (e.g., 8-nitroguanine [8-NO2Gua] and 4-hydroxy-2-nonenal-mercapturic acid [HNE-MA]) with RPL is limited. Therefore, we aimed to investigate the effect of OSBs exposure on RPL risk by performing a case-control study. Material and methodsWe use our established dataset, Taiwan Recurrent Pregnancy Loss and Environmental Study (TREPLES), which included 514 Taiwanese reproductive age women (aged 20–50 years; 397 cases and 117 controls) from National Cheng Kung University Hospital. RPL is clinically defined by a history of two or more consecutive miscarriages, where a miscarriage is defined as the termination of pregnancy before 20 weeks of gestation. The urinary levels of several OSBs (e.g., 8-hydroxy-2′-deoxyguanosine [8-OHdG], 8-NO2Gua, 8-isoprostaglandin F2α [8-isoPGF2α], and HNE-MA) and malondialdehyde (MDA) were measured using isotope dilution liquid chromatography-tandem mass spectrometry and thiobarbituric acid reactive substances, respectively. ResultsThe median levels of 8-NO2Gua (6.15 vs. 3.76 ng/mL) and HNE-MA (30.12 and 21.54 ng/mL) were significantly higher in the RPL group than in the control group. By categorizing the OSBs data into tertiles, after we adjusted for age and urine creatinine levels discovered that the RPL risk associated with 8-NO2Gua and HNE-MA levels in the third tertile were approximately 2 times higher than those in the first tertile (8-NO2Gua, adjusted OR = 3.27, 95 % CI = 1.66–6.43; HNE-MA, adjusted OR = 1.96, 95 % CI = 1.05–3.64; p < 0.05). These findings suggest that the oxidative stress biomarkers of 8-NO2Gua and HNE-MA are risk factors for RPL. ConclusionOur findings indicate that specific OSBs are associated with an increased RPL risk, suggesting that reducing OSB levels can improve RPL risk. Nevertheless, more studies on preventive medicine are required to understand the exposure sources and adverse outcome pathways of OSBs associated with RPL.

Factor VII R353Q (rs6046), FGA A6534G (rs6050), and FGG C10034T (rs2066865) Gene Polymorphisms and Risk of Recurrent Pregnancy Loss in Iranian Women.

Recurrent pregnancy loss is a multi factorial and heterogeneous disorder defined as two or more consecutive pregnancy losses before 20 weeks' gestation. Gene polymorphisms including factor VII R353Q (rs6046), fibrinogen alpha chain A6534G (rs6050) and fibrinogen gamma chain C10034T (rs2066865) have potential role in thrombophilia and the relation between these three polymorphisms and an increased risk of venous thrombosis have been reported. As thrombophilia is associated with a considerable proportion of pregnancy loss and the association between these gene polymorphisms and recurrent pregnancy loss remains controversial, the aim of the present study was to evaluate the relation of these polymorphisms and recurrent pregnancy loss in Iranian women. A total of 144 women with a history of two or more consecutive miscarriages as the patient group and 150 healthy women with two live births and no history of pregnancy loss as the control group were included in the study. Polymerase chain reaction and restriction fragment length polymorphism were used for genotyping. The results were validated by DNA sequencing. The SPSS, SNPStats and Finch TV were used to analyze the results. Factor VII R353Q (rs6046) gene polymorphism showed a significant difference between RPL patients and the control group according to multiple logistic regression models [codominant (OR=0.38; 95% CI=0.23-0.63, P≤0.0001), dominant (OR=0.32; 95% CI=0.20-0.52, P≤0.0001), over dominant (OR=0.46; 95% CI=0.29-0.75, P=0.0017) and log-additive (OR=0.35; 95% CI=0.23-0.53, P≤0.0001)]. Fibrinogen alpha chain A6534G (rs6050) and fibrinogen gamma chain C10034T (rs2066865) gene polymorphisms showed no correlation with recurrent pregnancy loss. Factor VII R353Q (rs6046) gene polymorphism can be considered a risk factor for recurrent pregnancy loss. Further studies in larger populations are needed to confirm the findings.

P-507 Oxidative/Nitrative Stress Biomarkers Increased the Risk of Recurrent Pregnancy Loss

Abstract Study question Whether oxidative/nitrative stress biomarkers increased the risk of recurrent pregnancy loss (RPL)? Summary answer Patients with higher oxidative/nitrative stress biomarkers of 8-NO2Gua and HNE-MA had an increased risk of recurrent pregnancy loss compared with controls. What is known already In reproductive medicine, recurrent pregnancy loss (RPL) is a major problem including the most unknown and lack of evidence-based diagnostics and therapies. Certain oxidative stress markers play an important role in the progress of some diseases. In one study, subsequent increases in 8-OHdG levels in the RPL group indicated extensive DNA damage and the lipid peroxidation products dramatically increased before an abortion occurred. Large unknowns of other indicators of oxidative stress, such as markers of lipid peroxidation (8-isoPF 2α, HNE-MA, and MDA), and DNA damage (8-NO2Gua), are studied for their impacts on RPL. Study design, size, duration We used an established case-control study, the Taiwan Recurrent Pregnancy Loss and Environmental Study (TRIPLES), which included 514 reproductive age (20-50) women (including 397 cases and 117 controls) from obstetric clinics at National Cheng Kung University Hospital in southern Taiwan from 2013 to 2022. Participants/materials, setting, methods The physicians diagnosed two or more consecutive miscarriages before 20 weeks of pregnancy as RPL cases. They excluded uterine anomalies, maternal diseases, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), premature ovarian failure, and endometriosis. As a control group, we included married women, who delivered at least one child without artificial reproduction, underwent laparotomy for other clinical reasons, and did not suffer from the above-mentioned gynecological diseases. Main results and the role of chance Recurrent pregnancy loss (RPL) groups were older (mean=35.13) and had more time to prepare for pregnancy (mean=10.66 months). Their marital status mainly was married, their household income exceeded around 33,000 USD, and they consumed coffee habits. The median oxidative/nitrative stress biomarkers of 8-NO2Gua and HNE-MA in the case group were significantly higher than those in the control group (6.15 and 30.12 vs. 3.77 and 21.54 ug/L, p&amp;lt;0.001), indicating that the oxidative stress biomarkers of 8-NO2Gua and HNE-MA could be an essential effect factor in RPL. By categorizing the data by tertile of oxidative/nitrative stress biomarkers, we found that the RPL risk was 3.19 times higher in the third tertile of log 8-NO2Gua than in the first tertile (OR: 3.19, 95% CI: 1.66–6.10) and that the RPL risk in log HNE-MA was higher in the third tertile (OR: 2.05, 95% CI: 1.12–3.74). After adjustment for age, time to pregnancy (months), and coffee drinking habits, the RPL risk in the third tertile of log 8-NO2Gua was 2.01 times significantly higher than that in the first tertile (AOR: 2.01, 95% CI: 1.00–4.04). Limitations, reasons for caution Limitation of a case-control study. The oxidative stress biomarkers 8-NO2Gua and HNE-MA were significantly higher in the RPL groups, however, the causes of oxidative stress (like multiple environmental exposures, etc.) remain more studies to elucidate. Wider implications of the findings We provided evidence for oxidative/nitrative stress biomarkers in RPL patients, which implies the reduction of oxidative/nitrative stress may improve the progress of RPL. As important information for preventive medicine, more studies are needed to understand the adverse outcome pathway of oxidative/nitrative stress in RPL. Trial registration number MOST 109-2314-B-400 −022 -MY3 and EM-112-PP-11

'An extra level of kind of torment': Views and experiences of recurrent miscarriage care during the initial phases of COVID-19 in Ireland-A qualitative interview study.

Maternity services underwent much change during the COVID-19 pandemic. Research on the impact on miscarriage care and experiences during this time is sparse. Within a national evaluation of recurrent miscarriage care, we qualitatively explored stakeholder views and experiences of recurrent miscarriage services in Ireland. This study describes the impact of the COVID-19 pandemic on those experiences and perceptions of care. People with professional and lived experience of recurrent miscarriage and service engagement were actively involved in this qualitative study from idea generation to analysis and reporting. We recruited women and men with two or more consecutive first-trimester miscarriages, and people involved in the management/delivery of recurrent miscarriage services and supports. We used purposive sampling to ensure that perspectives across disciplinary or lived experience, geographical, and health service administrative areas, were included. We conducted semi-structured interviews, virtually all due to COVID-19 restrictions, between June 2020 and February 2021. These were audio-recorded, and data were transcribed, and subsequently analyzed using reflexive thematic analysis. We interviewed 42 service providers and 13 women and 7 men with experience of recurrent miscarriage. We actively generated two central themes during data analysis. The first-'Disconnected'-describes how many women navigated miscarriage diagnosis and management and care in subsequent pregnancies alone; many felt that this resulted in increased trauma. At the same time, men struggled with not being present to support their partners and described feeling disconnected. The second theme highlighted 'The perceived dispensability of recurrent miscarriage services and supports'. Some service providers felt that service reduction and redeployment demonstrated a lack of value in the service. Virtual clinics facilitated access to services, but a preference for in-person care was highlighted. Our analysis provides rich insights into the significant impacts that the COVID-19 pandemic has had on the way recurrent miscarriage care is provided and experienced, with important implications for early pregnancy, miscarriage and recurrent miscarriage care. Services have undergone significant changes and, while these may be temporary, how services should be delivered in the future requires consideration, particularly given the deficits in care and care experiences highlighted prepandemic. Members of the multidisciplinary RE:CURRENT Project Research Advisory Group (including four parent advocates, two of whom are co-authors on this article) were actively involved throughout the study, including the generation of topic guides and the refining of themes.

Factors that shape recurrent miscarriage care experiences: findings from a national survey

BackgroundLearning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience.MethodsBetween September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata.ResultsWe included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35–44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41–26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28–10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95–67.13]).ConclusionsWhile overall experience of RM care was poor, we identified areas that could potentially improve people’s RM care experiences – which have international relevance – such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

ASSOCIATION BETWEEN RECURRENT PREGNANCY LOSS AND MATERNAL THROMBOPHILIA MUTATIONS

Pregnant women with hereditary thrombophilia have an increased risk of RPL. The role of genetic thrombophilia in women with recurrent pregnancy loss have been evaluated and assumed it to be a causing factor for recurrent pregnancy loss and other reproductive complications, which includes Factor V Leiden mutation, Prothrombin, MTHFR and PAİ 4G/5G mutation. In this study we aimed to investigate the prevalence of these molecular defects in subjects with a history of early RPL. 35 women with one or more consecutive unexplained first trimester miscarriages were detected. The presence of these mutations was assessed by polymerase chain reaction analysis. We detected a combined mutation of one or more genes in 33 women, 20% of patients with at least one homozygous mutation (7 women), oonly two women (5.7%) did not have any thrombophilic mutation. These results suggest that thrombophilic mutations have an important role in etiology of RPL.

Mutation of FLNA attenuating the migration of abdominal muscles contributed to Melnick-Needles syndrome (MNS) in a family with recurrent miscarriage.

Filamin A, encoded by the X-linked gene FLNA, links the cell membrane with the cytoskeleton and acts as a regulator of the actin cytoskeleton. Mutations in FLNA cause a large spectrum of congenital malformations during embryonic development, including Melnick-Needles syndrome (MNS). However, reports of MNS, especially in males, are rare, and the pathogenesis molecular mechanisms are not well understood. We found a family with two consecutive miscarriages of similar fetuses with multiple malformations. DNA was extracted from peripheral blood and tissues, and whole exome sequencing was performed for genetic analysis. Then, we created a C57BL/6 mouse with a point mutation by CRISPR/Cas-mediated genome engineering. The migration of primary abdominal muscle cell was detected by wound healing assay. The first fetus showed congenital hygroma colli and omphalocele identified by ultrasound at 12 wks; the second fetus showed hygroma colli and thoraco abdominoschisis at 12 wks, with a new hemizygous mutation c.4420G>A in exon 26 of the FLNA gene, which is predicted to cause an amino acid substitution (p.Asp1474Asn). The mother and grandmother were both present in the c.4420G>A heterozygous state, and the mother's healthy brother had wild-type FLNA. These FLNA-mutated mice exhibited a broader central gap between the rectus abdominis than the wild type (WT), similar to the midline structure dysplasia of the abdominal wall in the two fetuses. Wound healing assays showed the attenuated migration capacity of abdominal muscle cells in mice with mutated FLNA. Finally, we summarized the cases of MNS with FLNA mutation from the accessible published literature thus far. Our research revealed a mutation site of the FLNA for MNS and explored the mechanism of midline structure dysplasia in the abdominal wall of male patients, which could provide more evidence for the clinical diagnosis and genetic counseling of families with these disorders.

Altered Expression of the HLA-G and IL10RB Genes in Placental Tissue of Women with Recurrent Pregnancy Loss.

Several lines of evidence strongly suggest that the contribution of human leukocyte antigen-G (HLA-G) and interleukin 10 receptor (IL10R) to maternal immunological tolerance toward paternal alloantigens of the embryo limits the activation and function of the maternal immune system. This study is aimed to assess the varia-tion of the mRNA expression levels of HLA-G and IL10RB genes in placental tissue of women with recurrent pregnancy loss (RPL). Placental tissue samples were collected from 78 women with a history of at least two consecutive miscarriages and 40 healthy women with no history of pregnancy loss. The expression of HLA-G and IL10RB in placental tissue specimens was evaluated by the quantitative real-time PCR (qPCR) method. Moreover, the correlation be-tween the expression levels of these genes and clinicopathological parameters was analyzed. The results showed that the expression of HLA-G was down-regulated in placental tissues samples of RPL patients compared to healthy subjects, while the expression of IL10RB was up-regulated, but none of them was statistically significant (p-value > 0.05). The mRNA expression levels of HLA-G and IL10RB in placental tissue of RPL patients were negatively correlated with age and number of miscarriages (p-value > 0.05). A significant positive correlation was observed between the expression levels of HLA-G and IL10RB in women with RPL (p-value < 0.05). The altered expression of HLA-G and IL10RB in placental tissue may contribute to the pathogenesis of RPL and therefore serve as potential therapeutic targets for its prevention.

Impact of Interleukin-10 Promoter Region Polymorphisms on Recurrent Miscarriage: A Case-Control Approach.

Recurrent miscarriage (RM), defined as two or more consecutive miscarriages prior to the 20th week of gestation is characterised by multifactorial aetiology. The prevalence of RM varies from 0.8% to 13.5% amongst women of reproductive age. The aetiological basis of RM has been traced to chromosomal, anatomic, hormonal and immunologic factors while half of the cases remain idiopathic. This study aimed to investigate the association of interleukin-10 (IL-10) polymorphisms with RM amongst the Indian population. The present study included a total of 414 individuals including RM women (n = 199) with two or more pregnancy losses and healthy women (n = 215) without any previous history of pregnancy loss were taken as the control group. Demographic features and reproductive history of women with RM and healthy women were taken. Genotype analysis of IL-10 polymorphisms rs1800872 and rs1800896 was performed using the polymerase chain reaction (PCR) restriction fragment length polymorphism and amplification mutation refractory system PCR, respectively. Student's t-test was used to compare the demographic features and reproductive history amongst both groups. Pearson's Chi-square was used to calculate the Hardy-Weinberg equilibrium, allelic and genotypic frequencies. All the statistical analyses were performed using the SPSS (version 21, IBM SPSS, NY, USA). Our results suggested that the genotypic and allelic frequency of rs1800872 polymorphism did not differ significantly between RM cases and control women (P = 0.07 and P = 0.23, respectively). The GG genotype (P = 0.007) and G allele (P = 0.003) of rs1800896 were significantly associated with an increased risk of RM. A statistically significant difference was also found for the distribution of genetic models (dominant and co-dominant model) between both groups for rs1800896. However, haplotype analysis revealed that none of the haplotypes provides a risk for the progression of RM. The study is the first of its kind from our region and provides baseline data on the genetics of RM.

Finding Peace Through Recurrent Loss

Finding Peace Through Recurrent Loss L. Emily Cotter I had never felt exhausted on so many levels—emotionally, physically, and professionally. It was a year and a half into the Covid pandemic, [End Page 209] and I had been working as a palliative care physician bearing witness to unspeakable suffering and loss. With the more widespread availability of Covid vaccines, my partner and I decided we were ready to try to have another child. Now we were experiencing our second consecutive miscarriage, and the grief felt immense: my uterus cramping and emptied, my heart shocked and devastated, my mind wearied and numb. It had taken us more than a year to conceive our first child, a young girl who brightened our lives with her smile and infectious joy. Born a few months before the pandemic began, we raised her in an environment we had not envisioned nor hoped for her. Despite what felt like a non-traditional childhood experience, seeing her blossom into a thoughtful human being excited us to think of her one day becoming a big sibling to help love and care for a younger one. After our first positive pregnancy test, I tried to protect my heart, knowing the prevalence of miscarriages and risks we were facing. No attempt at building defenses could shield from the uncertainty that crept in when the first ultrasound showed a length shorter than expected without convincing cardiac activity. Adding insult to injury, I was sent for a formal (and quite expensive) ultrasound to confirm what my heart knew, and then I waited for another clinic referral to discuss options for miscarriage management. I recall only a melancholy joy getting pregnant a few months later—the hope and excitement overtaken by anticipation of recurrent heartbreak. This time, cardiac activity on our first ultrasound provided an opening for optimism, although the embryo was again measuring slightly smaller than expected. Trying to put these thoughts out of my head, I continued to live life in the best way I could: being a mother to our toddler and in service as a physician. I focused my energy on a gratitude practice, thankful for my health and the ability to try to become a mother again. Spotting then appeared and intensified, and once again my heart knew this was not meant to be. While the second miscarriage ended spontaneously, the experience with follow up medical care felt worse than the first. Fellow clinicians provided unsubstantiated and non-evidence based medical advice about waiting for multiple cycles prior to trying again, despite my age and likely dwindling ovarian reserve. Anger crept in for other patients who would not be able to easily fact-check this falsehood and potentially lose precious time if they, like me, were later in their fertility years. Multiple physicians and nurses projected emotions misaligned with my own, frequently entering the room with a version of "you must be [worried/anxious/ nervous]" without an attempt to understand my lived experience. Flippant comments referenced a presumed stress level with an insinuation this was a reason for my pregnancy losses. (While I acknowledge imperfections, I thought I was maintaining a decently well-balanced life raising a thriving toddler despite working as a palliative care provider amid a global pandemic.) I felt disillusioned leaving these medical appointments, embarrassed for my own profession, and alone without medical providers who I could trust to guide me. I had been candid with friends and loved ones discussing life after our first miscarriage, hoping to break the trend of carrying these losses silently. After the second miscarriage, I found it more difficult to invite people in. I could tell close friends that it occurred, but I didn't feel ready to grieve openly. I created distance from people who might ask about my pregnancy while simultaneously feeling abandoned by my own body. It seemed my body had failed, with a cruel twist of irony that after a year of struggling to conceive our daughter, here we were, spontaneously getting pregnant yet not making it past the first trimester. I wanted space to grieve alone but didn't know how to unpack these feelings in moments of protected time when not at...