M. Kloss

Treatment of Recurrent Aborters by Immunization With Paternal Cells—Controlled Trial

ABSTRACT: A paired sequential trial was undertaken to establish whether paternal mononuclear cells improved the prognosis in couples with recurrent abortions. For this purpose, 107‐108 cells obtained from the blood of partners were injected intravenously, subcutaneously, and intra‐dermally into women who had had three or more consecutive miscarriages with the same partner. Control women were given normal saline, injected in the same manner. The result of the sequential analysis showed that there was no significant beneficial effect of the cells compared to control. The overall success rate was 70% (32/46 couples). The success rate in patients given cells was 62% (13/21), while in those given saline it was 76% (19/25). While the overall success rate in this study compares with a number of other studies, we find an equally high success rate with non‐immunized patients. We conclude that the value of immunization for the prevention of recurrent miscarriage has not been established.

Prevalence of Factor V Leiden Is Not Increased in Women with Recurrent Miscarriage

The purpose of this study was to determine if there is an increased prevalence of the thrombophilic genetic mutant factor V Leiden in patients with recurrent miscarriage. Functional assays were conducted for activated protein C resistance and genetic detection of factor V Leiden in 100 women with recurrent miscarriage compared with a control group. The prevalence of factor V Leiden in patients was 6/100 (6%) compared with 3/85 (3.5%) in controls. The difference was not statistically significant. Antithrombotic prophylaxis with heparin and/ or aspirin in a subsequent pregnancy in five of the six patients with factor V Leiden was associated with maintenance of pregnancy and delivery of a live, healthy, full-term infant in four. We have been unable to demonstrate a statistically significant increased prevalence of factor V Leiden in women with recurrent miscarriage. If antithrombotic prophylaxis in pregnancy can be shown by controlled therapeutic trial to prevent miscarriage in these patients, identification of this subgroup would be important. Key Words: Recurrent miscarriage—Factor V Leiden—Activated protein C resistance.

Predictors of pregnancy success in repeated miscarriage.

ABSTRACT: Factors that may have a bearing on subsequent pregnancy success or failure in patients with recurrent abortion were examined in 165 women with a history of three or more consecutive miscarriages in the first trimester. The overall success rate was 67.9%. Factors that were found to correlate significantly with success rate were length of abortion history, total number of abortions, interval from last miscarriage to present pregnancy, and whether there was any degree of subfertility. Logistic regression analysis showed that the abortion × years index and maternal age accounted for all the variation observed in our data. Where all other known causes of abortions are excluded, recurrent aborters can be subdivided into two populations—namely, those with a relatively good prognosis characterized by a short abortion history and absence of subfertility problems, compared to those with a poor prognosis namely those with a long abortion history or presence of subfertility problems. These data clearly demonstrate major differences in success rates in women depending on the number of abortions and the length of abortion history (abortion × year index), particularly in women over the age of 30 years.

The Royal Women's Hospital Family Birth Centre: The First 10 Years Reviewed

EDITORIAL COMMENT: Results of obstetric practice are conventionally assessed by consideration of perinatal and maternal mortality rates, rates of intervention in labour (induction, epidural analgesia), rates of operative procedures for delivery (episiotomy, forceps, Caesarean section) and rates of postpartum complications (retained placenta, postpartum haemorrhage). Other important considerations are physical and emotional morbidity and whether or not the woman and her partner are pleased with the birthing experience and their birth attendants. The editorial committee wishes to request readers to provide information concerning the long‐term emotional results of the male partners decision to be present at the birth of his child since such data is not available and yet is relevant to the advice given to women regarding the partners role during parturition. This paper reports a marvellous perinatal mortality rate for births in a birth centre. Indeed the editor makes the prediction that this figure of less than 1 death per 1,000 births for women accepted for delivery in a Birth Centre, including those with intrauterine death diagnosed when the woman was admitted in labour, will stand as a record, since this rate is less than 10% of that for the state of Victoria as a whole (9.7 per 1,000 births in 1990). The results according to the method of delivery are also exemplary. It should be noted however, that 19 fetal deaths in utero occurred in the 889 women excluded from the group because of antenatal complications, and the authors do not provide information regarding neonatal deaths in this group or the number, if any, of these women admitted in labour with an intrauterine death. The data provided indicates that the perinatal mortality rate in the 5,365 women initially booked for delivery in the Birth Centre was at least 4.3 per 1,000 (23 in 5,365).

Family Births at the Royal Women's Hospital, Melbourne

Summary: A controlled study comparing clinical aspects of birthing unit confinement with orthodox obstetric care in a major obstetric hospital is detailed. The results confirm that this centre provides an acceptable and safe alternative for those who desire such an environment.

Immunogenetic Studies in Habitual Abortion

EDITORIAL COMMENT: Readers must judge whether their patients with habitual abortion warrant referral for the type of investigation and immunotherapy reported here. These patients are often anxious to explore every avenue to achieve a successful pregnancy. Many techniques are available with convincing and prestigious advocates. The treatment of infertility at its best is one of the marvels of modern scientific medicine — but there is a warning, many (most!) papers on the treatment of infertility lack controls, which makes it difficult to judge reported results. These comments apply to in vitro fertilization and embryo transfer, artificial insemination, tuba1 surgery, cervical ligation, ovulation induction, and immunotherapy. It is commonplace for couples with blocked tubes, anovulation and/or poor seminal quality/quantity to conceive happily, unexpectedly and successfully without treatment!

Single dose extra-amniotic prostaglandin gel for midtrimester termination of pregnancy.

Summary: The efficacy of a single dose of prostaglandin F2α gel instilled into the extra‐amniotic space to induce termination of pregnancy in the second trimester has been assessed and compared with intra‐amniotic prostaglandin F2α and with an extra‐amniotic infusion of prostaglandin F2α combined with intravenous oxytocin. There was no significant difference between the methods in time taken to abortion, incidence of retained placenta, need for blood transfusion, or rate of sepsis. Single dose extra‐amniotic prostaglandin gel is recommended as a safe, effective, and convenient method of midtrimester termination of pregnancy.

Predictors of pregnancy success in recurrent aborters

Factors which may have a bearing on subsequent pregnancy success or failure in patients with recurrent abortion were examined in 165 women with a history of three or more consecutive miscarriages in the first trimester. The overall pregnancy success rate was 68%. Factors which were found to correlate significantly with outcome were the length of abortion history, total number of abortions and whether women were over the age of 30 years. There were 37/165 (22.4%) couples with a prolonged abortion history index 20 (defined as the product of number of abortions and abortion history). Logistic regression analysis showed that the abortion history index, and maternal age accounted for all the variation observed in the data. Immunization with paternal cells does not appear to have a significant effect on prognosis. A paired sequential trial where women were given paternal cells (10 7 -10 8 ) compared to control women given normal saline showed success rate of 62% in the former and 76% in the latter. We conclude that a subgroup of recurrent aborters constituting about 22% of the total can be identified that have a poor prognosis compared to the majority of recurrent aborters. Immunization with paternal cells is not likely to help this group with a poor prognosis, and is not required by those with a good prognosis.

The Management of Severe Preeclampsia with Intravenous Magnesium Sulphate, Hydralazine and Central Venous Catheterization

EDITORIAL COMMENT; This paper reports satisfactory results in the management of severe preeclampsia in 46 patients using magnesium sulphate and hydralazine by intravenous infusion, and central venous catheterization for monitoring fluid balance. The reader may wonder what proportion of patients with preeclampsia warrant this type of intensive care. These patients were managed over a 3‐year interval and represent about 3% of patients with preeclampsia. In other words in 1,000 pregnancies about 100 patients will develop the signs of preeclampsia before or during labour, and in about 3 of the 100 the disease wilt be sufficiently severe to warrant the careful intensive management described in this paper.

Vaginal Prostaglandin F2α Gel Before First Trimester Termination of Pregnancy

Summary: Tylose gel containing either 10 mg prostaglandin F2α or sterile water was inserted into the posterior vaginal fornix of 130 patients either 12 hours or 4 hours before suction curettage. No benefit in terms of cervical softening or blood loss was noted in patients who received the prostaglandin gel.