Higher Risk Of Miscarriage Research Articles

Акушерские осложнения и исходы беременности у пациенток с эндометриозом

Objective of the Review: To study the impact of endometriosis on the course and outcomes of pregnancy; to propose methods for prevention of obstetrics complications in pregnant women with endometriosis. Key Points. Pregnant women with endometriosis are at a high risk of miscarriage, preterm delivery, preeclampsia, placental disorders, intranatal and postnatal bleeding, still birth, high rates of caesarean section; and at a risk of acute complications from endometriosis, e.g., spontaneous hemoperitoneum. Endometriosis is associated with progesterone resistivity, impaired endometrium receptivity; therefore, prescription of progesterone to pregnant women with endometriosis can be a key to prevention of not only miscarriages and preterm delivery, but also of preeclampsia and placental disorders. Folic acid has favourable effect for placenta formation. Low doses (75–150 mg/day) of acetylsalicylic acid prevent placentation disorders. Conclusion. In order to prevent impaired implantation, placentation, cytotrophoblastic invasion, and uteroplacental perfusion with a high risk of obstetric complications, pregnant women with endometriosis should take progesterone, folic and acetylsalicylic acids. Keywords: endometriosis, obstetric complications, pregnancy follow-up

Pregnancy Outcomes in Patients With Adult-Onset Still's Disease: A Cohort Study From China.

Objective: Adult-onset Still's disease (AOSD) is an autoinflammatory disease with a higher prevalence rate in young females. The purpose of this study is to investigate whether AOSD has an adverse impact on pregnancy outcomes, or conversely exacerbated by pregnancy.Methods: The outcomes of 191 pregnancies were evaluated in 86 female patients with AOSD. The generalized linear mixed model and propensity score matching method were conducted to evaluate the influence of AOSD on pregnancy outcomes. A dependent sample sign test was applied to assess the impact of pregnancy on the relapse of AOSD.Results: The results showed that the post-AOSD group had a lower proportion of normal delivery (25.0 vs. 52.4%, p = 0.036) and a higher proportion of spontaneous abortion (STA) (18.8 vs. 0.6%, p = 0.002) compared with the pre-AOSD group. Moreover, pregnancy after being diagnosed with AOSD was a significant high risk factor of STA (adjusted OR = 4.577, 95% CI: 4.166–845.119; p = 0.003). Disease flare upon conception was observed in one of 16 post-AOSD pregnancies (p = 1.000). There were 11 patients with new-onset AOSD during gestation or postpartum, among which five (45.4%) evolved into the polycyclic course.Conclusions: AOSD patients might suffer from a higher risk of STA, however, pregnancy might not be related with the exacerbation of diagnosed AOSD. New-onset AOSD during gestation or postpartum tend to evolve into the polycyclic course.

Micronized Vaginal Progesterone to Prevent Miscarriage: A Critical Evaluation of Randomized Evidence

Historically, a lack of methodologically strong and generalizable studies has limited policymakers fromrecommending the use of progesterone supplementation to improve outcomes in women at high risk of miscarriage. The PROMISE and PRISM trials were carried out to rectify this and generate robust evidence on the role of progesterone supplementation to prevent miscarriage. This review aims to evaluate the PROMISE and PRISM trials and their impact on collective academic understanding of the use of progesterone supplementation for miscarriage prevention, as well as to provide recommendations for clinical practice. The PROMISE trial was a randomized double-blind, placebo-controlled study that included 836 women from 45 hospitals in the United Kingdom and the Netherlands and found a 3% increase in live birth rate with progesterone supplementation; however, the P value associated with this finding was 0.45. A post hoc subgroup analysis was performed with cohorts stratified according to number of previous miscarriages that revealed a trend for greater benefit with increasing number of previous miscarriages. Small sample sizes in this subgroup analysis resulted in a P value of 0.41; however, these results were hypothesis-generating that a biological gradient existed with respect to improved benefit of progesterone treatment among women with an increasing number of prior miscarriages. The PRISMtrial was a randomized, double-blind, placebo-controlled study that involved 4153 women from48 hospitals in the United Kingdom and noted a 3% increase in live birth rate with vaginal micronized progesterone; however, the P value associated with this finding was 0.08. To followup on the gradient effect observed in the PROMISE trial, this study included a prespecified subgroup analysis analyzing the number of previous miscarriages with population split into 3 subgroups: women with zero prior miscarriages, women with 1 to 2 prior miscarriages, and women with 3 or more prior miscarriages. Among women with 1 or more priormiscarriages and bleeding in the current pregnancy, the live birth rate was 75%with progesterone versus 70% with placebo (risk ratio, 1.09; 95% confidence interval, 1.03 1.15; P = 0.003). Among women with 3 or more prior miscarriages and bleeding in the current pregnancy, live birth rate was 72% with progesterone versus 57% with placebo (risk ratio, 1.28; 95% confidence interval, 1.08 1.51; P = 0.004). Guidelines for interpretation of subgroup analyses translate into 11 criteria to assess credibility and therefore clinical applicability; 5 on design, 2 on analysis, and 4 on context. The PRISM trials subgroup analysis meets all 11 criteria in women with dual risk factors of previous miscarriage and current pregnancy bleeding, suggesting the subgroup effect of a gradient existing in the context of improving live birth rate with progesterone treatment is highly plausible. Given biologic plausibility, lack of short-term safety concerns, and observed positive treatment effect, providers should consider offering women with vaginal bleeding and a history of 1 or more previous miscarriages a course of treatment with vaginal micronized progesterone 400 mg twice daily.

Reproductive Outcomes of In Vitro Fertilization–Intracytoplasmic Sperm Injection after Transcervical Resection of Adhesions: A Retrospective Cohort Study

To investigate pregnancy and obstetric outcomes of patients with intrauterine adhesions (IUAs) after treatment with in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) and fresh embryo transplantation after transcervical resection of adhesions (TCRA). Retrospective cohort study. University-based reproductive medical center. A total of 535 patients with IUAs and with a history of TCRA and 1605 matched patients without a history of IUAs underwent IVF-ICSI and received fresh embryo transfers. Between January 2014 and December 2018, all patients underwent IVF-ICSI treatment and received fresh embryo transfers. The patients in the TCRA group were matched with the control group according to strict criteria. Pregnancy and obstetric outcomes were compared. There were no significant differences in clinical pregnancies, ectopic pregnancies, live births, preterm births, and obstetric outcomes between the 2 groups (p >.05). However, the TCRA group had a higher risk of miscarriage than the control group (p = .048). TCRA improved the reproductive outcomes of patients with IUAs, but the risk of miscarriage was higher than that in the general population. To avoid miscarriage, careful monitoring is critical for pregnant patients with a history of TCRA who undergo embryo transfers during IVF treatment.

Stillbirth Risk during the 1918 Influenza Pandemic in Arizona, USA.

The 1918 influenza pandemic, the deadliest pandemic on record, affected approximately 1/3rd of the population worldwide. The impact of this pandemic on stillbirth risk has not been studied in depth. In this study, we assessed the stillbirth risk during the 1918 influenza pandemic in Arizona, USA. We carried out a retrospective study using 21,334 birth records for Maricopa County, Arizona, for the period 1915-1925. We conducted logistic regression analyses to assess the effect of that pandemic on stillbirth risk. Though we did not find a statistically significant impact on stillbirth risk during the pandemic, there was a higher risk of stillbirth in July 1919 (42 stillbirths/1000 births), 9 months after the peak pandemic mortality, and a stillbirth risk of 1.42 (95% CI: 1.17, 1.72) in women ≥35 years compared to the women aged <35 years. The risk of stillbirth was lowest if the mother's age was approximately 26 years at the time of birth. We also report peaks in stillbirth risk 9-10 months after the peak pandemic mortality. Our findings add to our current understanding of the link between pandemic influenza and stillbirth risk.

The predicted clinical workload associated with early post-term surveillance and inductions of labour in south Asian women in a non-tertiary hospital setting.

Stillbirth increases steeply after 42weeks gestation; hence, induction of labour (IOL) is recommended after 41weeks. Recent Victorian data demonstrate that term stillbirth risk rises at an earlier gestation in south Asian mothers (SAM). To determine the impact on a non-tertiary hospital in Melbourne, Australia, if post-dates IOL were recommended one week earlier at 40+3 for SAM; and to calculate the proportion of infants with birthweight<3rd centile that were undelivered by 40weeks in SAM and non-SAM, as these cases may represent undetected fetal growth restriction. Singleton births≥37weeks during 2017-18 were extracted from the hospital Birthing Outcomes System. Obstetric and neonatal outcomes for pregnancies that birthed after spontaneous onset of labour or IOL were analysed according to gestation and country of birth. There were 5408 births included, and 24.9% were born to SAM (n=1345). SAM women had a higher rate of IOL≥37weeks compared with non-SAM women (42.5% vs 35.0%, P<0.001). If all SAM accepted an offer of IOL at 40+3, there would be an additional 80 term inductions over two years. There was no significant difference in babies<3rd centile undelivered by 40weeks in SAM compared with non-SAM (29.6% vs 37.7%, P=0.42). Earlier IOL for post-term SAM would only modestly increase the demand on birthing services, due to pre-existing high rates of IOL. Our current practices appear to capture the majority at highest risk of stillbirth in our SAM population.

The estradiol/oocyte ratio predicts the MII oocyte rate, but not live-birth rate in a depot gonadotropin-releasing hormone agonist long protocol.

To investigate whether the estradiol/oocyte ratio (E2 /O) can predict ovarian response and pregnancy outcomes. This is a retrospective cohort study on 1838 individuals undergoing in vitro fertilization with a depot gonadotropin-releasing hormone agonist (GnRH-a) long protocol. The patients were grouped by the quartiles of E2 /O: <131.2, 131.2-178.0, 178.0-242.9, and >242.9pg/mL. ANOVA and χ2 test with the Bonferroni adjustment were used for statistical analysis. With the rise of E2 /O, the MII oocyte rate increased, whereas the number of oocytes retrieved decreased. The number of MII oocytes, fertilization rate, and the number of high-grade embryos were similar among the four groups. There were no differences in live-birth rate, clinical pregnancy rate, ectopic pregnancy rate, and miscarriage rate, but there was a trend towards a higher miscarriage rate in the patients with E2 /O between 131.2 and 242.9pg/mL. E2 /O indicates the percentage of MII oocytes, but not the quality of an individual follicle. E2 /O does not predict live birth in a depot GnRH-a long protocol; however, there is a trend towards a higher risk for miscarriage in the patients with E2 /O between 131.2 and 242.9pg/mL.

A loop-mediated isothermal amplification (LAMP) assay for detection of Toxoplasma gondii infection in women with spontaneous abortion.

The present study aimed to use the loop-mediated isothermal amplification (LAMP) technique in comparison with serological tests to determine the rate ofT. gondii infection in women suffering from spontaneous abortion (SA). A total of 140 women suffering from their first SA were included in this study. The collected aborted fetal remains and blood samples from each patient were examined in sterilized conditions using the LAMP technique and ELISA. Of the 140 women, 80 (57.1%) tested seropositive for anti-Toxoplasma antibodies by ELISA, 72 (51.4%) women tested seropositive for the IgG antibody, 8 (5.7%) tested seropositive for the IgM antibody. Among the eight women who'd had their first SA who tested seropositive for IgM antibody by ELISA, only five cases (62.5%) reported positively to the LAMP test. The difference in the frequency distribution of the LAMP results for measuring the Toxoplasma infection in pregnant women under study was statistically significant (P < 0.001) from the results of the serological test (ELISA). Although there was a significant difference between age and positivity in the LAMP test (P = 0.017), no significant difference was observed between positivity in the LAMP test and other variables. The findings of the present investigation suggest that LAMP is a preferred method for determining Toxoplasma infection in pregnant women suffering from SA compared with other routine serological tests. Even in a field with limited facilities and equipment, this technique can be effective and efficient in accurately and specifically diagnosing Toxoplasma infections in women at high risk of SA.

THE EFFECT OF OBESITY ON EUPLOIDY RATES IN WOMEN UNDERGOING IN VITRO FERTILIZATION (IVF) WITH PREIMPLANTATION GENETIC TESTING (PGT)

Elevated body mass index (BMI) is associated with a higher risk of miscarriage and lower probability of live birth following IVF (1-3). The etiology underlying these disparities is currently unclear. It is plausible that obesity may be associated with higher rates of aneuploidy, which could result in worsened pregnancy outcomes, although this has not been previously studied. Thus, we examined the impact of BMI on euploidy rates in IVF cycles with PGT.

Association between Drinking Water Nitrate and Adverse Reproductive Outcomes: A Systematic PRISMA Review

One in six couples experience fertility problems. Environmental factors may affect reproductive health; however, evidence is lacking regarding drinking water nitrates and outcomes of male and female fertility. The aim of this study was to investigate if exposure to nitrates in drinking water is associated with adverse reproductive outcomes in humans, and animals of fertile age. We conducted a systematic literature search and included case-control studies, cohort studies, and randomized control trials reporting on the association between drinking water nitrate exposure of men, women, or animals and adverse reproductive outcomes, specified as: Semen quality parameters, time to pregnancy (TTP), pregnancy rates, assisted reproductive technologies (ART), and spontaneous abortion. Findings were reported in a narrative synthesis. A total of 12 studies were included. The only human study included reported a decrease in spontaneous abortion at any detectable nitrate level. Overall, the 11 included animal studies support a potential negative effect on semen quality parameters but report equivocal results on TTP and number of offspring produced, and higher risk of spontaneous abortion. In conclusion, animal studies indicate possible effects on semen quality parameters and spontaneous abortion. However, with a few studies, including some with methodological limitations and small sample sizes, caution must be applied when interpreting these results.

Factors Associated with Occurrence of Stillbirth before 32 Weeks of Gestation in a Contemporary Cohort.

We sought to quantify the distribution of stillbirths by gestational age (GA) in a contemporary cohort and to determine identifiable risk factors associated with stillbirth prior to 32 weeks of gestation. Population-based case-control study of all stillbirths in the United States during the year 2014, utilizing vital statistics data, obtained from the National Center for Health Statistics. Distribution of stillbirths were stratified by 20 to 44 weeks of GA, in women diagnosed with stillbirth in the antepartum period. Pregnancy characteristics were compared between those diagnosed with stillbirth <32 versus ≥32 weeks of gestation. Multivariate logistic regression estimated the relative influence of various factors on the outcome of stillbirth prior to 32 weeks of gestation. There were 15,998 nonlaboring women diagnosed with stillbirth during 2014 in the United States between 20 and 44 weeks. Of them, 60.1% (n = 9,618) occurred before antenatal fetal surveillance (ANFS) is typically initiated (<32 weeks) and 39.9% (n = 6,380) were diagnosed at ≥32 weeks. Women with stillbirth prior to 32 weeks were more likely to be of non-Hispanic Black race (29.0 vs. 23.9%, p < 0.001), nulliparous (53.8 vs. 50.6%, p = 0.001), have chronic hypertension (CHTN; 6.0 vs. 4.3%, p < 0.001), and fetal growth restriction as evidenced by small for GA (SGA < 10th%) birth weight (44.8 vs. 42.1%, p < 0.001) as opposed to women with stillbirth after 32 weeks. After adjustment, SGA birth weight (adjusted odds ratio [aOR] = 1.2, 95% confidence interval [CI]: 1.1-1.3), Black race (aOR = 1.2, 95% CI: 1.1-1.3), and CHTN (aOR = 1.3, 95% CI: 1.1-1.5) were associated with stillbirth prior to 32 weeks of gestation as opposed to stillbirth after 32 weeks. More than 6 out of 10 stillbirths in this study occurred <32 weeks of gestation, before ANFS is typically initiated under American College of Obstetricians and Gynecologists recommendations. Among identifiable risk factors, CHTN, Black race, and fetal growth restriction were associated with higher risk of stillbirth before 32 weeks of gestation. Earlier ANFS may be warranted at in certain "at risk" women. · Six out of 10 stillbirths occur before 32 weeks of gestation.. · We evaluated factors associated with stillbirth <32 weeks.. · Hypertension and fetal growth restriction were associated with early stillbirth..

Pregnancy Outcomes of Women Conceiving on Antiretroviral Therapy (ART) Compared to Those Commenced on ART During Pregnancy.

BackgroundGlobally, the number of infected women of childbearing age living with human immunodeficiency virus (HIV) and conceiving on antiretroviral therapy (ART) is increasing. Evidence of ART safety at conception and during pregnancy and adverse pregnancy outcomes remains conflicting. The Promoting Maternal and Infant Survival Everywhere (PROMISE) 1077 breastfeeding (BF) and formula feeding (FF) international multisite trials provide an opportunity to examine the impact of ART at conception on pregnancy outcomes with subsequent pregnancies.MethodsThe PROMISE 1077BF/1077FF trials were designed to address key questions in the management of HIV-infected women who did not meet clinical guidelines for ART treatment during the time of the trials. After the period of risk of mother-to-child transmission was over, women were randomized to either continue or discontinue ART. We compared subsequent pregnancy outcomes of nonbreastfeeding women randomized to continue ART following delivery, or breastfeeding women randomized to continue ART following breastfeeding cessation who conceived while on ART to women randomized to discontinue ART, who restarted ART after pregnancy was diagnosed.ResultsPregnancy outcomes of 939 subsequent pregnancies of 826 mothers were recorded. The intention-to-treat analyses showed increased incidence of low birth weight (<2500 g) for women who conceived while on ART (relative risk, 2.65 [95% confidence interval {CI}, 1.20–5.81]), and also a higher risk of spontaneous abortion, stillbirth, or neonatal death (hazard ratio, 1.40 [95% CI, .99–1.98]) compared to women who restarted ART after they were found to be pregnant during trial follow-up.ConclusionsWe found an increased risk for adverse pregnancy outcomes in women conceiving on ART, emphasizing the need for improved obstetric and neonatal care for this group.Clinical Trials RegistrationNCT01061151.

Circulating mRNAs are differentially expressed in pregnancies with severe placental insufficiency and at high risk of stillbirth

BackgroundFetuses affected by placental insufficiency do not receive adequate nutrients and oxygenation, become growth restricted and acidemic, and can demise. Preterm fetal growth restriction is a severe form of placental insufficiency with a high risk of stillbirth. We set out to identify maternal circulating mRNA transcripts that are differentially expressed in preterm pregnancies complicated by very severe placental insufficiency, in utero fetal acidemia, and are at very high risk of stillbirth.MethodsWe performed a cohort study across six hospitals in Australia and New Zealand, prospectively collecting blood from 128 pregnancies complicated by preterm fetal growth restriction (delivery < 34 weeks’ gestation) and 42 controls. RNA-sequencing was done on all samples to discover circulating mRNAs associated with preterm fetal growth restriction and fetal acidemia in utero. We used RT-PCR to validate the associations between five lead candidate biomarkers of placental insufficiency in an independent cohort from Europe (46 with preterm fetal growth restriction) and in a third cohort of pregnancies ending in stillbirth.ResultsIn the Australia and New Zealand cohort, we identified five mRNAs that were highly differentially expressed among pregnancies with preterm fetal growth restriction: NR4A2, EMP1, PGM5, SKIL, and UGT2B1. Combining three yielded an area under the receiver operative curve (AUC) of 0.95. Circulating NR4A2 and RCBTB2 in the maternal blood were dysregulated in the presence of fetal acidemia in utero. We validated the association between preterm fetal growth restriction and circulating EMP1, NR4A2, and PGM5 mRNA in a cohort from Europe. Combining EMP1 and PGM5 identified fetal growth restriction with an AUC of 0.92. Several of these genes were differentially expressed in the presence of ultrasound parameters that reflect placental insufficiency. Circulating NR4A2, EMP1, and RCBTB2 mRNA were differentially regulated in another cohort destined for stillbirth, compared to ongoing pregnancies. EMP1 mRNA appeared to have the most consistent association with placental insufficiency in all cohorts.ConclusionsMeasuring circulating mRNA offers potential as a test to identify pregnancies with severe placental insufficiency and at very high risk of stillbirth. Circulating mRNA EMP1 may be promising as a biomarker of severe placental insufficiency.

Factors contributing to late stillbirth among women with pregnancy hypertension in a developing country

ABSTRACT Objective To investigate the factors associated with late stillbirth among women with hypertensive disorders of pregnancy (HDP). Material and Methods The clinical details of women with HDP having late stillbirth were compared with controls having livebirth. Results Total 208 cases and 288 controls were included in the study. Inadequate antenatal visits (p < 0.001, OR–5.92). birth weight < 2000 gms (p < 0.001, OR 10.3) and BW/PW ratio > 8 contributed significantly (p = 0.0001, OR-5.6) to stillbirth. Conclusion Poor antenatal care, birth weight below 2000gms and high BW/PW ratio was associated with a higher risk of stillbirth.

Aortic Isthmus Doppler Velocimetry in Fetuses with Intrauterine Growth Restriction: A Literature Review.

Intrauterine growth restriction (IUGR) is associated with poor perinatal prognosis and a higher risk of stillbirth, neonatal death, and cerebral palsy. Its detection and the evaluation of its severity by new Doppler velocimetric parameters, such as aortic isthmus (AoI), are of great relevance for obstetrical practice. The AoI is a vascular segment that represents a point of communication between the right and left fetal circulations. It is considered to be a functional arterial shunt that reflects the relationship between the systemic and cerebral impedances, and has recently been proposed as a tool to detect the status of hemodynamic balance and prognosis of IUGR in fetuses. In the present review, we noticed that in healthy fetuses, the AoI net flow is always antegrade, but in fetuses with IUGR the deterioration of placental function leads to progressive reduction in its flow until it becomes mostly retrograde; this point is associated with a drastic reduction in oxygen delivery to the brain. The more impaired the AoI flow is, the greater is the risk of impairment in the Doppler velocimetry of other vessels; and the alterations of the AoI Doppler seem to precede other indicators of severe hypoxemia. Although there seems to be an association between the presence of retrograde flow in the AoI and the risk of long-term neurologic disability, its role in the prediction of perinatal morbi-mortality remains unclear. The AoI Doppler seems to be a promising tool in the management of fetuses with IUGR, but more studies are needed to investigate its employment in clinical practice.

Serum levels of uric acid may have a potential role in the management of immediate delivery or prolongation of pregnancy in severe preeclampsia

ABSTRACT Objective To investigate the biomarker(s) that could affect the decision for immediate or delayed delivery in severe preeclampsia. Methods Data on serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), creatinine, blood urea nitrogen (BUN), uric acid (UA) and platelet counts from 134 cases were collected and analysed. Results Higher UA levels were seen in case with immediate delivery. Higher stillbirth was seen in cases with delayed delivery. Conclusion UA levels could be a potential management biomarker for immediate or delayed delivery in severe preeclampsia. However, the higher risk of stillbirth must be considered in delayed delivery.

The Risk of Stillbirth at Term and Timing of Delivery in Obese Women [38D

INTRODUCTION: Studies have shown that a high body mass index (BMI), expressed in kg/m2, is an independent risk factor for stillbirth. The purpose of this study was to determine an optimal time of delivery in obese women in order to decrease the risk of stillbirth in this population. METHODS: We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth-Infant Death and Fetal Death data. The study population included all singleton, term births with a recorded pre-pregnancy BMI that occurred between 2014 and 2017, inclusively. The risk of stillbirths in each BMI class was estimated at each gestational week from 37 weeks and onwards. RESULTS: Of the 12,742,980 births in our cohort that met study criteria, 46.8% were to women with a normal BMI, 26.9% were to women who were classified as overweight, 14.5% were to women in obesity class I, 7.3% in obesity class II, and 4.8% in obesity class III. As compared to women at 41 weeks with a normal BMI, there was a higher risk of stillbirth in women of obesity class I at 39 weeks (OR 1.15 95% CI 1.00–1.31), at 38 weeks for obesity class II (OR 1.21 95% CI 1.04–1.41) and at 37 weeks for obesity class III (OR 1.30 95% CI 1.11–1.52). CONCLUSION: As compared to women with a normal BMI, there was a higher risk of stillbirth at term in women with each increase in BMI class. Consideration should be given to early induction among these women to reduce the risk of stillbirth.

Low anti-Müllerian hormone level is not a risk factor for early pregnancy loss in IVF/ICSI treatment.

Is a low (<1.0μg/L) or moderately low (1.0-1.9μg/L) serum anti-Müllerian hormone (AMH) level a risk factor for early pregnancy loss in IVF/ICSI with a fresh or frozen-thawed embryo transfer (ET)? A low or moderately low serum AMH level does not associate with miscarriage, non-visualized pregnancy loss or overall early pregnancy loss rate in the IVF/ICSI treatment. Low AMH predicts poor ovarian response and small oocyte yield in IVF/ICSI treatment, but its value in the evaluation of live birth rate (LBR) is modest. Little is known about the risk of early pregnancy loss in ART among women with low AMH. A retrospective cohort study on 1383 women undergoing their first oocyte retrieval for IVF/ICSI in Helsinki University Hospital in Helsinki, Finland, between 2012 and 2016, with all associated fresh (n = 1315) and frozen-thawed (n = 1418) ET cycles finished by August 2018. AMH was measured within 12months before the IVF/ICSI stimulation. Of all the women, 235 (17.0%) had low (<1.0μg/L), 278 (20.1%) had moderately low (1.0-1.9μg/L) and 870 (62.9%) had normal (≥2.0μg/L) AMH. The primary outcomes were miscarriage, non-visualized pregnancy loss and early pregnancy loss (miscarriage and non-visualized pregnancy loss combined) after fresh or frozen-thawed ET. The impact of AMH on these outcomes was calculated in three populations: among all women who became pregnant, among women with AMH ≤6.0μg/L and in a population weighted by the inverse probability of becoming pregnant (inverse probability weighting, IPW). The impact of AMH was also assessed on the secondary outcomes, cumulative pregnancy rate (cPR) and cumulative live birth rate (cLBR) across all ET cycles in the woman's first IVF/ICSI. Potential confounders (the woman's age, overweight, smoking, history of endometriosis and underlying medical conditions) adjusted the final results. Of 1123 pregnancies, 285 (25.4%) ended in non-visualized pregnancy loss and 143 (12.7%) in miscarriage. The LBR was 24.6% per ET (673/2733). Low or moderately low AMH, compared with normal AMH, did not associate with miscarriage or non-visualized pregnancy loss in analyses among all women who became pregnant (adjusted relative risk (RR) for miscarriage vs live birth, 0.70 and 95% CI 0.42-1.17 in low AMH and adjusted RR, 1.00 and 95% CI, 0.68-1.49 in moderately low AMH; adjusted RR for non-visualized pregnancy loss vs live birth, 0.90 and 95% CI, 0.65-1.23 in low AMH and adjusted RR, 1.09 and 95% CI 0.85-1.41 in moderately low AMH), nor did low or moderately low AMH associate with the overall early pregnancy loss rate (adjusted RR for early pregnancy loss vs live birth, 0.86 and 95% CI, 0.68-1.10 in low AMH and adjusted RR, 1.01 and 95% CI, 0.86-1.27 in moderately low AMH). Results remained similar after restricting the analysis to women with AMH ≤6.0μg/L. Women with low or moderately low AMH had fewer pregnancies and live births than women with normal AMH in their first IVF/ICSI (cPR/cLBR in women with low AMH 50.6/34.0%, moderately low AMH 59.0/36.3% and normal AMH 68.3/49.2%). When the lower probability for pregnancy was considered by using IPW, women with low or moderately low AMH did not have a higher risk for miscarriage, non-visualized pregnancy loss or overall early pregnancy loss compared with women with normal AMH. The number of miscarriages in women with low AMH was moderately small, limiting the power of the study. The real-world clinical setting of the study restricted the ability to control for all factors causing selection bias. The cLBR was higher among women with normal AMH than among women with low or moderately low AMH in their first IVF/ICSI treatment because these women had more oocytes and embryos. Women with low or moderately low AMH did not have an increased risk for early pregnancy loss. This information is reassuring for couples and useful in counseling. These results are also valuable when assessing the overall effectiveness of IVF/ICSI treatment. Research funds from Helsinki University Hospital (no. TYH2018232), Hyvinkää Hospital (no. M3080TUT18) and the Emil Aaltonen Foundation for P.P. Grants from the Paulo Foundation and the Finnish Medical Foundation for H.H. The authors report no conflicts of interest. HUS/138/2017.

Epidemiology and outcomes of gastroschisis in Tasmania.

To describe the epidemiology and outcomes of gastroschisis in Tasmania. A retrospective analysis of all pregnancies complicated by gastroschisis in Tasmania from 1996 to 2015 was undertaken (epidemiology cohort), and the presentation, surgical management and outcomes (surgery cohort) were reviewed for the period between September 1990 and July 2015. Gastroschisis was detected in 58 pregnancies during the 20-year epidemiology cohort period, giving an incidence of 4.4 per 10 000 live births for the 20-year period. Two of the four stillbirths occurred after 36 weeks' gestation. Of the 65 babies with gastroschisis treated at the Royal Hobart Hospital, 51 had a staged surgical repair (silo in 47, stoma formation in 4), and 14 had a primary closure. Staged repair was associated with a significantly longer duration of ventilation and stay in the neonatal intensive care unit. There were six post-natal deaths, all born in the first epoch. Death was significantly associated with the condition of the intestine at delivery (P = 0.02). There were no deaths in babies with simple gastroschisis. Complex gastroschisis was significantly associated with longer duration of total parenteral nutrition (P = 0.0002) and longer stay in hospital (P = 0.03). The incidence of gastroschisis in Tasmania is similar to that reported in other Australian regions and has not increased over the 20-year period of study. The high risk of stillbirth, and the significant association between mortality and the condition of the intestine at birth necessitates close fetal surveillance. Complex gastroschisis imposes a significant burden on hospital resources.

Stress and the impact on the outcome of medically assisted reproduction

ObjectivesThere is evidence to suggest that high perceived stress in early pregnancy is associated with increased rates of miscarriage.Our objective was to determine if psychological stressors have an impact on medically assisted reproduction (MAR) cycle outcomes including miscarriage rates. Study designA survey-based study of women recruited prior to commencing MAR treatment and followed prospectively for treatment outcome (negative/positive pregnancy test, miscarriage) during the study period 2013–2015. The survey focused on perceived stress, emotional well-being, maternal social support and outlook. The women were asked to grade their responses according to a specified scale. Results320 women responded to the survey (response rate 64 %, 320/498). 290 (90 %, 290/320) women proceeded to MAR of which 58 % (n = 167/290) conceived. Analysis of stressful life events in the preceding 12 months, including job stress or serious financial problems did not reveal significance in terms of conception. A small number had experienced serious illness in the preceding 12 months which demonstrated significance in terms of not achieving pregnancy.Overall, there were high rates of emotional wellbeing, very high rates of maternal support and medium to low levels of perceived stress and this did not differ amongst those who conceived and failed to conceive.The data were further analysed according to livebirth and miscarriage (biochemical pregnancy and miscarriage). Analysis of stressful life events revealed a higher rate of miscarriage amongst those who reported a stressful/demanding job (p < 0.05). A number of women reported non-specified stressful life events and separation/divorce in higher numbers amongst the miscarriage group, reaching statistical significance, however the numbers are small thus limiting interpretation.Psychological factors had no impact on the risk of miscarriage amongst the group. ConclusionThis study suggests that stressors do not impact greatly on conception rates from MAR but may negatively impact on miscarriage rates. Job-related stress, in particular, is associated with higher risk of miscarriage. This suggests that there may be a role for stress management in early pregnancy.