Lia A. Bernardi

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group

Pregnancy loss prior to viability is common and research in the field is extensive. Unfortunately, terminology in the literature is inconsistent. The lack of consensus regarding nomenclature and classification of pregnancy loss prior to viability makes it difficult to compare study results from different centres. In our opinion, terminology and definitions should be based on clinical findings, and when possible, transvaginal ultrasound. With this Early Pregnancy Consensus Statement, it is our goal to provide clear and consistent terminology for pregnancy loss prior to viability.

Frequency of euploid miscarriage is increased in obese women with recurrent early pregnancy loss

OBJECTIVE To determine whether the frequency of euploid miscarriage is increased in obese women with recurrent early pregnancy loss (REPL). DESIGN Observational cohort study using prospectively collected data. SETTING Academic RPL program. PATIENT(S) A total of 372 women with REPL, defined as ≥2 pregnancy losses<10 weeks, and at least one ultrasound-documented miscarriage with chromosome results. INTERVENTION(S) Body mass index (BMI) was measured at the initial consultation and at each subsequent pregnancy. Conventional cytogenetic analysis and, when indicated, microsatellite analysis and/or comparative genomic hybridization was performed. MAIN OUTCOME MEASURE(S) Frequency of euploid miscarriage in obese (BMI≥30 kg/m2) and nonobese (BMI<30 kg/m2) subjects, before and subsequent to REPL evaluation. RESULT(S) There were 578 miscarriages with chromosome results. Of the subjects, 18% were obese at the time of miscarriage. The mean maternal age at miscarriage was similar between the obese and nonobese groups. Due to the high rate of maternal cell contamination in the prior miscarriages, only subsequent miscarriages with chromosome results were included in the primary analysis. Of the 117 subsequent miscarriages, the frequency of an euploid miscarriage among obese women was 58% compared with 37% of nonobese women (relative risk=1.63; 95% confidence interval 1.08-2.47). CONCLUSION(S) Obese women with REPL have an increased frequency of euploid miscarriage, which is a known risk factor for subsequent miscarriage.

Impact of subclinical hypothyroidism in women with recurrent early pregnancy loss

OBJECTIVE To assess the impact of subclinical hypothyroidism (SCH) in women with recurrent early pregnancy loss (REPL). DESIGN Observational cohort study. SETTING REPL program in an academic medical center. PATIENT(S) 286 women with a history of ≥2 pregnancy losses <10 weeks. INTERVENTION(S) From 2004-2007, no treatment for women with SCH (thyroid-stimulating hormone [TSH] >2.5 mIU/L with a normal free thyroxine or free thyroxine index); from 2008 onward, levothyroxine treatment prepregnancy to maintain TSH ≤2.5 mIU/L. MAIN OUTCOME MEASURE(S) Live-birth rate (LBR). RESULT(S) The prevalence of SCH was 55 (19%) of 286 in this REPL cohort. The cumulative LBR was 27 (69%) of 39 for women with SCH versus 104 (74%) of 141 for euthyroid women. The per-pregnancy LBR was 34 (49%) of 69 for SCH versus 129 (58%) of 221 for euthyroid women. When the LBR was compared between treated and untreated SCH, the cumulative LBR was 17 (71%) of 24 versus 10 (67%) of 15, respectively. The per-pregnancy LBR for SCH treated versus untreated women was 22 (48%) of 46 versus 12 (52%) of 23, respectively. CONCLUSION(S) Although there was a high prevalence of SCH in the REPL cohort, there was no statistically significant difference in the subsequent live-birth rate when comparing women with SCH and euthyroid women, or treated and untreated SCH.

Is chromosome testing of the second miscarriage cost saving? A decision analysis of selective versus universal recurrent pregnancy loss evaluation.

OBJECTIVE To compare the cost of selective recurrent pregnancy loss (RPL) evaluation, which is defined as RPL evaluation if the second miscarriage is euploid, versus universal RPL evaluation, which is defined as RPL evaluation after the second miscarriage. Traditionally, an RPL evaluation is instituted after the third miscarriage. However, recent studies suggest evaluation after the second miscarriage, which dramatically increases health care costs. Alternatively, chromosome testing of the second miscarriage, to determine whether an RPL evaluation is required, has been proposed. DESIGN Decision-analytic model. SETTING Academic medical center. PATIENT(S) Couples experiencing a second miscarriage of less than 10 weeks size. INTERVENTION(S) Selective versus universal RPL evaluation after the second miscarriage. MAIN OUTCOME MEASURE(S) Estimated cost for selective versus universal RPL evaluation. RESULT(S) The estimated cost of selective RPL evaluation after the second miscarriage was

Molecular biology of endometriosis: from aromatase to genomic abnormalities.

3,352, versus

Relationship between obesity and anti-Müllerian hormone in reproductive-aged African American women

4,507 for universal RPL evaluation, resulting in a cost savings of

The effects of maternal thyroid hormone function on early pregnancy

1,155. With stratification by maternal age groups, selective RPL evaluation resulted in increased cost savings with advancing maternal age groups. CONCLUSION(S) Selective RPL evaluation, which is based upon chromosome testing of the second miscarriage, is a cost-saving strategy for couples with RPL when compared with universal RPL evaluation. With advancing maternal age groups, the cost savings increased.

Terminology for pregnancy loss prior to viability

Endometriosis has been initially described as the presence of ectopic endometrial tissue on pelvic organs or in extrapelvic sites; and this has been used as its key pathologic feature ever since. Endometriosis responds to fluctuations in estrogen and progesterone by growth and inflammation, leading to pain aggravated by menses. It was proposed that pelvic endometriosis primarily originate from retrograde menstruation of a critical number of eutopic endometrial cells with stem characteristics. This postulate is supported by the molecular defects found in ectopic endometriotic tissue. Genome-wide differences in CpG methylation between eutopic endometrial and endometriotic stromal cells are present. Defective CpG methylation affecting several genes that encode key transcription factors such as GATA6, steroidogenic factor-1, and estrogen receptor-β in endometriosis gives rise to overproduction of local estrogen and prostaglandins and suppression of progesterone receptor. Progesterone receptor deficiency leads to progesterone resistance, resulting in decreased retinol uptake and retinoic acid production and altered retinoic acid action. These molecular defects collectively give rise to poor cellular differentiation, enhanced survival, and increased inflammation, which are the biological hallmarks of endometriotic tissue.

Ureteral Trauma During Transvaginal Ultrasound-Guided Oocyte Retrieval: A Case Report.

To determine whether there is an association between obesity and anti‐Müllerian hormone (AMH) among reproductive‐aged African American women (AAW).

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE special interest group, early pregnancy

Purpose of review It is unclear whether pregnancy outcomes are impacted by nonovert thyroid disease, and whether detection and treatment of abnormalities improve outcomes. Consequently, there is an ongoing debate regarding universal thyroid screening in pregnancy. A lack of solid evidence has prompted researchers to evaluate the role of screening and to examine pregnancy outcomes in women with thyroid dysfunction. In addition, as IVF has developed into a commonly used procedure, its impact on thyroid function has also been investigated. The most current literature on these topics will be summarized in this review. Recent findings The multiple societies that have published guidelines on thyroid disease in pregnancy have developed different recommendations, with none definitively advocating for universal screening at this time. However, recent studies examining the role of screening have supported it from an economic and prevalence standpoint. Despite this, evidence has failed to consistently demonstrate that treatment of nonovert thyroid disorders improves maternal and fetal outcomes. Recent research does suggest that close monitoring for and treatment of thyroid dysfunction is warranted in women undergoing IVF. Summary Further research must be performed to determine whether treatment of nonovert thyroid disease during pregnancy impacts outcomes. Concrete evidence will likely influence the universal screening debate.