Risk of miscarriage in women conceiving after medically assisted reproduction with an ultrasound-verified viable pregnancy at 6–8 weeks’ gestation

Research questionWhat is the risk of miscarriage after a viable fetus verified on ultrasound at 6–8 weeks’ gestation among women who conceive with medically assisted reproduction (MAR), stratified by type of fertility treatment?DesignA nationwide register-based cohort study of women identified in the Danish ART-Registry with a viable singleton pregnancy at 6–8 weeks’ gestation between 2007 and 2010 (n = 10,011). Women were identified from The Danish Fetal Medicine Database (DFMD), which holds information on early (between 6–8 and 11–14 weeks) and late (between 11–14 and 22 weeks) miscarriages. The late miscarriage rate was compared with a control group of naturally conceived pregnancies with a viable fetus at 11–14 weeks’ gestation from 2008 to 2010, identified in the DFMD (n = 146,932).ResultsIn the MAR1 cohort, the overall miscarriage rate was 11.8% (1091/9261) after an ultrasound verified viable pregnancy at 6–8 weeks’ gestation. Most miscarriages occurred before the 11–14-week scan (1035/1091 [94.9%]). The early miscarriage rate was slightly higher in women who conceived with frozen embryo transfer compared with intrauterine insemination (IUI), corresponding to an adjusted OR of 1.31 (1.02 to 1.68). We found no significant risk associated with IVF and intracytoplasmic sperm injection compared with IUI pregnancies. The late miscarriage rate was 0.8% in women conceiving with MAR and 0.6% among controls (P = 0.013).ConclusionsAfter adjustment for maternal characteristics, none of the fertility treatment types were associated with an increased risk of miscarriage compared with naturally conceiving women.     

Meta-Synthesis of the Needs of Women Cared for by Midwives During Childbirth in Hospitals

ObjectiveTo identify and meta-synthesize results of qualitative studies on the needs of women cared for by midwives during childbirth in hospitals.Data SourcesMEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and the Cochrane Library.Study SelectionWe restricted the bibliographic search to articles published in English to July 31, 2020. The initial search yielded 6,407 articles, and after 2,504 duplicates were removed, we screened the titles and abstracts of 3,903 articles. We conducted a full-text review of 89 articles and included 13 qualitative studies about the needs of women who were hospitalized during childbirth and had midwives as their primary maternity care providers.Data ExtractionWe extracted data (e.g., authors, publication date, type of study, sample size, results, and quotes) from the full text of each article into a standardized table. Two authors reviewed all articles using the Critical Appraisal Skills Programme tool to assess study quality and to independently score each study.Data SynthesisWe analyzed the findings of each study and synthesized them to develop themes. We found 14 major themes that reflected the needs of women during hospitalization for childbirth: Nutrition, Hygiene, Privacy, Information, Bodily Respect, Respect for Social Role, Family Intimacy, Shelter, Pain Management, Partnership, Movement, Reassurance, Support, and Empowerment. We categorized these themes in Maslow’s hierarchy of needs to better understand the phenomenon.ConclusionWe identified 14 needs that midwives and nurses can meet when they care for women in hospitals during childbirth. Standardized methods to assess these needs and to link them to specific interventions can be used by midwives and nurses, which will likely affect women’s satisfaction with their experience and overall quality of care.     

Conception after early IVF pregnancy loss: should we wait?

Research questionIs the interval length between an early pregnancy loss and the following treatment cycle a predictor for achieving clinical pregnancy among IVF patients?DesignThis retrospective cohort study of 257 women who reinitiated treatment after first-trimester IVF pregnancy loss was conducted at a tertiary, university-affiliated medical centre between 1 January 2014 to 1 January 2018. Women aged 18–40 years, with normal uterine cavity, who experienced first-trimester pregnancy loss at less than 14 weeks after IVF, were included. Miscarriages were classified as spontaneous, biochemical, medical or surgical.ResultsAmong 257 women, interval to subsequent IVF treatment was not associated with achieving pregnancy. Patients after biochemical pregnancy (72.7 ± 56.4, median 60 days) or spontaneous miscarriage (97.7 ± 93.1, median 66 days) had shorter intervals to next cycle, compared with medical (111.9 ± 103.2, median 65 days) or surgical (123.4 ± 111.1, median 84 days) (Kaplan–Meier, P = 0.03) miscarriages.Logistic regression analysis showed that the chance of subsequent pregnancy was affected by the number of embryos transferred (P = 0.009) and the type of miscarriage. Medical (P = 0.005) and surgical (P = 0.017) miscarriages were related to lower likelihood of pregnancy compared with biochemical pregnancy (reference group).When pregnancy was achieved in the first post-miscarriage cycle, the chance of live birth increased with shorter intervals (median 57.5 days), whereas second miscarriage was related to longer intervals (median 82.5 days) between miscarriage and subsequent IVF cycle (P = 0.03).ConclusionOn the basis of this cohort, IVF should not be postponed after pregnancy loss, as shorter intervals were associated with greater likelihood of live birth.     

Effect of Previous Miscarriage on the Maternal Birth Experience in the First Baby Study

ObjectiveTo determine whether a history of miscarriage is related to birth experience and/or maternal fear of an adverse birth outcome for self or infant during a subsequent delivery.DesignSecondary analysis of a prospective cohort study, the First Baby Study.SampleWomen age 18 to 35 who were expecting to deliver their first live-born infants in Pennsylvania between January 2009 and April 2011.ParticipantsFour hundred fifty-three pregnant women who reported perinatal loss prior to 20 weeks gestation (miscarriage) in a previous pregnancy and 2401 pregnant women without a history of miscarriage were interviewed during pregnancy and again one month after their first live birth.MethodsMaternal birth experience and fear of an adverse birth outcome measured via telephone interview were compared across groups.ResultsMaternal birth experience scores did not significantly differ between women with and without previous miscarriage. Women with a history of miscarriage reported that they feared an adverse birth outcome for themselves or their infants more frequently than women without a history of miscarriage (52.1% vs. 46.6%; p = .033), however, this relationship was not significant after adjustment for confounders.ConclusionOur findings indicate that there is no association between miscarriage history and birth experience. Additional research on this topic would be beneficial including an in-depth examination of fear of adverse outcome during birth. However, nurses and midwives may consider using therapeutic communication techniques to ensure that women with a history of miscarriage receive strong emotional support and reassurance during birth.     

Risk of first trimester spontaneous miscarriage among singleton gestations following ICSI and its relation to underlying cause of infertility

Study objectiveTo assess the association between the first trimester miscarriage rates among women undergoing intracytoplasmic sperm injection (ICSI) and underlying etiology of infertility.DesignProspective cohort study.SettingAin Shams University maternity hospital.Materials and methodsThe study included women who became pregnant with singleton pregnancy following ICSI as a treatment for different causes of infertility. Women were followed up throughout the first trimester of pregnancy up to 12 weeks’ gestation (10 weeks after the day of embryo transfer).Main outcome measureFirst trimester miscarriage rate.ResultsTwo hundred and thirty four pregnant young women were included in the study, 164 (70.9%) women miscarried. The causes of infertility among these women were as follows: 41 (25%) mild male factor infertility, 40 (24.4%) severe male factor infertility, 45 (27.44%) tubal factor, 7 (4.27%) polycystic ovarian syndrome, 3 (1.83%) endometriosis, 20 (12.19%) unexplained and 8 (4.87%) multifactorial. Stepwise logistic multi-regression analysis showed that both maternal age (>31 years) and tubal block were the most sensitive discriminators for the prediction of first trimester spontaneous miscarriage among the study population (P < 0.01).Major conclusionsFirst trimester spontaneous miscarriage rates among pregnant women with singleton pregnancy following ICSI were related to maternal age >31 years and/or the presence of tubal block.     

The Role of Serum Testosterone in Early Pregnancy Outcome: A Comparison in Women With and Without Polycystic Ovary Syndrome

ObjectiveHyperandrogenic conditions in women are associated with increased rates of miscarriage. However, the specific role of maternal testosterone in early pregnancy and its association with pregnancy outcome is unknown. The purpose of this study was to compare serum testosterone levels during early pregnancy in women with and without polycystic ovary syndrome (PCOS) who either had successful pregnancies or miscarried.MethodWe collected serum samples from women attending a university-based fertility centre at the time of their first positive serum beta human chorionic gonadotropin pregnancy test. The samples were subsequently assayed for total testosterone level. We used logistical regression modelling to control for PCOS diagnosis, BMI, and age.ResultsTotal testosterone levels were available for 346 pregnancies, including 286 successful pregnancies and 78 first trimester miscarriages. We found no difference in total testosterone levels between women who subsequently had an ongoing pregnancy (mean concentration 3.6 ± 2.6 nmol/L) and women with a miscarriage (mean 3.6 ± 2.4 nmol/L). Using the Rotterdam criteria to identify women with PCOS, we also found no differences in serum testosterone between women who had ongoing pregnancies or miscarriages, either with PCOS (P = 0.176) or without PCOS (P = 0.561).ConclusionsOur findings show that early pregnancy testosterone levels do not predict pregnancy outcome, and they call into question the role of testosterone in causing miscarriage in populations of women with PCOS. Further research is needed to elucidate the normal progression of testosterone levels during pregnancy and to investigate further the relationship between PCOS and miscarriage.     

Weekly intramuscular progesterone for luteal phase support in women receiving oocyte donation is associated with a decreased miscarriage rate

Research questionTo determine whether adding intramuscular to vaginal administration of progesterone reduces miscarriage rates compared with those of vaginal administration alone for luteal phase support in women receiving oocyte donation and to determine the best time to introduce intramuscular progesterone.DesignRetrospective analysis of miscarriage rates in women receiving oocyte donation. Recipients underwent endometrial preparation by hormone replacement treatment. Vaginal progesterone alone or associated with intramuscular progesterone was used for luteal support.ResultsThis study analysed 186 oocyte donation cycles from January 2016 to May 2018 with embryo transfer on Day 2 or 3 and vaginal progesterone administration: 106 embryo transfer cycles with vaginal progesterone alone, 29 with weekly intramuscular progesterone added once the human chorionic gonadotrophin (HCG) assay was positive, and 51 with weekly intramuscular progesterone added the evening of embryo transfer. The rates of positive HCG assays, biochemical pregnancies and clinical pregnancies did not differ between the treatment groups. The miscarriage rate was significantly lower when intramuscular progesterone began the evening of embryo transfer than with vaginal administration alone (16.7% versus 47.0%, respectively; P = 0.049 after Bonferroni correction). The live birth rate was higher when intramuscular progesterone began the evening of embryo transfer than with vaginal administration alone (37.3% versus 16.0%, respectively; P = 0.009 after Bonferroni correction).ConclusionsAdding intramuscular to vaginal progesterone administration appears to decrease the miscarriage rate and increase the live birth rate in oocyte donations. The initiation of intramuscular progesterone is most beneficial when it is introduced the evening of embryo transfer.     

Influences of prior miscarriage and weight status on perinatal psychological well-being,exercise motivation and behavior

Objectiveswomen who have experienced miscarriage may be at increased risk for elevated depressive and anxiety symptoms in subsequent pregnancies. Exercise may be a useful strategy for coping with these symptoms. Little is known about how miscarriage influences prenatal exercise behavior. The study purpose was to examine the influences of miscarriage history and prepregnancy weight status on pregnant women’s psychological health, exercise motivation, and behavior using the Theory of Planned Behavior.Participants/SettingPregnant women (N=203; 41 with prior miscarriage; 72 overweight/obese; BMI > 25.0) in the northeast United States.DesignWomen prospectively reported their depressive/anxiety symptoms and exercise motivation/behavior in the 1st, 2nd, and 3rd trimesters via mailed surveys. Group differences in depressive/anxiety symptoms, exercise behavior, and its motivational determinants were examined using Chi Square analyses and Univariate and Multivariate Analyses of Covariance.Measurements and findingsWomen with a history of miscarriage had higher 1st and 2nd trimester depressive/anxiety symptoms and lower 1st trimester attitudes about exercise and 1st and 2nd trimester perceived behavior control than women without a history of miscarriage. Overweight/obese women had higher 1st and 2nd trimester pregnancy depressive/anxiety symptoms, engaged in less prepregnancy exercise, and had lower levels of exercise intention, attitude, and perceived behavior control throughout pregnancy than normal weight women.Key ConclusionsWomen with a history of miscarriage and overweight/obese women have poorer psychological health and lower motivation to exercise during pregnancy than women without a history of miscarriage and normal weight women.Implications for practitionersInterventions and healthcare provider communications aimed at promoting perinatal exercise behavior and psychological health should take into account pre-pregnancy weight status and pregnancy history to identify strategies to help women, particularly overweight/obese women with a history of miscarriage, to overcome exercise barriers.     

Narrative Study of the Significance of Infertility and Its Treatment for Maternal Identity

ObjectiveTo explore how women who experienced infertility and underwent fertility treatments constructed maternal identities after they successfully gave birth.DesignNarrative qualitative study.SettingFinland, Scandinavia.ParticipantsTwenty-six previously infertile Finnish women who later conceived were recruited via social media, health clinics, and relevant informal support organizations.MethodsNarrative analysis was used to process written accounts and individual episodic interviews with each of the 26 women.ResultsFour different identity stories emerged from the data: Fractured Maternity, Pursuing Maternity, Learning Maternity, and Discovering Maternity. Infertility, its treatment, and childbirth were narrated as turning points in the participants’ life courses, but the significance of these turning points for maternal identity varied across the four stories.ConclusionThese findings have important implications for nursing practice. Health care professionals should be aware of the effects of previous long-standing infertility on the subsequent experience of motherhood so they can provide women with understanding, sufficient support, and appropriate interventions throughout the transition to motherhood.     

Scoping Review of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy

ObjectiveTo synthesize the literature on the barriers and facilitators of breastfeeding among women on opioid maintenance therapy (OMT) to inform nursing interventions and improve breastfeeding outcomes.Data SourcesWe searched 11 databases using the following key terms: breastfeeding, barriers, facilitators, promotion, and opioid.Study SelectionWe included articles published in English since 2015 that addressed barriers and facilitators of breastfeeding in women on OMT. We did not limit our search to specific types of studies. Our search produced 65 records. After reviewing titles and abstracts, we assessed 21 full-text articles and excluded seven for lack of data related to our key terms. As a result, we included five qualitative studies, three reviews, three mixed-methods studies, two retrospective cohort studies, and one case report (14 articles) in our final review.Data ExtractionWe extracted data from each article and sorted them in a table for analysis and synthesis. Data included study purpose, research questions, design and methodology, and findings specifically pertaining to the identification of barriers and facilitators of breastfeeding for women on OMT.Data SynthesisWe identified three themes related to facilitators of and barriers to breastfeeding: Information, Support, and Health Care System Factors.ConclusionThe results of our review suggest that most barriers and facilitators of breastfeeding in women on OMT are manageable with improved health care practices. Primary and acute care health professionals should modify practices to minimize barriers to breastfeeding. Nurses should provide better breastfeeding education and preparation, sensitive care in the immediate postpartum period, and extended follow-up after hospital discharge for women on OMT.     

Sperm DNA fragmentation is a novel biomarker for early pregnancy loss

Research questionSpontaneous pregnancy loss affects 10–15% of couples, with 1–2% suffering recurrent pregnancy loss and 50% of miscarriages remaining unexplained. Male genomic integrity is essential for healthy offspring, meaning sperm DNA quality may be important in maintaining a pregnancy. Does sperm DNA fragmentation measured by alkaline Comet assay act as a biomarker for early pregnancy loss?DesignSperm DNA fragmentation was measured by alkaline Comet test in 76 fertile donors and 217 men whose partners had recently experienced miscarriage. Couples were divided into five groups for analysis: one miscarriage after spontaneous conception; two or more miscarriages after spontaneous conception; one miscarriage after fertility treatment; two or more miscarriages after fertility treatment and biochemical pregnancy.ResultsReceiver operator characteristic curve analysis was used to determine ability of the average Comet score (ACS), low Comet score (LCS) and high Comet score (HCS) to diagnose miscarriage and develop clinical thresholds comparing men whose partners have miscarried with men with recently proven fertility. Male partners of women who had miscarried had higher sperm DNA damage (ACS 33.32 ± 0.57%) than fertile men (ACS 14.87 ± 0.66%; P < 0.001). Average Comet score, HCS and LCS all have promise as being highly predictive of sporadic and recurrent miscarriage using clinical thresholds from comparisons with fertile men's spermatozoa: receiver operating characteristic curve AUC for ACS ≥26%, 0.965; LCS ≤70%, 0.969; HCS ≥2%, 0.883; P <0.0001.ConclusionsSperm DNA damage measured by the alkaline Comet has promise as a robust biomarker for sporadic and recurrent miscarriage after spontaneous or assisted conception, and may provide novel diagnoses and guidance for future fertility pathways.     

Metroplasty for AFS Class V and VI Septate Uterus in Patients With Infertility or Miscarriage: Reproductive Outcomes Study

Study ObjectiveTo assess reproductive outcomes in patients after surgical correction of septate uterus.DesignObservational retrospective study (Canadian Task Force classification II-2).SettingTwo university hospitals.PatientsOne hundred twenty-eight patients with primary infertility or recurrent miscarriage with partial (American Fertility Society [AFS] class Va), complete (AFS class Vb), or fundic (AFS class VI) septate uterus. Metroplasty is the current method of choice for surgically correcting septate uterus. The procedure and its indications are a matter of debate.InterventionsMetroplasty via hysteroscopy.Measurements and Main ResultsOutcomes including the numbers of pregnancies, first live births (FLBs), and miscarriages were determined. After metroplasty, 78 women (60.9%) became pregnant, and 70 live neonates were delivered. The FLB rate in infertile women was 53.1%. Of the 25 pregnancies, 13 (52%) resulted from assisted reproductive technology. In women who experienced recurrent miscarriage, the miscarriage rate was significantly improved. Outcomes (miscarriages and FLBs) differed significantly according to anatomical type of septum after surgery.ConclusionHysteroscopic septum resection is accompanied by safe improvement in reproductive performance in patients with symptoms of AFS class V/VI septate uterus.     

Support following miscarriage: what women want

Objective: Miscarriage is a frequent pregnancy complication often accompanied by psychological distress. The current study seeks to query women about their desire for support following miscarriage and specific aspects of content, type and timing of support. Method: An experimenter‐designed questionnaire was presented to Internet forums dealing with miscarriage or gynecological medical information. Three hundred and five women participated in the study. Results: The majority of women indicated that they would appreciate support following miscarriage. All proposed interventions appeared useful to women, particularly those dealing with the medical aspects of miscarriage. Women indicated that they felt poorly informed following miscarriage and had particular difficulty dealing with the emotional impact of their miscarriage. Conclusion: The results emphasise the need for providing more comprehensive care for women who have experienced miscarriage and provide information about how support could be best provided     

Attitudes of Clinicians and Patient Safety Culture Before and After the ARRIVE Trial

ObjectiveTo assess the attitudes of intrapartum clinicians about elective induction of labor before and after A Randomized Trial of Induction Versus Expectant Management (ARRIVE) and to assess the effect of different attitudes on patient safety culture.DesignRepeated cross-sectional design.SettingOnline surveys.ParticipantsClinicians (883 nurses and 201 physicians in the before-ARRIVE group and 1,741 nurses and 574 physicians in the after-ARRIVE group) who provided intrapartum care at 35 hospitals in California in 2017 and 57 hospitals in Michigan in 2020 and participated in statewide quality improvement efforts to reduce use of cesarean.MethodsWe used annual nulliparous, term, singleton, vertex cesarean rates to stratify hospitals into performance quartiles. We used cumulative proportional odds logistic regression to examine induction attitudes before and after ARRIVE by role and hospital performance quartile as well as induction attitudes and patient safety culture among clinicians. We used content analysis to examine qualitative data.ResultsAfter ARRIVE, physicians’ attitudes shifted in favor of induction at hospitals within the top three performance categories (top quartile: M = 3.48 vs. 2.81, p < .0001), whereas nurses’ attitudes did not change (p = .388). After ARRIVE, attitudes among clinicians were more aligned at hospitals with stronger patient safety cultures. Qualitative themes included The Timing of Induction is Important, Who Should Have Inductions, Need for Clear Protocols and More Staff, and Ideas to Improve the Induction of Labor Process.ConclusionPhysician attitudes about induction were significantly different before versus after ARRIVE, whereas nurse attitudes were not. Differences in attitudes may erode the quality of team-based care; intentional interdisciplinary engagement is essential when implementing ARRIVE findings.     

A Randomized Trial of a Bereavement Intervention for Pregnancy Loss

ObjectiveTo examine the effects of a secondary bereavement intervention on grieving in women who experienced a miscarriage (pregnancy loss) at 12–20 weeks gestation.DesignExperimental, posttest only, control group design.SettingObstetric emergency center of a county hospital in a large city.ParticipantsForty women who experienced complete spontaneous miscarriages in the first or second trimester (8–20 weeks gestation).MethodsParticipants were randomly assigned to the grief intervention treatment group or usual standard care control group. The Medical Professional Guidelines for Health Care Professionals were used to construct the perinatal grief intervention. The Perinatal Grief Scale (PGS) was completed during a routine follow‐up visit 2 weeks postloss.ResultsA one‐way multiple ANOVA (MANOVA) was used to examine the difference in grieving between the control and experimental groups. Three dependent variables were used: despair, difficulty coping, and active grieving. Analysis revealed a significant difference on the combined dependent variables, F(3, 36) = 22.40, p < .000. When considering the three dependent variables separately, the treatment group displayed significantly lower levels of despair, F(1, 38) = 42.27, p < .001. Active grieving was high in both groups with the treatment group mean higher than the control group. Group means were similar for coping difficulty.ConclusionA bereavement intervention administered immediately after the miscarriage promotes women's ability to cope with early pregnancy loss.     

Reproductive outcomes after preimplantation genetic testing in mosaic Turner syndrome: a retrospective cohort study of 100 cycles

PurposeThe purpose of this study is to explore the reproductive outcomes of women with Turner syndrome (TS) in preimplantation genetic testing (PGT) cycles.MethodsA retrospective study of 100 controlled ovarian stimulating cycles, 68 TS (sixty-four mosaic Turner syndrome (MTS) and four pure Turner syndrome (PTS)) women underwent PGT was conducted from 2013 to 2018.ResultsEmbryo X chromosome abnormal rates of TS women were significantly higher than women with normal karyotype (7.04 vs 1.61%, P<0.01). Cumulative live birth rates (CLBR) after PGT-NGS treatment were lower in TS than control (31.15 vs 45.59%, P<0.05). Clinical pregnancy rates per transfer (CPR), miscarriage rates (MR) and live birth rates per transfer (LBR) remained comparable between TS and control group. Reproductive outcomes (X chromosome abnormal rates, CPR, MR, LBR and CLBR) among low (<10%), medium (10–50%) and high (>50%) level 45,X mosaicism groups were not statistically different.ConclusionsTo avoid high risk of embryo X chromosome abnormalities, prenatal or preimplantation genetic testing should be recommended to mosaic or pure TS patients.