G20210A Prothrombin Gene Mutation Research Articles

Thrombophilic polymorphisms – factor V Leiden G1691A, prothrombin G20210A and MTHFR C677T – in Tunisian patients with cerebral venous thrombosis

Cerebral venous thrombosis (CVT) has been associated with thrombophilic defects. We performed a study to evaluate the role of three single nucleotide polymorphisms (SNP), factor V Leiden G1691A (FVL), prothrombin gene mutation G20210A (FII-G20210A) and methylenotetrahydrofolate reductase variant C677T (MTHFR-C677T), as risk factors for CVT in Tunisian patients. A single center case-control study (26 patients with CVT and 197 controls) was performed. Genomic DNA was tested for the three SNP. The principle finding was the association between FVL and CVT (p<0.001, Odds ratio=6.1, 95% confidence interval=2.3–16.5). However, neither the FII-G20210 (p=0.536) nor the homozygous MTHFR-C677T genotype (p=0.325) variant contributed to the risk of CVT in these Tunisian patients.

Unexplained infertility: Association with inherited thrombophilia

IntroductionUnexplained infertility represents one of the most common diagnoses in fertility care. Attention is being paid to the association between inherited thrombophilia and infertility causes. In this study we investigated the prevalence of inherited thrombophilia according to infertility causes. Materials and methodsWe studied Prothrombin gene G20210A mutation, Factor V Leiden, deficiencies in protein S and C and antithrombin in 930 Caucasian infertile women referred to Fertility Center of the Department of Sciences for Woman and Child's Health, University of Florence, of whom 230 with unexplained, 195 female and 283 male infertility, and in 240 women who have conceived naturally without hormonal stimulation therapy. ResultsA significant relationship between inherited thrombophilia [OR 95%CI 1.97 (1.05-3.68), p=0.03] and unexplained infertility was observed, whereas no association between thrombophilia and female and male infertility was found. Significantly higher prevalence of prothrombin gene mutation in unexplained infertile women in comparison to that observed in fertile women was observed (5.7% vs 2.1% p=0.04); the prevalence of the other thrombophilia determinants was higher, even if not significantly, in the unexplained infertile group. ConclusionsThis study demonstrates the relationship between inherited thrombophilia and unexplained infertility, thus suggesting the contribution of genetic components in modulating unexplained infertility, behind anovulation, male and tubal factor.

Abstract 3371: Inherited Thrombophilias In Cryptogenic Stroke Patients Under 55 Years Old

Background: inherited thrombophilias cause venous thrombotic events, however, their association with brain ischemia in adult patients is controversial. Our objective was to study the association between thrombophilia and cryptogenic stroke in patients under 55 years of age. Methods: prospective observational study of consecutive patients under 55 years of age who had had a brain ischemia (transient ischemic attack of brain infarction). The patients with cryptogenic brain ischemia were compared with the controls patients with brain ischemia of known cause. We examined the presence of thrombophilia (Factor V Leiden and prothrombin G20210A gene mutations; deficiencies in protein S, protein C and antithrombin levels; resistance to activated protein C) and patent foramen ovale (PFO) in all patients. Results: Two hundred fifty-four patients were included, 108 with cryptogenic brain ischemia and 146 controls patients with brain ischemia of known cause. Patients with cryptogenic brain ischemia were younger (mean age 42.4 vs. 45.6 years old, P=0.002). The frequency of thrombophilia was significantly higher among patients with cryptogenic brain ischemia than those with brain ischemia of known cause (22.2% vs. 6.8%, P&lt;0.001). Taking into account each thrombophilic disorder separately, prothrombin G20210A mutation and protein C or S deficiency were significantly higher in the cryptogenic brain ischemia group than in the known cause group (10.2% vs. 2.7% and 8.3% vs. 2.1%, respectively, P&lt;0.05) while Factor V Leiden mutation was similar in both groups (4.6% vs. 2.7%, P NS). The frequency of PFO and PFO plus thrombophilia were higher among patients with cryptogenic brain ischemia (35.2% vs. 12.3% and 8.4% vs. 0%, respectively, P&lt;0.001). The PFO (+) cryptogenic brain ischemia patients showed higher frequency of thrombophilia than the other patients (23.7% vs. 11.6%, P=0.043), in particular prothrombin G20210A mutation (15.8% vs. 4.2%, P=0.014). Multivariate analysis adjusted confounding factors showed than the presence of thrombophilia was independently associated with cryptogenic brain ischemia (OR 3.9; 95% CI, 1.69 - 8.97; P=0.001). Conclusion: there is an association between thrombophilia and cryptogenic brain ichemia in patients under 55 years old. These data suggest that systemic thrombophilic disorders are cause of thromboembolic phenomena in brain arteries

Painless Livedoid Vasculopathy in a Patient with G20210A Prothrombin Gene Mutation

87 year old Caucasian female with chronic painless non-healing ulcers over malleoli was admitted to the hospital. On a physical examination, there were two bilateral and laterally located malleoli ulcers with no discharge. A thorough work up was done: lower extremities venous and arterial Doppler ultrasound did not show any evidence of venous and arterial disease respectively. Heterozygous G20210A Prothrombin gene mutation was found, and the patient was started on anticoagulation. This case reports highlights a possibility of a painless livedoid vasculopathy presentation in a patient without significant past thrombotic events. Therefore, it is important to consider livedoid vasculopathy in the differential in a patient with painless ulcerative, atrophic and/or nodular skin lesions over the shins and malleoli.

Factor V Leiden and prothrombin gene G20210A mutation and in vitro fertilization: prospective cohort study

Factor V Leiden and prothrombin gene G20210A mutation and in vitro fertilization: prospective cohort study

Low‐molecular‐weight heparin added to aspirin in the prevention of recurrent early‐onset pre‐eclampsia in women with inheritable thrombophilia: the FRUIT‐RCT

Early-onset hypertensive disorders (HD) of pregnancy and small-for-gestational age infants (SGA) are associated with placental vascular thrombosis, these often recur and are also associated with inheritable thrombophilia. Aspirin reduces the recurrence risk. Adding low-molecular-weight heparin (LMWH) to aspirin at < 12 weeks gestation reduces the recurrence of HD in women with previous early-onset HD (pre-eclampsia, hemolysis, elevated liver enzymes and low platelets [HELLP] syndrome and eclampsia) and/or SGA, in the context of inheritable thrombophilia without antiphospholipid antibodies. In a multicenter randomized control trial (RCT), 139 women included were< 12 weeks gestation. previous delivery< 34 weeks gestation with HD and/or SGA; inheritable thrombophilia (protein C deficiency, protein S deficiency, activated protein C resistance, factor V Leiden heterozygosity and prothrombin gene G20210A mutation heterozygosity); and no antiphospholipid antibodies detected. either daily LMWH (dalteparin, 5000 IU weight-adjusted dosage) with aspirin 80 mg or aspirin 80 mg alone. recurrent HD onset (i) < 34 weeks gestation and (ii) irrespective of gestational age. recurrent SGA, preterm birth, maternal/neonatal hospitalization, spontaneous abortion and individual HD. Analysis by intention-to-treat. Low-molecular-weight heparin with aspirin reduced recurrent HD onset < 34 weeks gestation (risk difference [RD] 8.7%: confidence interval [CI] of RD 1.9–15.5%; P = 0.012; number needed to treat [NNT] 12). Recurrent HD irrespective of gestational age was not different between the arms. No women withdrew as a result of adverse effects. http://www.isrctn.org) (isrctn87325378). Adding LMWH to aspirin at < 12 weeks gestation reduces recurrent HD onset < 34 weeks gestation in women with inheritable thrombophilia and prior delivery for HD/SGA <34 weeks. However, close monitoring of the mother and fetus remains important throughout pregnancy.

Factor V G1691A (Leiden) and prothrombiG20210A gene mutation status, and thrombosis in patients with chronic myeloproliferative disorders.

The aim of this study was to examine Factor V G1691A (Leiden) (FVL) and prothrombin G20210A (PT) gene mutation status, and their relationship with thrombosis in patients with chronic myeloproliferative disorders (CMPDs). The study included 160 patients with a CMPD that were regularly followed-up between 1993 and 2009. FVL and PT mutation status was established based on blood samples analyzed via PCR using specific primers. The frequency of FVL and PT mutation was 12.5% and 4.4%, respectively. In total, 27 episodes of thrombosis occurred in 24 (15%) of the patients, and there wasn't an association between the observed thrombotic events, and FVL or PT mutations. Hepatic vein thrombosis was noted in 3 patients that had FVL mutation, of which 1 also had PT mutation. We did not observe a relationship between thrombosis, and FVL or PT mutations in CMPD patients; however, 3 of the patients that had hepatic vein thrombosis also had FVL mutation. Larger studies are needed to more clearly determine if all CMPD patients with hepatic vein thrombosis need be investigated for FVL and PT mutation.

An Interesting Case of Chronic Idiopathic Non-cirrhotic Portal Vein Thrombosis

Purpose: Introduction: Portal vein thrombosis was first reported in 1868 by Balfour and Stewart. It is a rare condition that typically presents in non-cirrhotic patients. Inherited (Factor V Leiden and Prothrombin gene mutation G201210A, Protein C, S, Anti thrombin III deficiency) and acquired thrombophilias (Lupus Anticoagulant, myeloproliferative diseases, malignancy, surgery and trauma) account for majority of the cases of portal vein thrombosis. Doppler ultrasound studies are usually the initial test of choice. Case Report: 63 year old Hispanic Female with history of hypertension, Diabetes Mellitus, coronary artery disease presented with complaints of epigastric pain & bloody vomiting. She initially had epigastric discomfort & 2 episodes of hematemesis. She denied alcohol use. Abdominal examination was unremarkable except for mild epigastric tenderness. Laboratory analysis revealed hemoglobin of 10.5 mg/dl with normal liver function tests and aminotransferases. An upper gastrointestinal endoscopic examination was done which revealed grade 4 esophageal varices with fresh blood in the distal esophagus which were subsequently ligated. She was started on octreotide and propranolol. She had another episode of GI bleed requiring emergent endoscopic intervention. She underwent a liver biopsy. Pathology revealed focal mild portal fibrosis with mild micro & macro vesicular steatosis but no cirrhosis. A Doppler Ultrasound revealed portal vein thrombosis and concomitant portal hypertension. An extensive hypercoaguable work up was done which included protein C & S levels, anti thrombin III, Prothrombin gene mutation G20210A, Factor V Leiden, Lupus anticoagulant, Anticardiolipin antibodies, Homocysteine level & they were all negative. We also tested her blood for flow-cytometry for CD 55 and CD 59 but the test was normal and in the process effectively ruled out paroxysmal nocturnal hemoglobinuria. She also was also tested for the JAK 2 mutation. It was negative. We gave her the clinical diagnosis of chronic idiopathic non-cirrhotic portal vein thrombosis. She subsequently had a meso-caval shunt done to relieve the portal hypertension. She was started on warfarin anticoagulation 3 days later with close monitoring for bleeding. She clinically got better and was then discharged home. Discussion: Non-cirrhotic portal vein thrombosis can be acute or chronic. Acute cases need at least 3 months of anticoagulation. Chronic cases needs porto-systemic shunting. The use of anticoagulation in chronic cases should be decided upon on a case by case basis weighing the risk of bleeding versus thrombosis. We opted to give longterm anticoagulation to our patient to prevent re-thrombosis of the mesocaval shunt/graft.

Does testicular sperm improve ICSI outcome in patients with necrozoospermia?

Does testicular sperm improve ICSI outcome in patients with necrozoospermia?

Factor V Leiden and prothrombin gene G20210A mutation and in vitro fertilization: prospective cohort study

The influence of thrombophilia on fertility and on IVF outcome is very controversial. The objectives of this study were: (i) to compare the prevalence of Factor V Leiden (FVL) and prothrombin gene G20210A mutation (PGM) in women undergoing IVF to women with spontaneous pregnancy; (ii) to compare the IVF outcomes and the risk of complications in FVL and PGM carrier to non-carrier women. From March 2005 to December 2009, a total of 510 women requiring IVF were recruited in a prospective cohort study. A separate population of 490 nulliparous women who conceived naturally was also evaluated as fertile controls. All women were tested for the presence of FVL and PGM. The prevalence of thrombophilic mutations was the same among women requiring IVF (6.9%) and women with spontaneous pregnancy (6.9%). A total of 480 patients underwent 1105 IVF cycles. There were 30 women carriers (86 IVF cycles) and 450 non-carriers for thrombophilic mutations (1019 IVF cycles). No significant differences in the mean number of oocytes retrieved and the number of good quality embryos transferred were found between the mutation carrier and non-mutation carrier women; likewise the reproductive outcome and the IVF complications were not statistically different between the two groups. The cumulative live birth rate after six IVF cycles was similar in the mutation carrier and non-mutation carrier women. For the mutation carrier women, the optimistic estimate of cumulative live birth rate after six IVF cycles was 60.8% and the conservative estimate was 50.0%. Corresponding rates for the non-mutation carrier women were 56.8 and 36.2%, respectively. The results of this study suggest that FVL and PGM presence in asymptomatic women and in the absence of other risk factors do not influence IVF outcome, or represent risk factors for ovarian hyperstimulation syndrome (OHSS), or favour thrombosis after IVF. Screening for FVL and PGM does not appear to be justified to identify the patients at the risk for IVF failure, and/or for OHSS, and/or for thrombotic complications.

Livedoid vasculopathy secondary to high levels of lipoprotein(a)

Funding sources: none. Conflicts of interest: none declared. Madam, Livedoid vasculopathy (LV) was first described by Bard and Winkelmann in 1967.1 It is characterized by a long history of recurrent painful ulcerations of the feet and legs2 and scar lesions named atrophie blanche.3 LV is a thrombotic (occlusive) vasculopathy of the small vessels of the lower extremities.3 Histology shows microthromboses and/or segmental hyalinization of the subendothelial intimal layer of blood vessels of the middle and lower dermis.3 Its exact aetiology remains uncertain, but thrombotic and microcirculatory phenomena have been implicated as possible pathogenic factors.3, 4 Several thrombophilic conditions have been reported to be associated with LV (Table 1).2–7 We report two patients with LV secondary to high levels of lipoprotein(a) [Lp(a)]. Patient 1 was a 29‐year‐old white woman, referred to us because of recurrent painful ulcerations in the legs associated with extensive livedo racemosa on her upper and lower limbs. There were several shallow ulcerations in the malleolar regions, necrosis and crusts (Fig. 1). She had previously been treated with oral aspirin and pentoxifylline without response. Skin biopsy confirmed the clinical diagnosis of LV. Results of extensive laboratory testing for the established abnormalities associated with LV were all negative, including thrombophilic states [factor V G1691A gene mutation (Leiden), prothrombin G20210A gene mutation, methylenetetrahydrofolate reductase (MTHFR) mutation and homocysteinaemia, protein C and/or protein S deficiency, antithrombin III deficiency, anticardiolipin antibodies, lupus anticoagulant], hepatitis B and C infection and autoimmune diseases. We introduced oral warfarin and international normalized ratio (INR) was maintained at 3. One week after the treatment onset, the pain ceased. Total healing of the cutaneous ulcerations was obtained after the third month under warfarin therapy. After this, ulcerations relapsed twice, but on both occasions the INR was below the therapeutic level (2–3) and the patient quickly responded after that level was reached. Because of the recent description of an association between LV and elevated levels of Lp(a),6 we reviewed the case and found an increased level of Lp(a) (51 mg dL−1; normal < 30).

Venous thromboembolism in Asia – an unrecognised and under-treated problem?

Venous thromboembolism (VTE) has been perceived for a long time to be less common in Asian populations, particularly in the Far East, than in Western populations. Generally, thromboprophylaxis is not implemented as frequently as it should be in high-risk patients. However, recent prospective studies undertaken in Asian countries have demonstrated higher rates of VTE after major surgery and in medical wards, approaching those observed in Western populations. Risk factors for VTE are not different in Asian patients from those of Western patients with the exception of thrombophilic mutations. Deficiencies of the natural anticoagulants (protein S, protein C, and antithrombin) are the predominant thrombophilias in Asia whereas factor V Leiden and prothrombin G20210A gene mutation are not found or rarely reported. Further large well-designed clinical studies are needed to evaluate the magnitude of the risk of VTE and the appropriate use of thromboprophylaxis in different clinical situations.

Duration of Anticoagulation: Applying the Guidelines and Beyond

Despite an improved understanding of the risk factors underlying venous thromboembolism (VTE), extensive clinical investigation, and detailed clinical guidelines, the decision to extend anticoagulation indefinitely for an individual patient with VTE is often problematic. Patients with VTE in association with major surgery, trauma, immobilization, or pregnancy are at relatively low risk of recurrence and generally do not require more than 3 to 6 months of anticoagulant therapy. For patients with a first unprovoked, or idiopathic, episode of VTE, an individualized approach should be taken in deciding on the duration of anticoagulation based on the patient's recurrence and bleeding risk, as well as their personal preference. Although the presence of genetic thrombophilic disorders (factor V Leiden and prothrombin G20210A gene mutations; deficiencies of antithrombin, protein C, and protein S) predispose patients to a first episode of VTE, there is inconsistent data on whether testing for these defects changes patient outcomes or should alter their management. In patients with a single unprovoked VTE, measurement of D-dimer several weeks following the completion of anticoagulant therapy appears useful in stratifying patients with a first unprovoked episode of VTE with regard to recurrence risk. Through a series of clinical vignettes, the utility of the laboratory in risk-stratifying patients with respect to recurrence risk will be discussed, along with decision making regarding the duration of anticoagulation. The potential impact of having a nonremovable inferior vena caval filter will also be addressed.

Activated protein C resistance among postmenopausal women using transdermal estrogens

Although the route of estrogen administration is known to be an important determinant of the thrombotic risk among postmenopausal women using hormone therapy, recent data have shown that norpregnane derivatives but not micronized progesterone increase venous thromboembolism risk among transdermal estrogens users. However, the differential effects of progesterone and norpregnanes on hemostasis have not yet been investigated. We set up a cross-sectional study among healthy postmenopausal women aged 45 to 70 years. The impact of activated protein C (APC) on endogenous thrombin potential was investigated in the plasma samples of 108 women who did not use any hormone therapy (n = 40) or who were treated with transdermal estrogens combined with micronized progesterone (n = 30) or norpregnane derivatives (n = 38). After exclusion of women with factor V Leiden and/or G20210A prothrombin gene mutations, there was no significant change in APC sensitivity among women who used transdermal estrogens combined with micronized progesterone compared with nonusers. Women using transdermal estrogens combined with norpregnanes were less sensitive to APC than were nonusers (P = 0.003) or users of transdermal estrogens combined with micronized progesterone (P = 0.004). In addition, prothrombin fragment 1 + 2 concentration was higher in users of transdermal estrogens plus norpregnanes than in nonusers (P = 0.004). Other hemostatic parameters did not vary significantly across the different subgroups. Transdermal estrogens combined with norpregnanes may induce APC resistance and activate blood coagulation. These results provide a biological support to epidemiological data regarding the potential thrombogenic effects of norpregnanes. However, these findings need to be confirmed in a randomized trial.

Estados de hipercoagulabilidad e ictus isquémico en pacientes jóvenes

Introduction Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group. Materials and methods Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome. Results We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04). Conclusions The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them.

Factors that Predict Risk of Thrombosis in Relatives of Patients with Unprovoked Venous Thromboembolism

Conclusion: Unprovoked venous thromboembolism (VTE) occurring at a young age is associated with increased risk of VTE in families of patients with VTE. Summary: About one-quarter of all VTE is idiopathic or “unprovoked.” One-third of these patients will have identified genetic predispositions to thrombosis. The factor V-Leiden and G20210A prothrombin gene mutations account for 90% of detected genetic abnormalities (Lancet 2003;138:19-25). If a genetic mutation is not identified in a patient with VTE, it is often assumed that relatives do not have increased risk of thrombosis. Such an assumption may not be true, however, because it is likely there are many causes of heredity thrombophilia that have yet to be discovered. The authors' primary hypothesis was at the risk of VTE would be similar in families of patients who had factor V-Leiden or the G20210A prothrombin gene mutation compared with relatives of patients with neither of these two abnormalities. The authors assumed that most patients with unprovoked VTE, who have negative tests for thrombophilia, do in fact have hereditary defects that have yet to be discovered and that these abnormalities would increase the risk of thrombosis in the patient's first-degree relatives. This was a cross-sectional study. Investigators were blinded to whether patients or their relatives had thrombophilia. The prevalence of previous venous VTE in 1916 first-degree relatives of 348 unselected patients with a first episode of unprovoked VTE was investigated. Patient characteristics and the presence of factor V-Leiden or the G20210A prothrombin gene mutation was assessed as predictors of VTE in the patient's first-degree relatives. The first-degree relatives had sustained 102 previous episodes of VTE (prevalence 5.3%). Patient thrombosis at a young age was the strongest predictor of VTE in relatives. There was an odds ratio (OR) of 3.27 (95% confidence interval [CI], 1.68-6.38) for younger patients (patients aged <45 when VTE occurred; lowest quartile) compared with older patients (patients aged >71; highest quartile). The presence of factor V-Leiden or G20210A prothrombin gene mutation was a weak independent predictor of VTE in relatives (adjusted OR, 1.48; 95% CI, 0.94-2.33). Comment: The data indicate that the age of patients with unprovoked VTE is probably the single best way to stratify the risk of VTE in those patients' families. Testing for factor V-Leiden or the G20210A prothrombin gene mutation in a patient with unprovoked VTE has limited ability to predict VTE in first-degree relatives. The data also provide indirect evidence that there are undiscovered hereditary thrombophilic abnormalities in many patients with unprovoked VTE.

Prothrombin G20210A carriers the genetic mutation and a history of venous thrombosis contributes to thrombin generation independently of factor II plasma levels.

The prothrombin (PT) G20210A gene mutation is a common risk factor for venous thrombosis (VT), which is mainly mediated through an increase in factor II (FII) plasma levels. High FII plasma levels may act through an increase in endogenous thrombin potential (ETP) a key step in hemostasis and thrombosis. While FII may be the main contributor to ETP in PT G20210A carriers, the knowledge of other environmental or genetic factors influencing ETP may help to better identify those at risk of VT. ETP was determined in 472 non-carriers of PT G20210A (PT-) and in 325 unrelated carriers of PT G20210A (PT+) with (symptomatic n = 158) or without (asymptomatic, n = 167) a history of VT. All PT+ were heterozygous and free of other thrombophilic defects. ETP was higher in asymptomatic PT+ than in PT- (2038 +/- 371 vs. 1616 +/- 267 nmol L(-1) min; P < 0.0001). ETP was significantly higher in symptomatic PT+ than in controls PT+ (2129 +/- 430 vs. 2038 +/- 371 nmol L(-1) min; P = 0.01). Multivariate analyses evidenced the importance of FII and fibrinogen plasma levels in determining ETP. After taking these variables into account, a personal history of VT remained associated with ETP in PT+ carriers. Moreover, PTG20210A still contributes to ETP after consideration of FII levels. In conclusion, the increase in ETP observed in carriers is not entirely explained by higher FII or fibrinogen plasma levels but also by the history of VT.

ORIGINAL ARTICLE: A Prospective Case–Control Study Analyzes 12 Thrombophilic Gene Mutations in Turkish Couples with Recurrent Pregnancy Loss

Citation Yenicesu GI, Cetin M, Ozdemir O, Cetin A, Ozen F, Yenicesu C, Yildiz C, Kocak N. A prospective case–control study analyzes 12 thrombophilic gene mutations in Turkish couples with recurrent pregnancy loss. Am J Reprod Immunol 2010; 63: 126–136Problem Recurrent pregnancy loss (RPL) is a heterogeneous disorder. The contribution of specific thrombophilic genes to the pathophysiology of RPL has remained controversial. We evaluated the prevalences of 12 thrombophilic gene mutations among homogenous Caucasian couples with RPL and fertiles.Method of study This was a prospective case–control study evaluating 272 women with RPL and 152 of their male partners, and a control group of 56 fertile couples. We investigated mutations including FV Leiden, factor V H1299R, factor II prothrombin G20210A, F XIII V34L, β‐fibrinogen −455G&gt;A, plasminogen activator inhibitor‐1, GPIIIa L33P (HPA‐1 a/b L33P), MTHFR C677T, MTHFR A1298C, ACE I/D, Apo B R3500Q, and Apo E.Results Overall, heterozygous mutations of FV Leiden, FXIII V34L, GPIIIa L33P, Apo E4, and prothrombin G20210A and homozygous mutations of PAI‐1and MTHFR C677T were associated with RPL. There was no meaningful association between RPL and other studied genes.Conclusion In contrast to the other mutations and polymorphisms, FV Leiden, FXIII V34L, GPIIIa L33P, Apo E, prothrombin G20210A, PAI‐1 and MTHFR C677T gene mutations may help to identify the couples at risk for recurrent pregnancy loss.

Risk factors for clinical manifestations in carriers of Factor V Leiden and prothrombin gene mutations

Carriers of Factor V Leiden and prothrombin G20210A gene mutations have an increased risk of developing thromboembolic events and adverse outcomes of pregnancy. The objective of the present study was to identify risk factors which may predispose carriers of Factor V Leiden and/or prothrombin G20210A gene mutations to develop thromboembolic events and adverse outcomes of pregnancy. A retrospective case-control study of 217 carriers of Factor V Leiden and/or prothrombin G20210A gene mutations at two tertiary centers between January 2000 and December 2006. Symptomatic carriers (cases) were compared with asymptomatic carriers (controls) for the following risk factors: environmental, cardiovascular, family history of thrombosis, and presence of other thrombophilias. For female carriers, we included the use of female hormones, pregnancy, and the postpartum period. Of the 217 carriers, there were 155 (71%) cases and 62 (29%) controls. Of the 155 cases, 90 (58%) had venous thrombosis and 26 (17%) arterial thrombosis. Among the 123 symptomatic female carriers, 55 (45%) had recurrent pregnancy losses and nine (7%) other adverse outcomes of pregnancy. The postoperative state and the presence of antiphospholipid antibodies were risk factors for thromboembolic events and adverse outcomes of pregnancy in 10 (6%) and 22 (13%) cases, respectively. The presence of antiphospholipid antibodies in symptomatic carriers increased the risk of developing thromboembolic events 4.4-fold. The postoperative state and the presence of antiphospholipid antibodies were significant risk factors for thromboembolic events and adverse outcomes of pregnancy among Factor V Leiden and/or prothrombin G20210A gene mutation carriers. Testing for the presence of antiphospholipid antibodies may be warranted in Factor V Leiden and/or prothrombin G20210A gene mutation carriers who develop these adverse clinical manifestations.

Diagnostic algorithm for thrombophilia screening

Thrombophilia screening is aimed at detecting the most frequent and well-defined causes of venous thrombosis, such as activated protein C resistance/factor V Leiden mutation, prothrombin G20210A gene mutation, deficiencies of natural anticoagulants, such as antithrombin, protein C and protein S, the presence of antiphospholipid antibodies, hyperhomocysteinemia and increased factor VIII activity. At this time, thrombophilia screening is not recommended for those possible congenital or acquired risk factors, whose association with increased risk of thrombosis has not been proven sufficiently. Laboratory investigations should include a step-wise approach to the diagnosis of thrombotic disorders with respect to the assays and methods of analysis that are used. The assays recommended for the first diagnostic step of screening should establish, whether the subject has one of the common causes of thrombophilia. If one or more abnormal results are obtained, the second diagnostic step includes the assays recommended for confirmation and/or characterization of the defect. When performing the investigation of thrombophilia, it is important to consider all pre-analytical and other variables that may affect the results of thrombophilia testing, including time of testing, age, gender, liver function, hormonal status, pregnancy or the acute phase response to inflammatory diseases. This is necessary, in order to avoid, any misinterpretation of the results. This review summarizes the current knowledge concerning thrombophilia investigations, with special focus on the diagnostic algorithm regarding patient selection, the assays and methods of analysis used and all the variables that should be considered when employing tests for the diagnosis of thrombophilia.