Juan Mozas

Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus

Aim. To compare pregnancy outcome and factors related to adverse perinatal outcome in women with type 1 versus type 2 diabetes mellitus (DM). Material and methods. Multicentre retrospective study. Some 404 women were studied, 257 with type 1 DM and 147 with type 2 DM. Main outcome measures were rates of prematurity, macrosomia, instrumental deliveries, congenital malformations, need for neonatal intensive care unit (NICU), and perinatal mortality. Results. There were no significant differences in pregnancy outcome between women with type 1 and type 2 DM, except for an increased rate of instrumental deliveries in women with type 1 DM. In these women, duration of diabetes was a significant predictor of caesarean delivery (OR =1.06 (1.01–1.12); p = 0.02). Chronic hypertension was positively related to prematurity (p = 0.02), and proved to be a significant predictor of birth weight lower than 2,500 g (OR =3.54 (1.4–12.49); p = 0.043) and perinatal mortality (OR =10.6 (1.15–117.6); p = 0.04). In women with type 2 DM, third trimester higher glycosylated haemoglobin was related to both prematurity (OR 4.9 (1.7–14.4; p = 0.004) and low birth weight. Macrosomia was a significant risk factor for caesarean section. First trimester glycosylated haemoglobin was related to congenital malformations and proved to be a significant predictor of perinatal mortality (OR =2.4 (1.02–5.74); p = 0.04). Conclusions. Duration of DM and chronic hypertension were the most influential factors related to adverse perinatal outcomes in women with type 1 DM, and poor metabolic control and macrosomia in women with type 2 DM.

Proposal of guidelines for the appraisal of SEMen QUAlity studies (SEMQUA)

STUDY QUESTION Is there a need for a specific guide addressing studies of seminal quality? SUMMARY ANSWER The proposed guidelines for the appraisal of SEMinal QUAlity studies (SEMQUA) reflect the need for improvement in methodology and research on semen quality. WHAT IS KNOWN ALREADY From an examination of other instruments used to assess the quality of diagnostic studies, there was no guideline on studies of seminal quality. STUDY DESIGN, SIZE AND DURATION Through systematic bibliographic search, potential items were identified and grouped into four blocks: participants, analytical methods, statistical methods and results. PARTICIPANTS/MATERIALS, SETTING AND METHODS Our findings were presented to a panel of experts who were asked to identify opportunities for improvement. Then, a checklist was designed containing the questions generated by the items that summarize the essential points that need to be considered for the successful outcome of a SEMQUA. MAIN RESULTS AND THE ROLE OF CHANCE Eighteen items were identified, from which 19 questions, grouped into four blocks, were generated to constitute the final checklist. An explanation for the inclusion of each item was provided and some examples found in the bibliographic search were cited. LIMITATIONS AND REASONS FOR CAUTION We consider that not all items are equally applicable to all study designs, and so the hypothetical results are not comparable. For that reason, a score would not be fair to critically appraise a study. This checklist is presented as an instrument for appraising SEMQUAs and therefore remains open to constructive criticism. It will be further developed in the future, in parallel with the continuing evolution of SEMQUAs. WIDER IMPLICATIONS OF THE FINDINGS The final configuration of the SEMQUA is in the form of a checklist, and includes the items generally considered to be essential for the proper development of a SEMQUA. The final checklist produced has various areas of application; for example, it would be useful for designing and constructing a SEMQUA, for reviewing a paper on the question, for educational purposes or as an instrument for appraising the quality of research articles in this field. STUDY FUNDING/COMPETING INTEREST(S) None.

Mononuclear cell subpopulations in human follicular fluid from stimulated cycles.

ABSTRACT: The study of lymphocyte subsets from human follicular fluid (FF) provides an opportunity to evaluate immunological features of the ovary. We investigated the mononuclear cell subsets in FF and peripheral blood obtained at the time of laparoscopy from ten in vitro fertilization (IVF) patients. Midcycle nonpregnant peripheral blood was used as the control. A marked increase in the proportion of monocytes (CD14+) was observed in FF. Although FF was enriched with CD8+ lymphocytes, a decrease in the proportion of CD4+ lymphocytes was observed. “Memory” T cells in FF, identified by the CD4+ CD45R− phenotype, predominated over “naive” T cells (CD4+ CD45R+) at a ratio of 2:1, which differs from the ratio yielded by control blood samples (1:1). The percentage of activated T cells (CD3+ HLA‐DR+ cell) increased significantly in FF. When lymphocyte subsets were studied in the peripheral blood of IVF patients, changes similar to but less significant than those in FF were found. These data support the concept that lymphocytes play an important role in ovarian physiology.

Obstetric and perinatal outcome in women with twin pregnancy and gestational diabetes

Objective: The aim of this study was to evaluate pregnancy complications and obstetric and perinatal outcomes in women with twin pregnancy and GDM. Study Design: An observational multicentre retrospective study was performed and 534 pregnant woman and 1068 twins infants allocated into two groups, 257 with GDM and 277 controls, were studied. Main Outcome Measures: Pregnant women characteristics, hypertensive complications, preterm delivery rate, mode of delivery and birthweight were analysed. Results: Pregnant women with GDM were older (p < 0.001) and had higher body mass index (p < 0.001) than controls. GDM was associated with higher risk of prematurity in twin pregnancy (odds ratio 1.64, 95% confidence interval [1.14–2.32], p = 0.005). This association was based on the association with other pregnancy complications. Birthweight Z-scores were significantly higher in the GDM group (p = 0.02). The rate of macrosomia was higher in the GDM group (p = 0.002) and small for gestational age (SGA) babies were significantly less frequent (p = 0.03). GDM was an independent predictor of macrosomia (p = 0.006). Conclusion: The presence of GDM in twin pregnancy was associated with a higher risk of hypertensive complications, prematurity and macrosomia, but significantly reduces the risk of SGA infants. Prematurity was related to the presence of other associated pregnancy complications.

Influence of obstetric and perinatal care on perinatal mortality

OBJECTIVE Cases of perinatal death attributed to suboptimal perinatal care between 1979 and 1992 inclusive at a large, tertiary care center are reviewed. STUDY DESIGN The study compared two periods: 1979-1985 and 1986-1992. The perinatal morbidity-mortality committee analyzed patient records for the mothers and neonates, delivery room records, the results of fetal autopsy, and histological sections of the placenta. RESULTS In the first period, 21.5% of the deaths were found to have received suboptimal care; this figure declined 13.5% in the second period (P < 0.05). During the second period, antenatal, intranatal and postnatal care improved, as shown by the lower suboptimal care rate for antepartum (15.8% versus 9.8%; P < 0.05), intrapartum (49.2% versus 22.1%; P < 0.001) and postpartum death (19.9% versus 8.1%; P < 0.001). During both periods, fetal death during pregnancy made up the largest proportion of deaths attributed to suboptimal care, with 44 cases (43.1%) during 1979-1985, and 36 cases (64.3%) during 1986-1992 (P < 0.01). Of these cases, fetuses with intrauterine growth retardation were the most frequent recipients of suboptimal care (20 cases (45.5%) during the first period; 18 cases (50%) during the second period). CONCLUSION Despite better prenatal care, the highest suboptimal care rate was due to suboptimal care during pregnancy, when some high risk situations were overlooked by the obstetrician.

Randomised clinical trial comparing elective single-embryo transfer followed by single-embryo cryotransfer versus double embryo transfer

OBJECTIVE To analyze the impact of the eSET followed by single-embryo cryotransfer versus double embryo transfer in older women (<38 years) without taking into account embryo quality. STUDY DESIGN This is a prospective randomised clinical trial performed on 194 couples attempting a first IVF cycle in a Public Hospital in Spain. The women in Group 1 received eSET plus a single-embryo cryotransfer, and those in Group 2 received a double embryo transfer (DET). RESULTS In the intention-to-treat analysis, the cumulative live birth delivery rate in the eSET group was similar to the results obtained for the DET group (45.2% vs. 41.8%; p = 0.60). The rate of multiple gestation was significantly lower in the eSET group than in the DET group (0% vs. 26.4%; p < 0.05). The findings obtained in the per-protocol analysis were similar to those obtained in the intention-to-treat analysis. The per-protocol analysis revealed no significant differences in the rate of implantation (29.8% in eSET vs. 29.7% in DET; p = 0.98), in cumulative pregnancy rates per transfer (49.1% in eSET vs. 46.9% in DET; p = 0.80) or in the cumulative live birth delivery rate (38.6% in eSET vs. 42.2% in DET; p = 0.69). In the cycles with eSET, there were no twin pregnancies (0% in eSET vs. 27.6 in DET; p < 0.05). CONCLUSIONS For women aged under 38 years with good prognosis, without taking embryo quality as a criterion for inclusion, an eSET policy can be applied, achieving acceptable cumulative clinical pregnancy rates and birth rates.

Lowering the age at menarche and risk of early menarche in a population of Spanish postmenopausal women during the past two decades.

Aim. The purpose of this study is to confirm in our population the decreasing secular trend in the age of menarche (AAM) observed in other European countries. Another aim is to investigate the association between early menarche and breast cancer, metabolic disorders risk or early menopause. Materials and Methods We conducted a nationwide population-based study of 1980 Caucasoid Spanish postmenopausal women from 2003 to 2006 to investigate the AAM, the duration of the fertile period and the relation of early menarche with breast cancer and some metabolic disorders. Results Regression analysis of AAM demonstrates a trend towards the younger AAM in our population during the past decades (P > 0.001). Parallel to this decrease we observe a significant increase in the fertility period and the height of our population (P < 0.001). In the women with AAM less than 11 years, there is an increased risk of hypercholesterolaemia, being overweight and obesity. However, early menarche does not raise the risk of adult onset diabetes, hypertension or breast cancer. Conclusions These data indicate a decreasing secular trend of AAM in a Spanish population in the last decades. Furthermore, hypercholesterolaemia and obesity, but not breast cancer, appears to be influenced by younger AAM. Only women who have their menarche at the age of nine years or less are more likely to have an earlier menopause.

PGS-FISH in reproductive medicine and perspective directions for improvement: a systematic review

IntroductionEmbryo selection can be carried out via morphological criteria or by using genetic studies based on Preimplantation Genetic Screening. In the present study, we evaluate the clinical validity of Preimplantation Genetic Screening with fluorescence in situ hybridization (PGS-FISH) compared with morphological embryo criteria.Material and methodsA systematic review was made of the bibliography, with the following goals: firstly, to determine the prevalence of embryo chromosome alteration in clinical situations in which the PGS-FISH technique has been used; secondly, to calculate the statistics of diagnostic efficiency (negative Likelihood Ratio), using 2 × 2 tables, derived from PGS-FISH. The results obtained were compared with those obtained from embryo morphology. We calculated the probability of transferring at least one chromosome-normal embryo when it was selected using either morphological criteria or PGS-FISH, and considered what diagnostic performance should be expected of an embryo selection test with respect to achieving greater clinical validity than that obtained from embryo morphology.ResultsAfter an embryo morphology selection that produced a negative result (normal morphology), the likelihood of embryo aneuploidies was found to range from a pre-test value of 65% (prevalence of embryo chromosome alteration registered in all the study groups) to a post-test value of 55% (Confidence interval: 50–61), while after PGS-FISH with a negative result (euploid), the post-test probability was 42% (Confidence interval: 35–49) (p < 0.05). The probability of transferring at least one euploid embryo was the same whether 3 embryos were selected according to morphological criteria or whether 2, selected by PGS-FISH, were transferred. Any embryo selection test, if it is to provide greater clinical validity than embryo morphology, must present a LR-value of 0.40 (Confidence interval: 0.32–0.51) in single embryo transfer, and 0.06 (CI: 0.05–0.07) in double embryo transfer.DiscussionWith currently available technology, and taking into account the number of embryos to be transferred, the clinical validity of PGS-FISH, although superior to that of morphological criteria, does not appear to be clinically relevant.

Multigenic combination of estrogen-related genes is associated with age at natural menopause in a Spanish population

Objective Age at natural menopause (ANM) can be considered a complex parameter that depends on the interaction of multiple factors. In the present study, the role of interaction between genetic variants within estrogen synthesis and signalling pathways in the ANM in Spanish women is studied. Material and methods Nine single nucleotide polymorphisms (SNPs) located at different candidate genes related to the estrogen signalling pathway were analysed in 1980 Spanish postmenopausal women. Results Independently, none of the nine markers were significantly associated with early ANM. Only heterozygosis at the NRIP rs2229741 locus could be associated with early menopause; however, this marker does not maintain statistical significance. In contrast, linear regression analysis suggests several epistatic interactions including these markers in relation to ANM, especially between ESR2, NRIP1 and BMP15. The genetic variant that appears most in these interactions is that of the BMP15 rs3897937. It was observed that AA-TC combined genotype for NRIP-BMP15 (rs3897937), respectively, appears to be associated with a lower ANM than other possible combinations of these SNP (46.1±5.9 versus 50.4±3.3; P = 0.002). In the multilocus analysis, the multigenic interaction formed by ESR2 (AA), BMP15 rs3897937 (TC) and NRIP1 (AA) has the lower ANM (45.37±6.8 versus 48.69±5; P = 0.038). Conclusions The results suggest that epistatic interactions of estrogen-related alleles may contribute to variance in ANM in Spanish women. Moreover, BMP15 and NRIP1 also appear as attractive candidate genes for premature menopause but require further investigation to confirm them.

Improving patient safety by detecting obstetric care-related adverse events: application of a new screening guide

PurposeDetermining the magnitude and importance of patient safety-related incidents and the effectiveness of measures to improve patient safety (PS) are high-priority goals in efforts to improve the quality of obstetric care. The aim of this study was to evaluate the usefulness of the MRF1-OBST screening guide in detecting adverse events in women who received obstetric care.MethodsThis retrospective cohort study included 244 women who were hospitalized for delivery. All medical records were reviewed with the MRF1-OBST screening guide to identify adverse events and incidents. This tool is a modified form of the MRF1 screening guide regularly used in epidemiological studies of PS, to which we added items developed specifically for obstetric care. We calculated the positive predictive value and compared the ability of the MRF1 and MRF1-OBST guides to detect incidents related to PS in Obstetrics.ResultsThe MRF1-OBST guide did not identify any additional complications during hospitalization or incidents related to PS that were not also identified by the MRF1 guide.ConclusionsThe MRF1-OBST guide did not improve the detection of obstetric AE. The modified version of the guide required more work to use as a screening aid than the original MRF1 instrument. Efforts to improve the detection of incidents related to PS in obstetrics require complementary tools to be developed for information analysis.