Occurrence of ectopic pregnancy among women with recurrent spontaneous abortion

Ectopic pregnancy is a major health problem accounting for about 10% of all maternal mortality. To determine whether patients with a history of recurrent spontaneous abortion (RSA) have a higher frequency of ectopic pregnancy than the general population, the obstetrical histories of 630 patients with a diagnosis of RSA from two centers were studied. Thirty-eight of 376 USA women, (10%) and 10 of 193 British women (5%) previously had suffered an ectopic pregnancy. These data provide an overall prevalence of 9% for ectopic pregnancy among patients who recurrently abort. The total number of pregnancies was 1,716 in the USA group and in the British group was 1,270, for a total of 2,986 including live births, stillbirths, abortions, hydatidiform moles, and ectopic pregnancies. In the US series, 45 of the 1,716 pregnancies were ectopic. If these women had the same relative proportion of ectopic pregnancies as the general population, there should have been 20.6 ectopic pregnancies. This represents a 2.2-fold increase in patients with a history of RSA. There was no association between pregnancy order and occurrence of ectopic pregnancy. The prevalence of known risk factors for ectopic pregnancy in patients with a history of ectopic pregnancy was PID, 3%; tubal surgery, 20%; and used IUD, 3%. Seventy-four percent of the women had no identifiable risk factor. These results suggest a comorbidity for ectopic pregnancy and RSA which may indicate shared etiologies.     

X-chromosome inactivation patterns in Korean women with idiopathic recurrent spontaneous abortion

Recurrent spontaneous abortion (RSA) defines as two or more consecutive losses at < or = 20 weeks of gestation and affects an estimated 1 of every 100 couples wishing to have children. However, it remains a poorly understood phenomenon. Recent reports observed a significant association between highly skewed X chromosome and RSA, supporting that X chromosome inactivation might be an important and previously unknown cause of RSA. X-inactivation pattern, using polymeric X-linked women with idiopathic RSA and 80 control subjects with a single successful pregnancy and no history of spontaneous abortion. The ratio of heterozygotes was 68.2% (45/66) in women with RSA and 67.5% (54/80) in control group. Among 45 informative RSA cases, only 1 (2.2%) woman showed extreme skewed X inactivation (> or = 90%) and 4 (8.9%) had mild skewed inactivation (> or = 85%). In 54 heterozygous control subjects, 5 (9.3%) women showed extreme skewed X inactivation and 7 (13.0%) had mild one. The frequency of skewed X inactivation between RSA patients and control group was not significantly different (p>0.05). This finding suggests that skewed x chromosome be not associated with unexplained RSA patients.     

Occurrence of other reproductive failures among women with recurrent spontaneous abortion

We have previously reported an association between recurrent spontaneous abortion and ectopic pregnancy. We now report that not only ectopic pregnancy, but also other reproductive failures including hydatidiform moles, preterm births, and stillbirths are also associated with recurrent spontaneous abortion. The obstetrical histories of 455 women who had experienced two or more consecutive spontaneous abortions were studied for the occurrence of term births, preterm births, stillbirths, spontaneous abortions, ectopic pregnancies, and hydatidiform moles. The observed frequencies of these reproductive outcomes were compared with the expected frequencies of 920 term births, 80 preterm births, five stillbirths, 150 spontaneous abortions, 14.5 ectopic pregnancies and 0.5 molar pregnancies per 1,000 livebirths. The 455 women had experienced 1,968 pregnancies of which 184 were term births, 30 were preterm births, 16 were stillbirths, 1,669 were spontaneous abortions, 63 were ectopic pregnancies, and six were molar pregnancies. The ratio of observed to expected values was term births 0.1, preterm births 1.6, stillbirths 14.0, spontaneous abortion 6.6, ectopic pregnancy 2.6, and molar pregnancy 7.1. The gravid specific proportions of reproductive outcomes were constant suggesting comorbidity or common cause(s). The commonality that links these types of reproductive failure will provide insight into the mechanisms of reproductive wastage.     

Systemic changes in haemostatic balance are not associated with increased levels of circulating microparticles in women with recurrent spontaneous abortion

PROBLEM: Placental fibrin deposits in patients wih recurrent spontaneous abortion (RSA) indicate an exaggerated haemostatic response. This 'hypercoagulability' may involve pro-coagulant factors such as circulating microparticles (MPs). We investigated the relationship between circulating pro-coagulant MPs and systemic coagulation in RSA patients. METHOD OF STUDY: Platelet- and endothelial cell-derived microparticles (PMPs, EMPs) were evaluated by flow cytometry in RSA patients (n = 51) and compared to controls (n = 24) using annexin V (total numbers of MP), and antibodies against CD61, CD63 and CD62P (PMP), as well as CD144 and CD62E (EMP). Prothrombin fragment 1 + 2 (F(1+2)) and thrombin generation were determined to assess the pro-coagulant potential of MP. RESULTS: Numbers of annexin V-binding MP were nearly similar in RSA patients and controls. However, a subgroup of ten RSA patients (10/51; 20%) presented with MP concentrations >10,000 x 10(6)/L, compared to only one women out of the control group (1/24; 4%; P = 0.038). Neither PMP and EMP nor F(1+2) and thrombin generation differed significantly within the study population. CONCLUSION: The present study shows that circulating MPs are not directly associated with the extent of systemic coagulation activation in RSA patients. We hypothesize that increased numbers of circulating MPs either are only indirectly associated with coagulation during pregnancy of RSA patients, or affect abortion via mechanisms independently from hypercoagulation.     

HLA-DR typing of women with recurrent late spontaneous abortion and unsuccessful cervical cerclage

The release of certain cytokines, e.g. tumour necrosis factor (TNF)- alpha, in the amniotic fluid has been suggested to be a cause of preterm birth. The predisposition to excessive liberation of cytokines from peripheral leukocytes has been shown to depend partly on the individual's HLA-DR genotype. The HLA-DR1 and -DR3 alleles have previously been reported as being associated with a TNF-alpha high responder status and have also been associated with unexplained recurrent spontaneous abortions. In the present study, HLA-DR typing was performed in 10 women who had experienced recurrent very early preterm births resulting in perinatal death, or late spontaneous abortions under a clinical picture resembling that traditionally attributed to cervical incompetence. All patients had had at least one mid-trimester miscarriage in spite of the insertion of a cervical cerclage. Nine out of 10 (90%) patients had the HLA-DR phenotypes DR1 and/or DR3 compared with 37% in the background population (P < 0.005). The results suggest that HLA-DR-associated immunological factors might play a part in recurrent late spontaneous abortions and extremely preterm births under a cervical incompetence-like picture, at least in the subset of cases not treatable by cervical cerclage.      

Interleukin-6 and soluble interleukin-6 receptor serum levels in recurrent spontaneous abortion women immunized with paternal white cells

PROBLEM: Recurrent spontaneous abortion (RSA) could be interpreted as the cause for the incapacity of the mother to recognize paternal antigens to produce the desired protective response. The practise of alloimmunization was introduced in an attempt to induce in the mother the production of an alloimmune response; some authors proposed an association between cytokines and RSA. The production of IL6 and its soluble receptor (sIL6R) before and after lymphocyte immunotherapy was evaluated in sera of 33 patients suffering from two or more RSA, and in sera of 47 women with normal pregnancy. METHOD OF STUDY: The immunization of RSA patients was achieved by injection of four doses of 10(5) mononuclear cells (MNC) from the husband, at weekly intervals, before pregnancy. The IL6 and sIL6R levels were measured using sandwich ELISAs and the results evaluated by Tukey-Kramer multiple comparison-tests. RESULTS: Our data show no significant differences between IL6 and sIL6R serum levels of normal pregnant women and RSA pregnant women with white-cell immunization before pregnancy. In contrast, the sera of pregnant RSA patients without allogeneic therapy show higher values. We also found significant differences between IL6 levels in non-pregnant RSA women with and without immunotherapy. CONCLUSION: These results show that the alloimmunization with paternal white cells leads the serum IL6 and sIL6R-levels to the values observed in the course of normal pregnancy, suggesting a role for IL6 and sIL6R in the modulation of the immune response's quality.     

Endocrine abnormalities during the follicular phase in women with recurrent spontaneous abortion.

The frequency of endocrine abnormalities during the follicular phase in non-pregnant women with a history of recurrent abortion was investigated in a case-control study. A total of 42 consecutive women with recurrent spontaneous abortion (three or more consecutive abortions, mean +/- SD: 3.9 +/- 1.1 range 3-8) with no parental chromosome rearrangement or uterine abnormality were studied during the early follicular phase under standardized conditions. Serum concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, androstenedione, testosterone, dehydroepiandro-stenedione, 17-OH-progesterone, oestradiol, progesterone and thyroid stimulating hormone (TSH) were measured by commercially available radioimmunoassays. Controls were 42 nulligravid females with tubal or male factor infertility without miscarriage. Mean (SD) concentrations of prolactin and androstenedione were 14.2 +/- 6.7 ng/ml versus 10.5 +/- 3.5 ng/ml (95% CI 0.8-6.1) and 2.3 +/- 0.9 ng/ml versus 1.7 +/- 0.6 ng/ml (95% CI 0.2-0.9) in the study and control groups respectively. The other endocrine parameters were comparable in both groups. Obesity [BMI weight (kg)/height (m2) > or = 25] was more prevalent (23 versus 5 women, P = 0.0001) in the study than the control group. Recurrent spontaneous abortion is associated with abnormalities in prolactin and androgen secretion during the follicular phase, suggesting an endocrine aetiology in this disorder. Reduction of body weight and correction of hyperprolactinaemia and of hyperandrogenism may reduce the rate of miscarriage in a subsequent pregnancy in these women.     

自然流产患者血清瘦素水平的研究

目的探讨孕早期母体血清瘦素水平与自然流产的关系及其临床意义.方法用放射免疫法测血清瘦素、胰岛素水平,并测量身高、体重,计算体重指数.结果自然流产患者血清瘦素水平平均为5.25±1.20ng/ml,正常妊娠者为9.15±1.96ng/ml,两组比较差异有显著性.血清瘦素水平与体重指数、胰岛素呈正相关.两组胰岛素水平差异无显著性.结论自然流产患者血清瘦素水平明显降低,低瘦素水平是自然流产发生的原因之一.     

Lack of soluble TNF-receptors in women with recurrent spontaneous abortion and possibility for its correction

PROBLEM: Tumor necrosis factor (TNF) and soluble TNF receptors (sTNF-Rs) system related with Th1 and Th2 and activity of NF-kappaB/IkappaB regulatory system. This study was designed to compare sTNF-R1 and sTNF-R2 production (shedding) and levels of late activated CD8+ T-lymphocytes in non-pregnant (n = 30) and pregnant (n = 20) normal women and non-pregnant (n = 20) and pregnant (n = 30) RSA women. Effects of progesterone (natural structure) injections in RSA women were studied. METHODS OF STUDY: Levels of sTNF-R1, sTNF-R2, TNF in peripheral blood serum were detected by enzyme-linked immunosorbent assay. Lymphocyte subsets were estimated by multicolor flow cytometry. NK cell cytotoxic activity of peripheral blood lymphocytes (PBL) in whole blood against K562 targets was determined using Europium-release cytotoxicity assay. Mitogen-induced proliferative response of PBL to PHA-P, Con A and PWM were determined by standard 3H-thymidine incorporation assay. RESULTS: Levels of soluble TNF-R1 and TNF-R2 in normal pregnancy were elevated when compared with non-pregnant normal women and pregnant RSA women. Levels of late activated CD8+ T-lymphocytes in normal pregnancy were decreased but no changes were detected in RSA women. After progesterone therapy (i.m. injections of 2.5% oil solution) in RSA women elevation of sTNF-R1 and sTNF-R2 to normal pregnancy ranges was observed. No changes in levels of late activated CD8+ T-lymphocytes after progesterone treatment were detected. CONCLUSIONS: Elevation of levels of sTNF-R1, sTNF-R2 and decrease of late activated cytotoxic T-lymphocytes are pronounce markers of normal human pregnancy. In RSA women there are no elevation of sTNF-R1 and sTNF-R2 levels during pregnancy. This deficiency may be restored by progesterone treatment.     

叶酸代谢酶基因多态性与反复自然性流产易感性的研究

目的探讨叶酸代谢相关酶基因多态性在不明原因反复自然流产遗传易感性中的作用地位。方法运用聚合酶链反应-限制性片段长度多态性技术（PCR—RFLP）检测蛋氨酸合成酶还原酶（MTRR）A66G,蛋氨酸合成酶（MS）A2756G,N5,10-亚甲基四氢叶酸还原酶（MTHFR）C677T,胱硫醚β-合成酶（CBβS）844ins68基因多态性。结果不明原因反复自然流产患者MTHFR的T等位基因突变频率较正常对照组明显升高。而MS、MTRR和CBβS突变频率在病例组与对照组之间无显著差异。结论MTHFR C677T基因突变多态性可作为不明原因反复自然流产预后的检测指标。     

HLA-E polymorphism in patients with recurrent spontaneous abortion

Abstract: The aim of this study was to compare the frequencies of five HLA-E alleles in 82 women with recurrent spontaneous abortions with that of 150 random Danish controls. PCR sequence-specific oligonucleotide typing was carried out to detect polymorphism in exons 2 and 3 of the HLA-E gene. In informative samples sequencing of these two exons was also undertaken to confirm the presence of the HLA-E*01031 allele. HLA-E*0101, HLA- E*01032 and HLA-E*01031 were detected with frequencies of 56.7%, 33.6% and 9.6% in controls and 58,5%, 32.9% and 8.5% in patients with recurrent abortion, respectively. No HLA-E*0102 and E*0104 alleles could be detected. Since the HLA-E allele distribution was similar in women with recurrent spontaneous abortion and controls, it is suggested that maternal HLA-E polymorphism per se does not play any role in the pathogenesis of this disorder of pregnancy.     

Immunological mechanisms in recurrent spontaneous abortion

The acceptance and maintenance of pregnancy remains a biological mystery. The conceptus expresses paternal and embryonic antigens that are foreign to its maternal host yet is not always immunologically rejected. In this chapter we have presented a review of protective immunologic mechanisms possibly responsible for the maintenance of pregnancy, as well as a summary of current data suggesting immunologic mechanisms responsible for pregnancy wastage. Major rapid advances in understanding immunoreproduction should occur over the next several years due to major advances in the rapidly expanding field of immunology. It is now possible to perform in depth studies of immunoregulatory mechanisms. Numerous biochemical mediators of immunological responses have been defined and mass produced for use in research. These mediators have enabled the definition of cellular and humoral interactions within the immune system, and between the immune system and reproductive tissues. Monoclonal antibodies have also been produced that identify many of these mediators and leukocyte markers associated with immune function. It is now possible using these new immunological reagents to probe the immune mechanisms and immunoregulatory events responsible for the success and failure of reproduction. Systematic approaches utilizing these techniques are and will continue to contribute significantly to a further understanding of the immunological mechanisms involved in recurrent spontaneous abortion, which is prerequisite for developing truly effective treatment modalities.     

Immunology: Outcome of pregnancy in women with recurrent spontaneous abortion following immunotherapy with allogeneic lymphocytes

The efficacy of immunotherapy in the prevention of habitualabortion remains controversial. It has been suggested that thebenefits are predominantly due to psychological factors. Wehave evaluated the success of pregnancy outcome following immunotherapywith allogeneic lymphocytes, in relation to the subsequent developmentof anti-paternal cytotoxic antibodies (APCA). It was observedthat in women who developed an APCA titre of 1:16, live birthsoccurred in 16 out of 21 cases (76%), while only two out ofseven (28%) women who failed to achieve an APCA titre of 1:16had successful pregnancies (P <0.05). In eight women whohad an APCA titre of 1: 16 on initial screening, and were, therefore,excluded from the trial, successful pregnancy outcome was notedin 62.5% of cases. Although these results are based on a smallsample and on an open, non-randomized trial, they show thatthe efficacy of immunotherapy is related to immune responseto allogeneic lymphocytes, and is not simply a placebo effect.Measurement of APCA titre could serve as a marker for immunopotentiation.     

Autoantibodies to serum proteins in women with recurrent spontaneous abortion: subsequent pregnancy outcome.

Sera from 130 first trimester pregnant women were tested for their serum antibody level against a naturally occurring serum antigen purified from non-pregnancy sera. IgG and IgM antibody level was measured using enzyme linked immunosorbent assay. Results indicate that patients with multiple abortion (n = 26) have significantly (p = 0.0029) lower level of IgG antibody and significantly (p = 0.0001) higher level of IgM antibodies against the serum antigen as compared to the patients with successful pregnancies with no history of miscarriage (n = 63). Western blot analysis identified the serum antigen recognized by the IgM antibody as a 24 kDa molecular mass component. These IgG and IgM antibodies may play an important role in the outcome of pregnancy.     

Epidemiology of recurrent spontaneous abortion.

With recent scientific advances leading to better understanding of the immunobiology of recurrent spontaneous abortion (RSA), interest has now focused upon the epidemiology of RSA. A cohort of 214 couples with a history of two or more consecutive abortions were studied for the prevalence of etiologic factors and association with other reproductive failures. The prevalence of causes of RSA in this cohort was compared with etiologic factors among 179 couples with a history of three or more consecutive abortions. The obstetrical histories of 214 women with RSA were analyzed for the total number of pregnancies, live births, stillbirths, spontaneous abortions, ectopic pregnancies, and hydatidiform moles. These numbers were compared with the expected frequency of each in the general population. The prevalence of etiologies among 214 with RSA were as follows: chromosomal-6%, anatomic-1%, hormonal-5%, immunologic-65%, and unexplained-23%. No differences in the prevalence of etiologic factors exist when couples with a history of two or more abortions are compared with three or more abortions. When the number of ectopic pregnancies, molar pregnancies, and stillbirths among 214 women with RSA were compared with the expected numbers, the odds ratios were 2.2 for ectopic pregnancies, 6.0 for molar pregnancies, and 2.3 for stillbirths. These data indicate that no difference in the prevalence of etiologies of RSA exist when couples with two or more abortions are compared with three or more and a comorbidity between RSA and other types of reproductive failure exists.     

Association of vascular endothelial growth factor gene polymorphisms with recurrent spontaneous abortion in Chinese Han women

Citation Xing X, Yan J, Zhao Y, You L, Bian Y, Chen Z‐J. Association of vascular endothelial growth factor gene polymorphisms with recurrent spontaneous abortion in Chinese Han women. Am J Reprod Immunol 2011; 65: 521–525 Problem An association of polymorphism ?1154G/A (rs1570360) in vascular endothelial growth factor (VEGF) gene with idiopathic recurrent spontaneous abortion (RSA) has been found in Caucasians. The aim of this study was to examine the association of VEGF ?1154 with RSA in a well‐defined group of Chinese Han patients. Method of study The VEGF ?1154G/A genotype was detected by real‐time PCR with TaqMan probes. The products were also subjected to gene sequence analysis to validate the PCR results. Results The allele frequencies of VEGF ?1154G/A showed no significant difference between RSA patients and the normal controls (P = 0.183). The frequencies of VEGF ?1154G/A genotypes were not significantly different between RSA patients and the normal controls (P = 0.228). Conclusion Our study revealed that VEGF ?1154G/A polymorphism was not associated with the susceptibility to RSA in Chinese Han women.     

VEGF与复发性流产的研究进展

VEGF（血管内皮生长因子）在正常妊娠中发挥重要的作用，其表达水平异常将导致病理性妊娠的发生。本文通过介绍VEGF与复发性流产发病的关系，为研究复发性流产的发病机制及其临床防治措施提供依据。     

白细胞介素-8mRNA与反复自然流产的相关性

目的:探讨反复自然流产患者绒毛、蜕膜和外周血单个核细胞白细胞介素-8(IL-8) mRNA 的表达与反复自然流产的相关性.方法:采用半定量逆转录-聚合酶链反应(RT-PCR)技术,检测 30 例反复自然流产患者(病例组)和 30 例正常妊娠妇女(对照组)绒毛、蜕膜及外周血单个核细胞内 IL-8 mRNA 表达水平的相对含量(%).结果:在绒毛组织中,病例组 IL-8mRNA 的表达明显高于对照组;在蜕膜组织中,病例组 IL-8 mRNA 的相对含量为(68.57±4.73)%,对照组的为0;在外周血单个核细胞中,病例组 IL-8 mRNA 的表达高于对照组.结论:病例组绒毛、蜕膜组织及外周血单个核细胞中 IL-8 mRNA 表达水平显著升高,提示 IL-8 可能与反复自然流产相关.     

HLA—E与原因不明习惯性流产的关联研究

目的探索HLA-E与原因不明习惯性流产的发生是否存在关联.方法采用地高辛标记的寡核苷酸探针杂交技术,对上海地区53例原因不明习惯性流产病人和156例正常对照进行了HLA-E等位基因检测.结果在病人和对照组中HLA-E*0101均是最常见的等位基因,其基因频率分别为50%和43.09%,其次是E*01032分别为29.25%和33.12%.E*01031则分别占20.75%和23.79%,HLA-E*0102和E*0104在两组标本中均未检出.检出的3个等位基因在两组之间比较均无显著性差异(P＞0.05).结论HLA-E等位基因多态性与原因不明习惯性流产的发生可能没有直接关联.