Primary Recurrent Pregnancy Loss Research Articles

Frequency of Gene Polymorphisms in Admixed Venezuelan Women with Recurrent Pregnancy Loss: Microsomal Epoxy Hydroxylase (rs1051740) and Enos (rs1799983).

Recurrent pregnancy loss (RPL) affects around 2% of women of reproductive age. Primary RPL is defined by ≥2 pregnancy losses and no normal birth delivery. In secondary RPL, the losses are after a normal pregnancy and delivery. Most cases have no clear aetiology, although primary cases are the most complex. Several gene single nucleotide polymorphisms (SNPs) have been associated with RPL. The frequency of some SNPs is increased in women suffering from RLP from Asian or Caucasian races; however, in admixed populations, the information on possible genetic links is scarce and contradictory. This study aimed to assess the frequency of two SNPs present in two different enzymes involved in medical conditions observed during pregnancy. It is a case-control study. Microsomal epoxy hydrolase (mEPH) is involved in detoxifying xenobiotics, is present in the ovaries, and is hormonally regulated. The endothelial nitric oxide synthase (NOS3) that forms nitric is involved in vascular tone. Two SNPs, rs1051740 (mEPH) and rs1799983 (NOS3), were assessed. The study included 50 controls and 63 primary RPL patients. The frequency of mutated alleles in both SNPs was significantly higher in patients (p < 0.05). Double-mutated homozygotes were encountered only in RPL patients (p < 0.05). Genetic polymorphisms rs1051740 and rs1799983 may be involved in primary RPL in the Venezuelan admix population. Genetic studies could provide crucial information on the aetiology of primary RPL.

A history of recurrent pregnancy loss is associated with increased perinatal complications, but not necessarily a longer birth interval: a population study spanning 18 years.

Is there a difference in the time interval between the first and second live births among individuals with and without recurrent pregnancy loss (RPL)? Primary RPL (two or more pregnancy losses before the first live birth) is associated with a shorter time interval between the first and second live births compared with individuals without RPL, but this association is reversed in patients with secondary RPL (RPL patients with no or one pregnancy loss before the first live birth). There is limited information regarding the ability to have more than one child for patients with RPL. Previous studies have investigated the time to live birth and the live birth rate from the initial presentation to clinical providers. Most of the previous studies have included only patients treated at specialized RPL clinics and thus may be limited by selection bias, including patients with a more severe condition. We conducted a population-based retrospective cohort study of 184241 participants who delivered in British Columbia, Canada, and had at least two recorded live births between 2000 and 2018. The aim was to study the differences in the time interval between the first and second live births and the prevalence of pregnancy complications in patients with and without RPL. Additionally, 198319 individuals with their first live birth between 2000 and 2010 were studied to evaluate cumulative second live birth rates. Among individuals with at least two recorded live births between 2000 and 2018, 12321 patients with RPL and 171920 participants without RPL were included. RPL was defined as at least two pregnancy losses before 20 weeks gestation. Patients with primary RPL had at least two pregnancy losses occurring before the first live birth, while patients with secondary RPL had no or one pregnancy loss before the first live birth. We compared the time interval from the first to second live birth in patients with primary RPL, those with secondary RPL, and participants without RPL using generalized additive models to allow for a non-linear relationship between maternal age and time interval between first and second live births. We also compared prevalence of pregnancy complications at the first and second live births between the groups using non-parametric Kruskal-Wallis H test and Fisher's exact test for continuous and categorical variables, respectively. We assessed the cumulative second live birth rates in patients with primary RPL and those without RPL, among participants who had their first live birth between 2000 and 2010. Cox proportional hazards model was used to estimate and compare hazard ratios between the two groups using a stratified modelling approach. The adjusted time interval between the first and second live births was the longest in patients with secondary RPL, followed by individuals without RPL, and the shortest time interval was observed in patients with primary RPL: 4.34 years (95% CI: 4.09-4.58), 3.20 years (95% CI: 3.00-3.40), and 3.05 years (95% CI: 2.79-3.32). A higher frequency of pregnancy losses was associated with an increased time interval between the first and second live births. The prevalence of pregnancy complications at the first and second live births, including gestational diabetes, hypertensive disorder of pregnancy, preterm birth, and multiple gestations was significantly higher in patients with primary RPL compared with those without RPL. The cumulative second live birth rate was significantly lower in patients with primary RPL compared with individuals without RPL. This study may be limited by its retrospective nature. Although we adjusted for multiple potential confounders, there may be residual confounding due to a lack of information about pregnancy intentions and other factors, including unreported pregnancy losses. The results of this study provide information that will help clinicians in the counselling of RPL patients who desire a second child. This study was supported in part by a grant from the Canadian Institutes of Health Research (CIHR): Reference Number W11-179912. M.A.B. reports research grants from CIHR and Ferring Pharmaceutical. He is also on the advisory board for AbbVie, Pfizer, and Baxter. The other authors report no conflict of interest. NCT04360564.

Depression, anxiety, and stress and adverse pregnancy outcomes in pregnant women with history of recurrent pregnancy loss in Nigeria.

The primary purpose of this study was to examine whether pregnant women with a history of recurrent pregnancy loss (RPL) are more likely to experience moderate-to-severe depression, anxiety, or stress symptoms than pregnant women without a history of RPL. The secondary purpose was to determine whether women with prior RPL experienced more unfavorable pregnancy outcomes if they had depression, anxiety, or stress. A prospective case-control study was conducted that included 47 pregnant women with a history of RPL and 94 pregnant women without prior RPL. Participants 20weeks of gestation or earlier were included. Both groups completed the Depression, Anxiety, and Stress Scale (DASS-21), and were followed up until delivery to determine the pregnancy outcomes. Multivariate logistic regression was used to compare adverse pregnancy outcomes. Among the 47 women with prior RPL, 10 had primary RPL (two or more miscarriages without a successful pregnancy) and 37 secondary RPL (two or more miscarriages with a history of successful pregnancy). RPL was significantly associated with moderate-to-severe levels of depression (P < .001), anxiety (P < .001), and stress (P < .001). Among the RPL group, high stress level was significantly associated with repeat miscarriage (adjusted odds ratio (AOR) = 5.28, 95%CI = 1.25-100.0, P = .03) and preterm labor (AOR = 6.07, 95%CI = 1.61-100.0, P = .04). Depression and anxiety were not associated with adverse pregnancy outcomes. Pregnant women with a history of RPL had considerably higher rates of moderate-to-severe depression, anxiety, and stress. Repeat miscarriage and preterm labor were considerably higher among pregnant women with RPL who were experiencing high stress levels at baseline.

O-262 The vaginal and faecal microbiome in women with recurrent pregnancy loss (RPL) before pregnancy according to the reproductive outcome after referral

Abstract Study question Is the vaginal or faecal microbiome different between primary RPL (pRPL) and secondary RPL (sRPL) patients, and is it related to reproductive outcome after referral? Summary answer Before pregnancy, the vaginal microbiome differed between pRPL and sRPL, and the faecal microbiome was altered in those who did not achieve pregnancy after follow-up. What is known already RPL is a heterogeneous condition leaving 50% of the couples without any known risk factors after the initial diagnostic workup. The microbiome of the reproductive tract seems to be an essential factor in women’s health, including pregnancy loss. Only a few studies have investigated the vaginal microbiome in women with RPL and found dysbiosis with a decrease in Lactobacillus crispatus. To our knowledge, the faecal microbiome in women with RPL has never been investigated. Study design, size, duration A prospective cohort study including 106 women referred with unexplained RPL between 04/2018 and 12/2019. Patients were routinely screened for established risk factors as recommended in the ESHRE RPL guideline. Exclusion criteria were &amp;gt;40 years, &amp;gt;1 shared child, the use of antibiotics, antimycotics and antiviral medication within the past two weeks, known chromosomal aberrations and major uterine malformations. Follow-up ranged between 12-31 months. Participants/materials, setting, methods The women were referred with a minimum of three unexplained consecutive pregnancy losses (64 pRPL and 42 sRPL) to the tertiary Recurrent Pregnancy Loss Unit at Copenhagen University Hospital (Rigshospitalet and Hvidovre Hospital), Denmark. Vaginal and faecal samples were collected before pregnancy and shot-gun sequenced on a DNBSEQ-G400 sequencer (MGI) using the high-throughput sequencing set (PE150 1000016952; MGI). Main results and the role of chance The beta diversity in the vaginal samples was significantly different (p = 0.001) between pRPL and sRPL, with Lactobacillus crispatus dominating more women with pRPL compared to sRPL who were dominated by Lactobacillus iners. Overall, twenty-nine patients (27.3% of the cohort) had vaginal dysbiosis defined as &amp;lt; 60% Lactobacillus spp. with no significant difference between pRPL and sRPL (vaginal dysbiosis in 21.8% vs. 35.7%, p = 0.118). During follow-up, 93 (87.7%) patients achieved pregnancy of which 50 (53.8%) resulted in a live birth and 43 (46.2%) in another pregnancy loss. There were no differences in age, BMI, alpha or beta diversity in the vaginal samples between the live birth group and pregnancy loss group. In the live birth group, 11 patients (22.0%) had vaginal dysbiosis compared with 32.1% of the rest of the cohort, p = 0.242. Ninety-three of 106 women collected a faecal sample at home after the first consultation and there was a significant difference in both alpha diversity (p = 0.014), beta diversity (p = 0.05) and richness (p = 0.001) between women who achieved pregnancy compared with those who did not conceive after follow-up. Limitations, reasons for caution Patients with recurrent pregnancy loss constitute a heterogenic population, which underlines the importance of subgroup comparisons such as pRPL and sRPL. Wider implications of the findings These findings underline the role of an altered vaginal and faecal microbiome as a potential risk factor for RPL. In-depth knowledge about the altered microbiome compositions in these patients can contribute to the generation of future treatment strategies and potentially improve patient care. Trial registration number not applicable

Intravenous immunoglobulin use in patients with unexplained recurrent pregnancy loss.

Recurrent pregnancy loss (RPL) affects up to 4% of couples attempting to conceive. RPL is unexplained in over 50% of cases and no effective treatments exist. Due to the immune system's pivotal role during implantation and pregnancy, immune-mediated RPL may be suspected and immunomodulatory treatments like intravenous immunoglobulin (IVIg) have been administered but remain controversial. The goal of our study was to evaluate our center's 6year-outcomes and to develop a framework for IVIg use in RPL. Retrospective, single-center cohort study. All patients having received IVIg for unexplained RPL at the McGill Reproductive Immunology Clinic (MRIC) from January 2014 to December 2020 were included if maternal age was <42years, body mass index (BMI)<35kg/m2 , non-smoker and having had ≥3 consecutive RPL despite previous treatment with aspirin and progesterone. IVIg 0.6-0.8g/kg was given prior to conception and monthly during pregnancy until 16-20weeks' gestation. We compared IVIg treated patient's outcomes to a separate "natural history cohort". This cohort was composed of patients consulting at the McGill recurrent pregnancy loss clinic and the MRIC over a 2-year period (January 2020 to December 2021) with similar inclusion criteria as the treatment cohort but did not receive IVIg or other immunomodulatory treatments. The association of IVIg with outcomes (compared to no IVIg) was evaluated among the groups of patients with primary RPL and secondary RPL. The primary outcome was live birth rate (LBR), secondary outcomes included IVIg safety, obstetrical, and neonatal complications. Among 169 patients with unexplained RPL that were included in the study, 111 had primary RPL (38 exposed to IVIg and 83 controls) and 58 had secondary RPL (nine exposed to IVIG and 49 controls). Among patients with primary RPL (n=111), the LBR was 64.3% (18/28) among patient exposed to IVIg compared to 43.4% (36/83) in controls (p=0.079); regression analysis adjusting for BMI and number of previous miscarriages showed benefit favoring the use of IVIg (OR=3.27, CI 95% (1.15-10.2), p=0.03) when evaluating for live birth. In the subgroup of patients with ≥5 previous RPL and primary RPL (n=31), IVIg was associated with higher LBR compared to control (10/15 (66.7%) vs. 3/16 (18.8%); p=0.0113) but not the in the sub-group of patients with <5 miscarriages and primary RPL (8/13 (61.5%) vs. 33/67 (49.3%); p=0.548). IVIG treatment did not improve LBR in patients with secondary RPL in our study (3/9 (33.3%) vs. 23/49 (47%); p=0.495). There were no serious adverse events in the IVIg treatment group, obstetrical/neonatal complications were similar between groups. IVIg may be an effective treatment for patients with RPL if appropriately used in specific groups of patients. IVIg is a blood product and subject to shortages especially with unrestricted off-label use. We propose considering IVIg in well-selected patients with high order RPL who have failed standard medical therapy. Further mechanistic studies are needed to understand immune-mediated RPL and IVIg's mode of action. This will enable further refinement of treatment criteria and the development of standardized protocol for its use in RPL.

CLINICO-EPIDEMIOLOGICAL PROFILE AND EVIDENCE BASED MANAGEMENT OF RECURRENT MISCARRIAGES IN A TERTIARY CARE CENTRE

Methodology:An observational prospective study was conducted on 100 patients. 100 patients with recurrent pregnancy losses were studied. Study was conducted after ethical clearance by ethical committee. Counselling, Education And Informed Consent Accurate and realistic information about chances of a successful pregnancy was given depending on the number of losses. Women were seen in the intercurrent phase between pregnancies and at this visit, a thorough clinical history was recorded and an investigation protocol was followed to exclude known associations with recurrent miscarriage. Discussion: Early pregnancy loss, also known as miscarriage or Spontaneous abortion, is the loss of a clinical pregnancy before 20 weeks of gestation (18 weeks following conception), or, in cases when gestational age is uncertain, the loss of an embryo or foetus weighing less than 400 gm. Therefore molar, biochemical , and ectopic pregnancies are excluded. It is a rather frequent occurrence, occurring in 15% to 25% of pregnancies and becoming more prevalent as the mothers age increases. In fact, the risk is between 9% and 12% for women under the age of 35, but it rises to 50% for those over the age of 40. Different societies have employed a variety of nomenclatures. Because the causes of each type of miscarriage can vary, the term miscarriage can also refer to the loss of an embryo, also known as a early miscarriage, which occurs before 10 weeks of gestation and foetal loss, which occurs after 10 weeks. International societies have different definitions of recurrent pregnancy loss (RPL), which has been a subject of much discussion. RPL is defined as three successive pregnancy losses, including nonvisualized ones, by the Royal College of Obstetricians and Gynecologists7 and the European Society for Human Reproduction and Embryology4,6, respectively. The American Society for Reproductive Medicine, however, de fines it as two or more clinical pregnancy losses (verified by ultrasonography or histopathologic study), albeit they dont have to be consecutive. RPL is a significant concern for reproductive health because it affects 2% to 5% of marriages.2,7 Because o f the various definitions and criteria applied, as well as the characteristics of the populations, the incidence of RPL differs significantly between reports. While secondary RPL refers to multiple losses in a woman who has already given birth to a child beyond 20 weeks of gestation, primary RPL describes multiple losses in a woman who has never previously given birth to a live baby. Multiple pregnancies lost in between healthy pregnancies are referred to be secondary RPL.

Diagnostic factors for recurrent pregnancy loss: an expanded workup

PurposeThere is limited information on the risk factors for recurrent pregnancy loss (RPL).MethodsIn this study, a patient-based approach was used to investigate the possible involvement and relative relevance of a large number of diagnostic factors in 843 women with RPL who underwent an extensive diagnostic workup including 44 diagnostic factors divided into 7 major categories.ResultsThe rates of abnormalities found were: (1) genital infections: 11.74%; (2) uterine anatomic defects: 23.72%; (3) endocrine disorders: 29.42%; (4) thrombophilias: 62%; (5) autoimmune abnormalities: 39.2%; (6) parental karyotype abnormalities 2.25%; (7) clinical factors: 87.78%. Six hundred and fifty-nine out of eight hundred and forty-three women (78.17%) had more than one abnormality. The mean number of pregnancy losses increased by increasing the number of the abnormalities found (r = 0.86949, P < 0.02). The factors associated with the highest mean number of pregnancy losses were cervical isthmic incompetence, anti-beta-2-glycoprotein-1 antibodies, unicornuate uterus, anti-prothrombin A antibodies, protein C deficiency, and lupus anticoagulant. The majority of the considered abnormalities had similar, non-significant prevalence between women with 2 versus ≥ 3 pregnancy losses with the exception of age ≥ 35 years and MTHFR A1298C heterozygote mutation. No difference was found between women with primary and secondary RPL stratified according to the number of abnormalities detected (Chi-square: 8.55, P = 0.07). In these women, the only factors found to be present with statistically different rates were age ≥ 35 years, cigarette smoking, and genital infection by Ureaplasma.ConclusionA patient-based diagnostic approach in women with RPL could be clinically useful and could represent a basis for future research.

Association of cytotoxic T-lymphocyte-associated protein 4 polymorphisms with recurrent pregnancy loss: A case-control study.

A large proportion of cases of recurrent pregnancy loss (RPL) are associated with immunological factors. This study investigated the association between single nucleotide polymorphisms of cytotoxic T-lymphocyte-associated protein (CTLA)-4 gene in women with a history of RPL compared to healthy women. A case-control study was performed on 2 groups consisting of 120 healthy women with no history of abortion and at least one delivery (control) and 120 women with a history of 2 or more primary RPLs (case). In addition, 5 mL of peripheral blood sample was taken from all subjects. The frequencies of CTLA-4 rs3087243 and rs231775 polymorphisms were assayed by restriction fragment length polymorphism polymerase chain reaction and rs5742909 using the high-resolution melting real-time polymerase chain reaction method. The mean age of the women in the control and RPL groups were 30.03 4.23 (range 21-37), and 28.64 3.61 yr (range 20-35), respectively. Pregnancy loss numbers ranged between 2-6 in women with a history of RPL, and between 1 and 4 in the successful pregnancy group. Statistical analysis showed a significant difference between the genotypes of GG and AG in the 2 groups in rs3087243 polymorphism (OR 1.00 for GG genotype and OR 2.87 for AG genotype, p = 0.0043). No significant difference was observed in the genotype frequencies of rs231775 and rs5742909 polymorphisms, of the 2 groups (p = 0.37, and p = 0.095), respectively. Our findings indicated that CTLA-4 polymorphism, rs3087243, might be associated with a risk of RPL in Iranian women.

Endometriosis is associated with pregnancy loss: a nationwide historical cohort study

To study whether endometriosis is associated with pregnancy loss and recurrent pregnancy loss (RPL). Nationwide historical cohort study with a nested case-control analysis. National health registers. A total of 29,563 women born between 1957 and 1997 were identified in the national health registers, diagnosed with endometriosis between 1977 and 2017, and age-matched 1:10 with 295,630 women without endometriosis. The number of pregnancy losses was assessed, and data were analyzed with conditional logistic regression. Endometriosis (International Classification of Diseases, 8th Revision, 62530-62539, and International Classification of Diseases, 10th Revision, DN80.0-9). The primary outcomes of interest were the numbers of pregnancy losses categorized as 0, 1, 2, and ≥ 3 losses, unadjusted and adjusted for gravidity, and RPL. The secondary outcome measures were the predefined types of pregnancy losses. Pregnancy loss was defined as the spontaneous demise of a pregnancy until 22 weeks of gestation. Primary RPL was defined as 3 or more consecutive pregnancy losses with no prior live birth or stillbirth, and secondary RPL was defined as 1 or more births followed by 3 or more consecutive losses. A total of 18.9%, 3.9%, and 2.1% of ever-pregnant women with endometriosis had 1, 2, and ≥ 3 pregnancy losses compared with 17.3%, 3.5%, and 1.5% of the women without endometriosis, corresponding to the odds ratios of 1.13 (95% confidence interval, 1.09-1.17), 1.18 (1.10-1.26), and 1.44 (1.31-1.59), respectively. When adjusted also for gravidity, the corresponding results were 1.37 (95% confidence interval, 1.32-1.42), 1.75 (1.62-1.89), and 2.57 (2.31-2.85), respectively. The following predefined subgroups of RPL were positively associated with endometriosis: primary; secondary; secondary after giving birth to a boy; after a complicated delivery; and ≥ 3 pregnancy losses before the age of 30 years. Six endometriosis subgroup analyses found an association between endometriosis and pregnancy loss. These analyses were women diagnosed in the 4 decades between 1977 and 2017, women with adenomyosis, and women with adenomyosis only. This nationwide cohort study found endometriosis to be associated with pregnancy loss and RPL, and the association strengthened with an increasing number of losses.

Эндотелиальная дисфункция при привычном невынашивании беременности: генетические факторы и факторы внешней среды

Objective. To examine the association between the carriage of endothelial dysfunction-related gene polymorphisms and recurrent pregnancy loss (RPL). Patients and methods. This case-control study included 87 patients who were divided into two groups. The study group consisted of 65 patients with a history of two or more consecutive pregnancy losses (2 to 11 losses). Primary RPL was detected in 20 patients, secondary in 26, and tertiary in 19. The control group consisted of 22 women with a history of three or more full-term births without episodes of miscarriage. The frequency of polymorphisms of the VEGFA -634G&gt;C and IL6 -174G&gt;C genes was determined by a ready-to-use real-time polymerase chain reaction (RT-PCR) test kits. Results. Carrying the VEGFA -634G&gt;C GC genotype increases the risk of RPL 4-fold (p = 0.0072) and the IL6 -174G&gt;C GC genotype – 3-fold (p = 0.028). Analysis of the impact of combinations of unfavorable genotypes showed that 65.0% of patients with primary RPL, 61.5% with secondary RPL, 63.2% with tertiary RPL, and 9% of healthy controls had a combination of GC VEGFA -634G&gt;C and CC IL6 -174G&gt;C. One of the key environmental factors determining the realization of susceptibility genes is age: the maximum age at the time of the first intended pregnancy was observed in patients with primary RPL (32.6 years vs. 25.5 years in the control group; p &lt; 0.05), with 9% of healthy controls having a combination of two genotypes associated with pregnancy loss. That is, successful pregnancy at a younger age is possible even when carrying multiple risk alleles. The birth interval length is also important for successful pregnancy: a short inter-pregnancy interval allows to carry out the reproductive function during the most favorable period of the reproductive system before the influence of genotypes predisposing to RPL begins. Other environmental factors leading to the realization of carriage of RPL risk alleles include a history of intrauterine interventions and sexually transmitted infections. Conclusion. Study of the VEGFA -634G&gt;C and IL6 -174G&gt;C gene polymorphisms may serve as an effective method to predict RPL. For patients carrying these unfavorable gene polymorphisms, it is especially important to perform the reproductive function in time, i.e., before the realization of environmental factors. Key words: recurrent pregnancy loss, VEGF, endothelial dysfunction, susceptibility genes

Investigating the relation between chromosomal polymorphism and recurrent pregnancy loss: A cohort study

Chromosomal polymorphisms (CPM) are minor variation of karyotype, found in &amp;#62;1% of the general population. Heterochromatin, the inactive part of the chromosome, shows frequent polymorphism - increase/decrease in length. Recently, studies show that heterochromatin is not inert, but contains genes essential for spindle attachment, chromosome movement, meiotic pairing, and sister chromatid cohesion. Balanced translocation in parents, reciprocal and robertsonian, can disrupt important genes, and produce gametes with unbalanced gene dosage, causing spontaneous miscarriage. To correlate between chromosomal polymorphisms/ structural alterations and first trimester Recurrent Pregnancy Loss (RPL) primary infertility. : 100 couples with primary infertility or RPLs, were karyotyped by 72-h whole blood culture. Giemsa banding (GTG) was done in all cases. 20 metaphases were analysed according to the ISCN criteria. The total no. of RPLs was noted for each couple with abnormal karyotype. Of the 44 couples with abnormal karyotype, 36 (82%) had chromosomal polymorphism, 7 (16%) showed structural abnormality and 1 (2%) had numerical abnormality. Chromosome 9qh+ was present in the majority (33.33%). Among the D, G chromosomes, chromosome 15ps+/pstk+ were found in 22.22% but average no. of RPL was 2.15, whereas average RPL in Chr.22ps+ (incidence 5.55%.) was 3 (highest). Among male partners, Chr.Yqh+/Yqh- were found in 12 (33.33%) couples. Among the structural abnormalities (16%), balanced translocation accounted for 11.36%, maximum of which were Reciprocal translocations. The frequency of chromosomal abnormalities is higher among couples with RPLs and infertility, compared to the general population. Karyotyping gives important genetic information, thus acting as a good diagnostic tool, and helps to plan ART or perform prenatal testing.

Efficacy of lymphocyte immunotherapy in the treatment of recurrent pregnancy loss from alloimmunity: A systematic review and meta-analysis.

The efficacy of lymphocyte immunotherapy (LIT) in the treatment of recurrent pregnancy loss (RPL) from alloimmunity has been debated for years. There is conflicting evidence on the therapeutic role of LIT, since the etiology of most cases of RPL is previously classified as idiopathic. A systematic search of PubMed and Cochrane databases was done for randomized controlled trials that assessed the efficacy of paternal lymphocyte or third donor LIT among patients with primary or secondary RPL. The primary outcome was live birth rate after LIT. Random-effect meta-analysis was conducted using the software RevMan 5.4. Pre-planned subgroup analyses of source of lymphocytes, timing and frequency of administration, and concentration per immunization dose were conducted. Data from eight trials showed a statistically significant benefit of LIT (RR=1.45, 95% CI 1.05-2.01). The overall live birth rate is higher in the treatment group (65.6%) compared to placebo or no treatment (45.2%). Subgroup analysis based on source of lymphocytes revealed a trend towards benefit with paternal LIT but with wide confidence interval (RR=1.34, 95% CI=.84-2.14). Multiple doses of immunotherapy before pregnancy and low dose (5×106 cells) LIT showed significant benefit. Sensitivity analysis involving studies with a low risk of bias demonstrated significant benefit of increased live birth rate among patients treated with LIT compared to those who received placebo or no treatment (RR=1.97, 95% CI=1.53-2.53). LIT demonstrate benefit in improving pregnancy outcome of patients with RPL from alloimmunity.

Intravenous immunoglobulin treatment in women with four or more recurrent pregnancy losses: A double-blind, randomised, placebo-controlled trial.

SummaryBackgroundThere is no effective treatment for women with unexplained recurrent pregnancy loss (RPL). We aimed to investigate whether treatment with a high dose of intravenous immunoglobulin (IVIG) in early pregnancy can improve pregnancy outcomes in women with unexplained RPL.MethodsIn a double-blind, randomised, placebo-controlled trial, women with primary RPL of unexplained aetiology received 400 mg/kg of IVIG daily or placebo for five consecutive days starting at 4–6 weeks of gestation. They had experienced four or more miscarriages except biochemical pregnancy loss and at least one miscarriage of normal chromosome karyotype. The primary outcome was ongoing pregnancy rate at 22 weeks of gestation, and the live birth rate was the secondary outcome. We analysed all women receiving the study drug (intention-to-treat, ITT) and women except those who miscarried due to fetal chromosome abnormality (modified-ITT). This study is registered with ClinicalTrials.gov number, NCT02184741.FindingsFrom June 3, 2014 to Jan 29, 2020, 102 women were randomly assigned to receive IVIG (n = 53) or placebo (n = 49). Three women were excluded; therefore 50 women received IVIG and 49 women received placebo in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (31/50 [62·0%] vs. 17/49 [34·7%]; odds ratio [OR] 3·07, 95% CI 1·35–6·97; p = 0·009) and the live birth rate (29/50 [58·0%] vs. 17/49 [34·7%]; OR 2·60, 95% CI 1·15–5·86; p = 0·03) in the IVIG group were higher than those in the placebo group in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (OR 6·27, 95% CI 2·21–17·78; p < 0·001) and the live birth rate (OR 4·85, 95% CI 1·74–13·49; p = 0·003) significantly increased in women who received IVIG at 4–5 weeks of gestation as compared with placebo, but these increases were not evident in women who received IVIG at 6 weeks of gestation. Four newborns in the IVIG group and none in the placebo group had congenital anomalies (p = 0·28).InterpretationA high dose of IVIG in very early pregnancy improved pregnancy outcome in women with four or more RPLs of unexplained aetiology.FundingThe Japan Blood Products Organization.

Pregnancy loss and risk of multiple sclerosis and autoimmune neurological disorder: A nationwide cohort study

The loss of one or more pregnancies before viability (i.e. pregnancy loss or miscarriage), has been linked to an increased risk of diseases later in life such as myocardial infarction and stroke. Recurrent pregnancy loss (i.e. three consecutive pregnancy losses) and multiple sclerosis have both been linked to immunological traits, which could predispose to both occurrences. The objective of the current study was to investigate if pregnancy loss is associated with later autoimmune neurological disease. This register-based cohort study, included the Danish female population age 12 or older between 1977-2017. Women were grouped hierarchically: 0, 1, 2, ≥3 pregnancy losses, primary recurrent pregnancy loss (i.e. not preceded by a delivery), and secondary recurrent pregnancy loss (i.e. preceded by a delivery). The main outcome was multiple sclerosis and additional outcomes were amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis. Bayesian Poisson regression estimated incidence rate ratios [IRR] and 95% credible intervals [CI] adjusted for year, age, live births, family history of an outcome, and education. After 40,380,194 years of follow-up, multiple sclerosis was diagnosed among 7,667 out of 1,513,544 included women (0.5%), median age at diagnosis 34.2 years (IQR 27.4-41.4 years), and median age at symptom onset 31.2 years (IQR 24.8-38.2). The adjusted IRR of multiple sclerosis after 1 pregnancy loss was: 1.03 (95% CI 0.95-1.11), 2 losses: 1.02 (95% CI 0.86-1.20), ≥3 non-consecutive losses: 0.81 (95% CI 0.51-1.24), primary recurrent pregnancy loss: 1.18 (95% CI 0.84-1.60), secondary recurrent pregnancy loss: 1.16 (95% CI 0.81-1.63), as compared to women with no pregnancy losses. Seven sensitivity analyses and analyses for additional outcomes did not show significantly elevated adjusted risk estimates. In this nationwide study, pregnancy loss was not significantly associated with autoimmune neurological disorder.

Association of Factor V Leiden Mutation with Unexplained Recurrent Pregnancy Loss

Introduction: Recurrent pregnancy loss (RPL) is considered as a significant public health problem. In many studies, Factor V Leiden mutation is considered to have significant relationship with unexplained recurrent pregnancy loss. Aim of the study: The aim of this study was to determine the association of Factor V Leiden mutation with unexplained recurrent pregnancy loss. Methods: This case-control study was conducted in the out-patient Department of Fetomaternal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from November 2020 to April 2021 (6 months). Sample size was taken as 40 for each case and healthy control group. Result: Mean (±SD) age was found 28.2±4.9 years in RPL group and 27.1±5.24 years in non-RPL group. Maximum number of patients fell into the BMI category of 23.0-26.9 kg/m2 (BMI for Asian women) in both groups. Among the RPL cases, 30% had experienced consecutive 2 pregnancy losses with mean (±SD) number of losses 3.07±1.14. About more than half percentages (n=23, 57.5%) shared the primary RPL group. In this study, normal homozygous FVL mutation was equally distributed among RPL patients and control individuals. Only 2 cases (5%) were found positive for Factor V heterozygous mutation (GA) in the RPL group. G allele occurred in most of the cases (97.5%) of RPL. Two cases aged 25 years and 35 years respectively were found positive for heterozygous mutation of Factor V Leiden. Both of them exhibited 3 consecutive recurrent second trimester pregnancy losses. Factor V Leiden was found in higher prevalence (100%) in 2nd trimester recurrent pregnancy loss sub-group of cases and revealed significant association (p &lt;0.001) between two variables. Conclusion: The impact of Factor V Leiden mutation has not stated any causal association with unexplained recurrent pregnancy loss. The results do not support Factor V mutation screening as an initial approach in Bangladeshi women suffering from recurrent pregnancy loss.

Study of bad obstetric history cases attending tertiary care centre, Tirupati

To assess the obstetric and medical risk factors in patients with bad obstetric history (BOH) and outcome of pregnancy in case of BOH. A prospective cross-sectional study was conducted in Government maternity hospital, Tirupati for a period of 1 year from December 2017 to November 2018. All pregnant women who were fulfilling inclusion criteria of BOH, as study group and all possible variable were compared with control group, who got selected randomly from the rest of deliveries. And analysed the results in terms of sociodemographic factors, risk factors, pregnancy complications, mode of delivery, maternal and foetal outcome. Of 102 pregnant women in BOH, 76.5% were in age group between 21-30yrs, and 14.7% in age group &amp;#62;30yrs. Primary Recurrent pregnancy loss (RPL) was 51% and that of secondary recurrent pregnancy loss was 49%.History of hypertensive disorders including preeclampsia, eclampsia and chronic hypertension, noted in 11.8% cases, which was higher than previous studies, indicating changing trends in incidence.In foetal complications IUGR (0% vs 9.8%, p=0.026) and IUFD (0% Vs 7.8%, p=0.05) were more in BOH group and statistically significant also. Even though the maternal complications were more in BOH group, there was no statistical significance (P=0.075).Among the various causes of RPL found in the present study, endocrine causes were seen in 12.7%, Anatomical causes were found in 11.8% and in about 63.7% cases no definite cause was found and aetiology was unexplained. Present study, supporting the change in definition of recurrent pregnancy loss from 3 consecutive losses to 2. So early evaluation and with appropriate interventions in most of couples outcomes were fruitful.

Characterisation of peri-implantation endometrial Treg and identification of an altered phenotype in recurrent pregnancy loss

Recurrent Pregnancy Loss (RPL) affects 2–4% of couples, and with increasing numbers of pregnancy losses the risk of miscarrying a euploid pregnancy is increased, suggesting RPL is a pathology distinct from sporadic miscarriage that is due largely to lethal embryonic aneuploidy. There are a number of conditions associated with RPL including unspecified “immune” pathologies; one of the strongest candidates for dysregulation remains T regulatory cells as depletion in the very early stages of pregnancy in mice leads to pregnancy loss. Human endometrial Treg and conventional CD4T cells were isolated during the peri-implantation period of the menstrual cycle in normal women. We identified an endometrial Treg transcriptomic signature and validated an enhanced regulatory phenotype compared to peripheral blood Treg. Parous women had an altered endometrial Treg transcriptome compared to nulliparity, indicating acquired immune memory of pregnancy within the Treg population, by comparison endometrial conventional CD4T cells were not altered. We compared primary and secondary RPL to nulliparous or parous controls respectively. Both RPL subgroups displayed differentially expressed Treg gene transcriptomes compared to controls. We found increased cell surface S1PR1 and decreased TIGIT protein expression by Treg in primary RPL, confirming the presence of altered Treg in the peri-implantation RPL endometrium.

DOES IN-VITRO FERTILIZATION AFFECT INTER-DELIVERY INTERVAL IN PATIENTS WITH RECURRENT PREGNANCY LOSS? A POPULATION STUDY

This study aimed to compare the interval to second live birth in women with recurrent pregnancy loss (RPL) who required IVF to those who conceived spontaneously. This retrospective study included women with live births in 2008-2018 from the British Columbia Perinatal Data Registry. This provincial registry collected perinatal variables from the mandatory reporting of all attended births. The cohort included RPL women with 2 recorded live births and were nulliparous at first delivery. The time interval was compared using a log-logistic survival model, controlling for factors such as age, BMI, city of residence, and number of miscarriages. There were 9503 women with RPL and 2 recorded deliveries; 4% of which required IVF to conceive the second child. IVF use was associated with older maternal age at first delivery (age 33.8 vs 28.9), previous IVF use (38.7% vs 1.5%), primary RPL (38.14% vs 28.73%), and higher number of miscarriages before the second delivery (2.64 vs 2.25) compared to those who conceived spontaneously (P all < 0.0001). In the unadjusted analysis, the duration from first delivery to second birth was significantly longer in those who required IVF compared to the control group, 4.1 and 3.8 years respectively (P = 0.0002). After adjustment, those who required IVF had a longer interval to second birth among younger women, but this difference was attenuated among older women. There was no significant difference in the time to second delivery after IVF use compared to spontaneous conception in RPL patients ≥ 35 years old at first birth. However, the study showed that younger women who conceived the second child with IVF had a longer inter-delivery interval. This may be related to underlying differences in infertility diagnosis and/or family planning.

Cancer diagnosis among women with recurrent pregnancy loss: a retrospective cohort study

Research questionWhat is relationship between unexplained recurrent pregnancy loss (RPL) and risk of cancer morbidity? DesignA retrospective observational cohort study was conducted, based on data from a tertiary medical centre. RPL cases (exposed) were defined as women presenting with three or more unexplained confirmed pregnancy losses at 5–24 weeks, whose first visit to the RPL clinic was between 1990 and 2010. The unexposed group included women giving birth who were not RPL patients; these were matched by age and year of giving birth/admission (1:5 ratio). Data from the RPL and the live birth registries were cross-linked to the Israeli national cancer registry according to the unique ID number and merged into one database. ResultsThe study group comprised 937 RPL patients who were matched by maternal age (P = 1.0) and admission date (P = 0.84) to 4685 women achieving a live birth. There was no difference in overall cancer incidence between groups (adjusted odds ratio [OR] 0.76, 95% confidence interval [CI] 0.55–1.03; P = 0.08). The secondary RPL group showed a trend towards decreased cancer morbidity incidence compared with primary RPL (adjusted OR 0.65, 95% CI 0.41–1.03; P = 0.07). Analysis by cancer type showed a similar risk for breast cancer among women with RPL compared with live birth, but a significantly lower risk for gynaecological cancers among women with RPL (adjusted OR 0.25, 95% CI 0.08–0.79; P = 0.018). ConclusionsUnexplained RPL may be related to a lower risk of gynaecological cancers, possibly explained by hyper-responsive immunological mechanisms involving uterine natural killer cells.

P–355 Cancer diagnosis among patients with recurrent pregnancy loss: a cohort study

Abstract Study question Is unexplained recurrent pregnancy loss (RPL) related to long term cancer morbidity? Summary answer Recurrent unexplained pregnancy loss patients showed lower cancer morbidity. This trend was significant in the secondary aborters and in a sub-analysis for gynecological cancers. What is known already The association between infertility and cancer was studied, but has scarcely been studied in RPL; One study reported a higher incidence of breast and uterine cancers, while another found no association. Immune dysfunction is a possible cause of ‘unexplained RPL’; RPL patients have an increased number of toxic natural killer cells (NKs) in both peripheral blood and decidua. The immune system is also involved in the recognition of cancer cells, potentially leading to effective killing. It is possible that the NK populations in RPL are capable of a better response towards cancer cells in the uterine environment and related organs. Study design, size, duration A retrospective cohort study comparing RPL patients and patients with normal deliveries presenting between 1990 –2010 and followed up until 2018. Participants/materials, setting, methods The RPL (exposed) group consisted of patients with 3 or more losses between 5–24 weeks. The comparison (unexposed) group included women who gave birth, and were not listed in the registry of RPL patients. Matching was based on maternal age and year of delivery, which was matched to the date of admission to the RPL clinic. Patients’ data were cross-linked to the national cancer registry. Kaplan-Meier survival curves were used to compare cancer incidence. Main results and the role of chance The RPL group comprised of 937 RPL patients, compared to 4685 patients with a live birth. The mean follow up time was 16.3 ±5.3 years for RPL cases and 15.9 ± 4.9 for the comparison group. Groups were compared in terms of lifetime risk, post-admission risk and according to cancer type. In a Univariate analysis, the life time risk for cancer was 5.3% (49/937) among RPL patients and 6.8% (317/4685) in the comparison group (p = 0.08). Survival analysis showed the same trend - a lower cancer morbidity in RPL patients (p = 0.06). The low cancer morbidity was more prominent, reaching statistical significance in secondary RPL patients (p = 0.05) , but not in primary RPL (p = 0.4). Breast cancer was the most common tumor, but was neither more nor less common in RPL than in the comparison group. Gynecological cancers, however, were significantly less common in RPL patients: 0.3% (3/937) compared to 1.3% (60/4685) in the comparison group (p = 0.01). After adjustment for maternal age the odds ratio for gynecological cancer was 0.247 (p = 0.018, 95% CI 0.077–0.791) and significantly represented in the survival analysis (p = 0.01). Limitations, reasons for caution There was no access to BMI and smoking status. Patients were followed for a mean period of 16 years; cancer may present later than 16 years. Wider implications of the findings: Unexplained RPL is assumed to have an immunological basis. Our study may provide an indirect support for hyper-responsive immunological mechanisms in RPL patients. Further research is needed to deepen our understanding of the underlying mechanisms and possibly to facilitate treatment options. Trial registration number Not applicable