Trimester Miscarriage Research Articles

Hysteroscopy in the Evaluation of Recurrent First Trimesteric Miscarriages

Abstract Background Recurrent pregnancy loss (RPL) is one of the most frustrating and difficult areas in reproductive medicine because the etiology is often unknown and there are few evidence-based diagnostic and treatment strategies. Studies on the etiology, evaluation, and management of RPL are often flawed, uterine factors (acquired and congenital)are responsible for 10 to 50 %of recurrent pregnancy loss,hysteroscopy is the gold standard for evaluation of the eendometrial cavity. Aim of the work to evaluate the role of hysteroscopy in the diagnosis of possible uteri.ne congenital and acquired causes of recurrent first trimesteric miscarriages. Patients and methods This prospective cohort study was conducted on 164 patients with recurrent (3 or more), first trimester miscarriage planned to undergo office (diagnostic) hysteroscopy to assess the uterine cavity, who attend Ain Shams University maternity Hospital Early Cancer detection Unit during period from July 2018 to December 2018. Results the largest proportion 53% of our study population had abnormal hysteroscopic findings, and the uterine septum had the highest prevalence among women with recurrent first trimesteric miscarriages. Conclusion In women with recurrent pregnancy loss, hysteroscopy is a useful diagnostic tool in the diagnosis of possible uterine causes of recurrent miscarriages. Uterine septum is the most common congenital uterine abnormality found in patients with recurrent first trimesteric miscarriages.

Euploid miscarriage is associated with elevated serum C-reactive protein levels in infertile women: a pilot study

PurposeIncreased serum C-protein (CRP) levels reduce fecundity in healthy eumenorrheic women with 1–2 pregnancy losses. Subclinical systemic inflammation may impede maternal immune tolerance toward the fetal semi-allograft, compromising implantation and early embryonic development. Some miscarriages with normal karyotypes could, therefore, be caused by inflammation. Whether pre-pregnancy CRP relates to karyotypes of spontaneously aborted products of conception (POCs) was investigated.MethodsA study cohort of 100 infertile women with missed abortions who underwent vacuum aspirations followed by cytogenetic analysis of their products of conception tissue was evaluated at an academically affiliated fertility center. Since a normal female fetus cannot be differentiated from maternal cell contamination (MCC) in conventional chromosomal analyses, POC testing was performed by chromosomal microarray analysis. MCC cases and incomplete data were excluded. Associations of elevated CRP with first trimester pregnancy loss in the presence of a normal fetal karyotype were investigated.ResultsMean patients’ age was 39.9 ± 5.8 years; they demonstrated a BMI of 23.9 ± 4.6 kg/m2 and antiMullerian hormone (AMH) of 1.7 ± 2.4 ng/mL; 21.3% were parous, 19.1% reported no prior pregnancy losses, 36.2% 1–2 and 6.4% ≥ 3 losses. Karyotypes were normal in 34% and abnormal in 66%. Adjusted for BMI, women with elevated CRP were more likely to experience euploid pregnancy loss (p = 0.03). This relationship persisted when controlled for female age and AMH.ConclusionsWomen with elevated CRP levels were more likely to experience first trimester miscarriage with normal fetal karyotype. This relationship suggests an association between subclinical inflammation and miscarriage.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve.

Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy. To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve. Women aged 18-44years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy. Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6±4.6years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00pmol/L (range 5-67pmol/L) vs 15.25pmol/L (range 3-96pmol/L), P=0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40pmol/L (range 3.9-37.8pmol/L) vs 13.67pmol/L (range 2.8-30.5pmol/L), P=0.185). Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Study of Spectrum of Chromosomal Rearrangements in Recurrent Pregnancy Loss.

Recurrent pregnancy losses (RPLs) are seen in up to 15-20% of all clinically recognized pregnancies, 1-2% of women in general population. Repeated losses are seen in 5-10% of women. The prevalence of chromosomal rearrangements is 6.65% in couples with repeated pregnancy losses. Two to 4% of RPL are associated with parental balanced reciprocal and Robertsonian translocations. The study was conducted at a tertiary care hospital in New Delhi, and in total, 204 couples with RPL enrolled in the study. In total, 4490 couples presented to the obstetric clinic, of which 204 (4.5%) couples had repeated pregnancy losses. Cytogenetic analysis was done in 198 couples. Out of total 198 patients, 14 patients (7.1%) had cytogenetic alterations. Most common aberrations observed were structural rearrangements, of which reciprocal translocations were more common. In our study cohort, all the couples had maternal age of ≤ 35years and all the alterations were seen either in mother or in both parents. Our study highlights that cytogenetic alterations not only are common in first trimester miscarriages, but are an important event in miscarriages presenting at later period of gestation and in young mothers as well.

The use of autologous platelet-rich plasma (PRP) versus no intervention in women with low ovarian reserve undergoing fertility treatment: a non-randomized interventional study

To investigate the impact of a 3-month course of intracortical injections of autologous platelet-rich plasma (PRP) upon ovarian reserve markers versus no intervention in women with low ovarian reserve prior to undergoing assisted reproductive technology (ART). Prospective controlled, non-randomized comparative study conducted in a private fertility clinic,in Venezuela. Women with abnormal ovarian reserve markers (FSH, AMH and AFC) who declined oocyte donation were allocated to one of the following groups according to patient choice: monthly intracortical ovarian PRP injections for three cycles, or no intervention. Primary outcomes were the change in FSH, AMH and AFC pre- and post-treatment. Secondary outcomes included the number of oocytes collected and fertilized, biochemical/clinical pregnancy rates and miscarriage and live birth rates. Eighty-three women were included, of which 46 received PRP treatment and 37 underwent no intervention. Overall median age was 41years (IQR 39-44). There were no demographic differences between the study groups. At the 3-month follow-up, women treated with PRP experienced a significant improvement in FSH, AMH and AFC, whereas there was no change in the control group. Furthermore, overall rates of biochemical (26.1% versus 5.4%, P = 0.02) and clinical pregnancy (23.9% versus 5.4%, P = 0.03) were higher in the PRP group, while there was no difference in the rates of first trimester miscarriage and live birth between groups. PRP injections are effective and safe to improve markers of low ovarian reserve prior to ART, although further evidence is required to evaluate the impact of PRP on pregnancy outcomes.

Dinoprostone in First Trimester Miscarriages: A Prospective Observational Study in a Malaysian Tertiary Healthcare Institution

The objective of this paper was to evaluate the outcome of medical evacuation of first trimester miscarriages using dinoprostone. A prospective observational study in a tertiary centre between 1st January and 31st December 2018 in Obstetrics and Gynaecology unit, UKM Medical Centre. Women diagnosed with incomplete and missed miscarriage (n=41) at or less than 13 weeks of gestation were recruited. Dinoprostone 3 mg was inserted into the posterior fornix, twice within 6 h apart on day-1 followed by similar protocol on day-2. Patients were reassessed clinically and sonographically upon passing out products of conception, at 48 h and day-7. Complete evacuation was defined as closed cervical os and/or endometrial thickness of less than 15 mm sonographically. Treatment failure was defined as failure to achieve complete evacuation by day-7. Overall success rate was 55.3% (n=26) being better in incomplete (n=6, 100%) as compared to missed miscarriage (n=21, 48.8%, p=0.03). Those with successful evacuation required dinosprostone at a mean of 8.4 ± 2.9 mg achieving complete miscarriage within a mean of 27.8 ± 16.6 h. Mean pain score was 5.8 ± 0.8 with mean patient satisfaction score of 8.7 ± 0.8. Mean drop in haemoglobin was 0.7 ± 0.2 g/dL. No major adverse effects were reported. Medical evacuation of miscarriage using intravaginal dinoprostone is safe and promising, with acceptable success rate and high patient satisfaction. This study supported previous studies suggesting presence of prostaglandin E2 receptors in the first trimester.

Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy

Objective To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage. Study design A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery. Results During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient’s choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425). Conclusions This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.

Routine Histopathological Analysis of the Products of Conception: Is there a Value?

Background:Spontaneous miscarriage is one of the two most common problems encountered in the first trimester of pregnancy. The value of histopathological analysis of products of conception (POC) obtained as a result is a source of controversy. The aim of this study is to evaluate the histopathological characteristics of suspected POC following the first-trimester miscarriage and determine the clinical value of such histopathological analyses.Materials and Methods:This is a retrospective study of the histopathological analysis of POC over a period from January 1st to December 31st of 2016 carried out in the histopathology laboratory of a university teaching hospital. Materials for the study were POC obtained following spontaneous first trimester miscarriage and received in our laboratory. Relevant information about the patients was retrieved from the laboratory database and matched with laboratory request forms and copies of histopathology reports archived in the laboratory. Obtained data were analyzed by simple statistical methods.Results:The most common clinical diagnosis on admission was incomplete abortion (n = 52; 48.6%), followed by complete abortion (n = 31; 29.0%); the lowest was blighted ovum (n = 1; 0.9%). The predominant histopathological type was normal POC which constituted 73 cases (68.2%). Other histopathological diagnoses include hydatidiform mole (9, 8.4%) and no evidence of conception (15, 14%). Clinical and ultrasound evaluation missed 2 (22.2%) of the 9 histopathologically diagnosed hydatidiform moles.Conclusion:Histopathological analysis of POC helps to diagnose molar pregnancies and other conditions which can be missed by clinical and ultrasound evaluation. Therefore, routine histopathological analysis of POC is advocated.

Spontaneous Resolution of Traumatic AV Malformation of the Uterus Following Hysteroscopic Cold Knife Evacuation of Retained Products of Conception

Uterine myometrial arteriovenous malformations (AVM) are reported on color doppler ultrasonography as mosaic pattern of blood flow with different peak systolic velocities (PSV) at different places. High PSV within the AVM may require arterial embolization as treatment. However, we present a case of traumatic AVM with incomplete abortion managed by hysteroscopic cold knife evacuation. This case report is of a young patient with off and on vaginal bleeding for 3 1/2 months following 2nd trimester spontaneous abortion. She had undergone dilation and evacuation (D & E) for incomplete abortion. Now the bleeding was heavy and intermittent not responding to medications. The subsequent TVS examination shows incomplete abortion with myometrial AVM with high PSV. Hysteroscopic cold knife removal of products of conception resulted in immediate resolution of Uterine AVM.

835: How accurate is the prenatal diagnosis of a fatal fetal abnormality?

The objective of the study was to examine the outcomes of prenatally diagnosed fatal fetal abnormalities in a high volume European center. We examined both termination rates and spontaneous fetal loss. Data was gathered prospectively in a large tertiary referral center over 5 years from 2013-2017 inclusively. We defined fatal fetal abnormalities as conditions where death was predicted before or shortly after birth. We included all cases of prenatally diagnosed Trisomy 13, Trisomy 18, Triploidy, Renal agenesis, limb body wall complex and anencephaly. Baseline demographic and delivery details were recorded on an anonymized computerized database, these data are subject to continuous audit. The gestation at diagnosis, associated anomalies and the nature of diagnostic tests were recorded. Outcomes including termination of pregnancy (TOP), miscarriage, stillbirth and neonatal death were recorded. There were a total of 44,750 deliveries in the study period. There were 1836 congenital anomalies diagnosed in the study period including 163 cases (8.8%) of fatal abnormalities. There was an incidence therefore of 0.3% or 1 in 333. 67% women chose a termination of pregnancy following the diagnosis. There was an incidence of 9.5% for second trimester miscarriages and 11.7% for stillbirths. The total fetal loss rate prior to delivery in those that did not undergo termination was 65%. There were 35% neonatal deaths with only 1 surviving to 5 weeks. All cases of prenatally diagnosed fatal fetal abnormalities in the study resulted in death, the diagnosis was therefore accurately made. This study was based in a unit where termination of pregnancy required travel to another jurisdiction during the study period, allowing a unique opportunity to observe the natural history. In this study in 99% of cases babies did not survive beyond 4 weeks of life. 65% died before birth and 35% died in the early neonatal period. Accurate outcome data is beneficial when counselling those who choose to continue their pregnancy or in settings where there is limited access to termination of pregnancy.

Fetoplacental ratios in stillbirths and second trimester miscarriages.

An abnormal fetoplacental (F/P) ratio is a risk factor for poor pregnancy outcomes including fetal death, but studies of F/P ratio among stillbirths are limited. In the Wisconsin Stillbirth Service Program cohort of second and third trimester fetal deaths, 1,022 were at ≥24 weeks with data on fetal and placental weight. Comparison with data for viable infants of the same gestational ages (GAs) showed that the F/P ratio increases more rapidly with GA for stillbirths than for viable infants. While placentas of stillborn infants are small at all GA, weights of deceased fetuses are lowest early in the second trimester, becoming nearly normal by term. Excess high F/P ratios are noted at all GAs, increasing toward term, while low ratios are frequent at early gestation but rare near term. Analysis by cause of death shows that F/P ratios are markedly elevated for placental and maternal causes (about 50% above the 90th centile), somewhat elevated for cord accidents, non-hydropic fetal, and unknown causes (about 1/3 above the 90th centile), and variable with 40% below the 10th centile for hydropic stillbirths. Across all causes and GAs, placental weights are more abnormal than fetal weights, suggesting that diminished placental function may contribute to fetal demise even when non-placental causes (e.g., premature membrane rupture, cord accidents, and chromosomal disorders) are identified. About half of all stillbirths have abnormal F/P ratios, suggesting that improvements in prenatal assessment of placental size and function might aid in identifying pregnancies at risk for demise; unfortunately, therapeutic options for ongoing pregnancies with diminished placental function remain limited.

Evaluation of First Trimester Miscarriage among Sudanese Woman in Khartoum State Using Ultrasonography

Background: Miscarriage is that the commonest complication of early pregnancy. In recent years, there has been a trend towards more conservative management for women with first trimester miscarriage. Most miscarriages are due to uterine malformations or chromosomal abnormalities, which account for the majority that occur within 10 weeks of gestation. Ultrasonography is that the most popular modality to verify the presence of a viable intrauterine gestation. In some instances, creating an identification of early pregnancy loss is simple and requires restricted testing or imaging. Purpose: the purpose of this study was to evaluate the first trimester miscarriage among Sudanese women in Khartoum state using ultrasonography. Methods: descriptive prospective across sectional study conducted in Khartoum state hospitals during period from June 2017 to June 2018 using ultrasound. Out of 100 patients whom in the first trimester and accomplishing the exclusion and inclusion criteria included in the study. Results: the results of the study shows that the mean age of pregnant women was 26-± 30 years majority of them between (26-30) years old. (58%) of abortion occur in homemakers occupations groups. Incomplete and complete miscarriage are the most common (34%) and the most common cause of miscarriage was unexplained (80%), trauma (12%), uterine defect (4%), fibroid (2%), febrile diseases (2%). Conclusion: The study concluded that most common type of miscarriage found at Khartoum is incomplete and complete miscarriage. Ultrasound characterized various kinds of miscarriage.

Pregnancy outcomes in a patient with Fontan circulation for single ventricle congenital heart disease and aberrant praevia placental lobe

Single ventricle heart (SVH) is a very rare congenital heart disease. However, since the introduction of Fontan's intervention, the survival rate of patients with SVH has been significantly improved, increasing the number of women who may become pregnant in this condition. It has been already reported, in isolated case presentations or in some series of patients, that the pregnacy in the context of SVH and Fontan circulation carries a very high risk for first trimester miscarriage, maternal cardiovascular or obstetric complications and for an increased rate of pre-term birth. Therefore, it is an open field of debate weather or not to allow pregnancy in this category of patients. We are presenting the case of a 22 years old patient who underwent two surgeries for SVH: a Glenn procedure when she was 2 years old and the implantation of a Fontan circuit at the age of 16 years. Since the last surgery she was under permanent internal cardiac stimulation. During the pregnancy the patient was hemodynamically stable, with a normal resting oxygen saturation and a good ejection fraction of the single ventricle. However, the evolution of this patient has become even more challenging due to an aberrant praevia placental lobe. This condition brought her to hospital for several episodes of metrorrhagia and uterine contractions. She delivered at 33 weeks of gestation by emergency Caesarian section with a good evolution until discharge, for mother and the newborn. This case is supporting the opinion that pregnancy can be tolerated without important cardiovascular events in patients with SVH and Fontan circulation, unless heart failure or cardiac arrythmia are associated. Nevertheless, the obstetrical complications remain an important problem in pregnancy overcome of patients with Fontan circulation for SVH that can be superimposed with other unfavorable conditions, like aberrant praevia placental lobe in this case. During the management of such particular clinical settings difficult decisions must be taken, including those addressing the antithrombotic therapy that will be covered in the presentation of this case. Keywords: Pregnancy outcome; Cardiovascular pregnancy complications; Fontan procedure; Delivery, obstetrics.

Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019.

Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother's womb, her womb develops as two separate halves from two tubular structures called 'müllerian ducts', which fuse together before she is born. Abnormalities that occur during the baby's development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother's womb (fetal growth restriction), pre-eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence-based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1 >.

Real World Data on Obstetric (OC) and Maternal Complications (MC) Occurring in a Cohort of Patients with Ph Negative Myeloproliferative Neoplasms (MPN): Argentinian Multicentric Study

Introduction: Up to 20% of patients (pts) with essential thrombocythemia (ET) and up to 10-15% of pts with polycythemia vera (PV) are diagnosed before the age of 40 years and the percentage is even lower in pts with primary myelofibrosis (PMF). Pregnancy (Pcy) in MPN is associated with an increased incidence of thrombotic and bleeding events and obstetric complications with live birth rates of 50% to 70%. There are no evidence-based guidelines for the management of these pts and most of the data come from case series of few pts. There are no validated variables that can predict outcomes in pregnant women with MPN. Objetives: Primary: To learn the incidence of thromboembolic, hemorrhagic and OC in pregnant women with MPN in Argentina. Secondary: To evaluate parameters such as mutational status, platelet count, history of complications in previous Pcy, use of aspirin (ASA), low molecular weight heparin (LMWH) or interferon (IFN) and their relationship with obstetric outcomes. Materials and methods: Retrospective evaluation of medical records of pts with diagnosis of MPN and Pcy. Quantitative variables were expressed as median and interquartile range (IQR) and qualitative variables as total number and percentage (%). Fisher's exact test was used to analyze variables and their association with events and Wilcoxon test for platelet counts. Results: A total of 30 Pcy in 23 women with a diagnosis of MPN were recorded, 20 Pcy in pts with ET, 4 Pcy in pts with PV and 6 MF pregnancies. Pcy was planned in 56.6% of cases. There were OC in 15/19 previous Pcy. The median age was 32.9 years (IC25-75% 30-36 years). Mutational status was assessed in 22 pts: 9/22 JAK2 +, 7/22 CALR +, 1/22 triple-negative, 1/22 JAK2-CALR- and MPL not performed, 6/22 JAK2- CALR and MPL without data. The overall number of live births and first trimester spontaneous abortions (SA) were 26(86%) and 4(13.3%) respectively, without cases of second (2T) and third trimester (3T) fetal loss or stillbirths. There was a case of neonatal death in a patient with MF. We detected 13 obstetric events (ET: 9/20, PV: 2/4, and MF 2/6): 4 SA, 5 cases of fetal growth retardation, 1 partial placental abruption and 3 placental hematomas. There was no significant association between JAK2 mutational state, history of complications in previous Pcy, platelet count, use of ASA, LMWH or IFN and obstetric outcomes. Two of the pts who had SA presented smoking as a cardiovascular risk factor. There was heterogeneity among hematologist regarding therapeutic management: ASA was indicated in 24 Pcy and LMWH in prophylactic doses during Pcy in 15. In 21/25 cases LMWH was indicated as postpartum prophylaxis, only in 3/21 it was extended for 6 weeks(wks). Before Pcy 17 cases received cytoreductive treatment: 2 with HU and 1 with anagrelide that were discontinued at the time Pcy was confirmed, 5 with peg IFN, and 9 conventional IFN. During Pcy 8 continued with cytoreductive treatment (6/9 conventional IFN, 2/9, pegIFN, including 1 patient previously receiving HU) and 5 initiated IFN (1/5 conventional, 4/5 pegIFN). Platelet counts in pts who did not require cytoreduction dropped from 600 x 109/L (290-1596 x 109/L) at the beginning of Pcy to 470 (240-1548) x 109/L, p=0.0068, and 423 (240-843) x 109/L, p=0.0005, in the 2T and 3T, respectively, with non-significant increase after delivery to 494 x 109/L (122-1600 x 109/L). No cases of maternal thrombosis and 2 episodes of major postpartum bleeding who required surgical intervention one of them with hysterectomy were found.The median time of delivery was at 38 wks of gestation (IC25-75% 36.5-38.5). Vaginal delivery was performed in 6 Pcy, caesarean section (CS) was required due to emergency in 2, because of lack of fetal progression in 2, and 16 were scheduled CS. The median birth weight was 2900g (IC25-75% 2500-3300g). No congenital malformations in live births were detected. Conclusions: Pcy is a rare but high-risk event in MPN pts with 11/30 OC in this cohort. The live birth rate was high compared to the literature. The risk of MC was low, without thrombotic complications and 2/30 episodes of major postpartum bleeding. There was no correlation between mutational status, platelet count or treatments received and obstetric outcomes. There was a significant reduction in the number of platelets in pts with thrombocytosis without requiring cytoreduction. The high percentage of pts who finished their pregnancy with scheduled CS is highlighted. Disclosures No relevant conflicts of interest to declare.

Influence of surgical evacuation on pregnancy outcomes of subsequent embryo transfer cycle following miscarriage in an initial IVF cycle: a retrospective cohort study

BackgroundIt is still uncertain whether surgical evacuation adversely affects subsequent embryo transfer. The present study aims to assess the influence of surgical evacuation on the pregnancy outcomes of subsequent embryo transfer cycle following first trimester miscarriage in an initial in vitro fertilization and embryo transfer (IVF-ET) cycle.MethodsA total of 645 patients who underwent their first trimester miscarriage in an initial IVF cycle between January 2013 and May 2016 in Nanjing Drum Tower Hospital were enrolled. Surgical evacuation was performed when the products of conception were retained more than 8 h after medical evacuation. Characteristics and pregnancy outcomes were compared between surgical evacuation patients and no surgical evacuation patients. The pregnancy outcomes following surgical evacuation were further compared between patients with ≥ 8 mm or < 8 mm endometrial thickness (EMT), and with the different EMT changes.ResultsThe EMT in the subsequent embryo transfer cycle of surgical evacuation group was much thinner when compared with that in the no surgical evacuation group (9.0 ± 1.6 mm vs. 9.4 ± 1.9 mm, P = 0.01). There was no significant difference in implantation rate, clinical pregnancy rate, live birth rate or miscarriage rate between surgical evacuation group and no surgical evacuation group (P > 0.05). The live birth rate was higher in EMT ≥ 8 mm group when compared to < 8 mm group in surgical evacuation patients (43.0% vs. 17.4%, P < 0.05).ConclusionsThere was no significant difference in the pregnancy outcomes of subsequent embryo transfer cycle between surgical evacuation patients and no surgical evacuation patients. Surgical evacuation led to the decrease of EMT, especially when the EMT < 8 mm was association with a lower live birth rate.

Management of first trimester pregnancy loss: mifepristone plus misoprostol versus misoprostol alone

Miscarriage occurs in 20% of all pregnancies. Misoprostol is implemented alone for the medical management of first trimester pregnancy loss in New Zealand and the UK. However, current research reports mifepristone plus misoprostol is significantly more effective than misoprostol alone. Results from current randomised control trials indicate efficacy rates of mifepristone, plus misoprostol range between 73%-89.3% compared to 34.8%-67.1% for misoprostol alone. Further research is recommended to ascertain medication regimes and associated adverse effects. Current guidelines for the medical management of first trimester miscarriage should be reviewed in regards to implementing mifepristone in management pathways.

The association between vaginal bacterial composition and miscarriage: a nested case-control study.

ObjectiveTo characterise vaginal bacterial composition in early pregnancy and investigate its relationship with first and second trimester miscarriages.DesignNested case–control study.SettingQueen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London.Population161 pregnancies: 64 resulting in first trimester miscarriage, 14 in second trimester miscarriage and 83 term pregnancies.MethodsProspective profiling and comparison of vaginal bacteria composition using 16S rRNA gene‐based metataxonomics from 5 weeks’ gestation in pregnancies ending in miscarriage or uncomplicated term deliveries matched for age, gestation and body mass index.Main outcome measuresRelative vaginal bacteria abundance, diversity and richness. Pregnancy outcomes defined as first or second trimester miscarriage, or uncomplicated term delivery.ResultsFirst trimester miscarriage associated with reduced prevalence of Lactobacillus spp.‐dominated vaginal microbiota classified using hierarchical clustering analysis (65.6 versus 87.7%; P = 0.005), higher alpha diversity (mean Inverse Simpson Index 2.5 [95% confidence interval 1.8–3.0] versus 1.5 [1.3–1.7], P = 0.003) and higher richness 25.1 (18.5–31.7) versus 16.7 (13.4–20), P = 0.017), compared with viable pregnancies. This was independent of vaginal bleeding and observable before first trimester miscarriage diagnosis (P = 0.015). Incomplete/complete miscarriage associated with higher proportions of Lactobacillus spp.‐depleted communities compared with missed miscarriage. Early pregnancy vaginal bacterial stability was similar between miscarriage and term pregnancies.ConclusionsThese findings associate the bacterial component of vaginal microbiota with first trimester miscarriage and indicate suboptimal community composition is established in early pregnancy. While further studies are required to elucidate the mechanism, vaginal bacterial composition may represent a modifiable risk factor for first trimester miscarriage.Tweetable abstractVaginal bacterial composition in first trimester miscarriage is associated with reduced Lactobacillus spp. abundance and is independent of vaginal bleeding.

Histopathologic Profile of Miscarriages during First Trimester of Pregnancy in Teaching Hospital of Grand Yoff in Dakar (Senegal)

Background: Mainly for economic reasons, histopathologic analysis is not a systematic practice in medical structures in Senegal, and the utility of this exam is being questioned by many authors. The purpose of this paper is to report the results of this exam, in our medical practice and try to determine if this exam should be systematic of kept only for individualized cases. Material and Methods: It was a retrospective study from January 2010 to December 2018, carried out in the Laboratory of Pathology of the Teaching Hospital of Grand Yoff in Dakar. The data were collected from the register of pathologic examinations of the laboratory. Results: We registered 543 results of histopathologic examination of products of conception from the first trimester abortion. The women mean age was 22.4 years ± 6.2 with extremes of 17 and 46 years. The routine histopathologic assessment of products of first- trimester miscarriages highlighted in our study three pathologies: hydatidiform mole (24.7%), infection (4.6%) and ectopic pregnancy (0.09%). Only 11.7% of cases of Hydatidiform mole (HM) were suspected before the histopathologic assessment. In our sample, molar pregnancy seems to be higher in anembryonic conception with a prevalence of 45%. The prevalence of Complete Hydatidiform Mole (CHM) was higher than the one of Partial Hydatidiform Mole (PHM) (14.8% vs. 9.9% of miscarriages). Indeed, both require follow up to prevent or manage at time the occurrence of choriocarcinoma. Conclusion: The results of the histologic analysis after abortion in the first trimester of pregnancy show that this exam should be practiced systematically in routine in our context because of high prevalence of hydatidiform mole.

Outcome of First Trimester Pregnancy in cases with impending embryonic demise

Background: Miscarriage is the most common adverse pregnancy outcome which has detrimental psychological consequences for the woman and her partner and delays successful childbearing. Normal embryonic heart rate is about [100-200] bpm at 5 weeks gestation then it increases progressively over the subsequent 2-3 weeks. Fetal demise often occurs within one week after the slow embryonic heart rate and always occurs by the end of the first trimester. Aim of the work: The aim of the present study was to investigate the relation between first trimester miscarriage and slow embryonic heart rate at sixth week of gestational age and other risk factors of miscarriage. Patients and methods: A prospective observational cohort study was conducted in the department of Obstetrics and Gynecology, Al-Azhar Faculty of medicine [Damietta] during the period from September 2017 to September 2018 on 90 pregnant women who had slow embryonic heart rate [80-100] bpm at sixth week of gestational age. All were submitted to full history taking, clinical and ultrasound examination and followed up till the end of their pregnancy and outcome was documented. Results: Percentage of aborted cases at the 8th week of gestational age was [38.9%], while, [20%] at the 10th week and [15.4 %] at 13th week. Whom fetus had a heart rate less than 90 were at risk 23.8 times for experiencing abortions more than other females. Conclusion: Slow embryonic heart rate is one of the earliest predictors for the first trimester fetal demise and it is one of the newest studies