A practical approach to the management of thyroid dysfunction during pregnancy.

Pregnancy has an important impact on the thyroid gland and its function. Thyroid activity changes as a consequence of the novel physiological state of pregnancy and requires a complex hormonal and metabolic adaptation, which is possible only in the presence of a perfectly functioning thyroid gland. In fact, thyroid function is crucial for the success of the implantation and the progression of pregnancy. Abnormal thyroid function is very common among childbearing age women, explaining the high incidence of thyroid diseases that occur during pregnancy. Aim of this work is to analyze the adaptive events that characterize the thyroid function during pregnancy, exploring their hormonal, metabolic and molecular mechanisms. Moreover, the interpretation of the laboratory data necessary to monitor the thyroid functioning during normal pregnancy or in the presence of thyroid abnormalities will be discussed.

Explorative genetic association study of GSTT2B copy number variant in complex disease risks.

BACKGROUND: Glutathione S-transferases (GSTs) are the main phase II enzymes involved in cellular detoxification. Through phase I and phase II detoxification reactions, the cell is able to detoxify endogenous and exogenous toxic compounds. AIMS: This study focused attention on the GSTT2B copy number variant (CNV) in order to explore its involvement in the genetic pre-disposition to asthma, Alzheimer's disease (AD), allergic rhinitis (AR), essential hypertension (EH), hypothyroidism and recurrent miscarriage (RM). METHODS: The study population consists of 1225 individuals divided into six case-control groups. The genotyping of the GSTT2B CNV was performed by using a duplex-PCR. Odds Ratios (ORs) were calculated, adjusting for the confounding variables, to estimate the association between GSTT2B CNV and the disease status. RESULTS: The χ(2)-test and ORs did not show any association between this genetic marker and pathological phenotypes. CONCLUSION: The data highlights that GSTT2B CNV is not associated with the investigated complex diseases in Italian patients. However, further investigations are necessary to replicate these findings in larger sample sizes and to explore other health-related phenotypes.

Prediction of early pregnancy maternal thyroid impairment in women affected with unexplained recurrent miscarriage.

BACKGROUND: Proper maternal thyroid function is necessary for a successful pregnancy. In order to identify women who may experience miscarriage due to transient impairment of the pituitary-thyroid axis in early pregnancy, we aimed to investigate the ratio between basal and peak thyroid stimulating hormone (TSH) [following stimulus with thyrotrophin-releasing hormone (TRH)] in euthyroid women with unexplained recurrent miscarriage (RM). METHODS: We have established a 'iTSHa index' (TSH increase after TRH adjusted for the levels of basal TSH), determining TSH serum levels at time 0 and 20 min after TRH stimulus in 463 consecutive women attending two antenatal care units for two or more miscarriages occurring within the first 10 weeks of pregnancy. RESULTS: The mean basal TSH serum levels were higher (P < 0.001) in RM women [2.1 µIU/ml; 95% confidence interval (CI): 2.0-2.2] compared with the controls (1.3 µIU/ml; 95% CI: 1.2-1.4). Establishing serum TSH at an individual level, a large overlap was observed and the receiver operating characteristic curves did not allow us to find an optimal cut-off point with an adequate sensitivity/specificity ratio. Therefore, we suggest a novel statistical model, the 'iTSHa index' (available on www.afar.it/tsh-trh-miscarriage), that is capable of identifying women with RM due to transient thyroid function impairment of the early pregnancy, in particular when baseline serum TSH is less than 1.5 µIU/ml, i.e. well below the conventional upper cut-off indicated as 'safe' in those who want to conceive. CONCLUSIONS: A transient impairment of thyroid function in early pregnancy may cause an inadequate adaptation to the increased thyroid requirement and may be implicated in RM. The evaluation of the proposed iTSHa index, if validated in a larger cohort of patients, may provide information useful to identifying a subset of healthy women, without evidence of thyroid dysfunction or autoimmunity and a TSH in the low-normal reference range, who may be at risk of RM.

Glutathione S-transferase variants as risk factor for essential hypertension in Italian patients.

Involvement of genetic polymorphisms in arterial hypertension has already been reported, including GST genes, with contrasting results. The present research evaluates the possible association between GST gene polymorphisms and essential hypertension (EH) in an Italian population sample. 193 hypertensive subjects and 210 healthy controls were recruited. Buccal cells were collected from each subject using an oral swab and DNA was extracted using the phenol:chloroform:isoamilic alcohol method. GST SNPs were determined using the PCR-RFLP method, while GST null polymorphisms were determined using a Multiplex PCR. Among GST polymorphisms, only the frequency of the GSTT1 null phenotype was significantly higher in hypertensive patients than in normotensive participants. GSTT1 null individuals were significantly associated with increased risk of hypertension [P < 0.001; adjusted OR 2.24 (1.43-3.50)]. In sex-based analysis, the risk was significantly higher in female hypertensives [P < 0.001; adjusted OR 3.25 (1.78-5.95)] but not in male subjects. This study analyzed all GST gene that, in other research, have been studied in relation to arterial hypertension and the GSTO polymorphisms, showing an association only with GSTT1. The results for the GSTO genes represent the first analysis of this GST class in relation to blood pressure regulation. The association between the GSTT1 null phenotype and EH was confirmed in the overall population and in women, but not in men. These data suggest that GSTT1 could be a sex-specific candidate gene for EH.

IVF pregnancies: neonatal outcomes after the new Italian law on assisted reproduction technology (law 40/2004).

OBJECTIVE: To compare maternal and neonatal outcome of pregnancies achieved by assisted reproduction technique (ART) according to the guidelines of the newly established Italian ART law 40/2004, with that of naturally conceived. DESIGN: Three hundred and sixty-four ART pregnancies and 304 naturally conceived pregnancies were analyzed in terms of the incidence of obstetric complications and perinatal outcome. Control group was enrolled prospectively after being matched for an extensive number of maternal characteristics. RESULTS: Among singletons, ART pregnancies when compared to naturally conceived pregnancies showed a higher incidence of pregnancy loss (23.4% versus 10.5%) and a lower mean birth weight. A higher but not significant incidence of small for gestational age fetuses was observed in ART pregnancies, compared to those from normally conceived pregnancies (7.2% versus 2.7%). Moreover, the ART pregnancies showed a slightly, but nonetheless significantly shorter mean gestational age (38.6 versus 39.3 weeks) and more frequent preterm deliveries (11%) than the control group (2.7%). No difference was found in terms of other obstetric complications such as pregnancy-induced hypertension, gestational diabetes and placental abruption. Neonatal outcome was similar in both groups. CONCLUSION: Although the obstetric outcome among singleton ART pregnancies was good, these patients should be considered obstetric risk cases. The different frequency of complications is not related to maternal age or parity and could be the consequence of infertility or the procedures by which these women conceived. The reasons are, however, unclear and further studies are necessary.

Diagnostic evaluation of women experiencing repeated in vitro fertilization failure.

OBJECTIVE: The aim of the study was to propose a set of tests to clarify the diagnosis of repeated implantation failure in patients undergoing in vitro fertilization (IVF). STUDY DESIGN: Fifty-nine patients with at least two unsuccessful IVF attempts were included in the study. Blood samples were evaluated for the presence of underlying thyroid abnormalities, antiphospholipid antibodies (aPL), increased levels of natural killer cells (NK), inherited thrombophilia and mouse embryo assay factor (MEA-f). The same tests were performed on 20 normal fertile control patients. RESULTS: Seventy-six percent of IVF patients showed at least one abnormal result. This incidence was higher with respect to that found among control patients (45%). The prevalence of thyroid abnormalities, aPL and increased NK level was higher in IVF patients whereas no differences were observed in terms of prevalence of inherited thrombophilias and MEA-f. CONCLUSIONS: A better understanding of reproductive failure mechanisms should allow an effective diagnostic flow chart and a focused therapeutic option for patients experiencing repeated IVF failure. With this objective in mind, our data provide two important results: thyroid abnormalities, aPL and increased NK levels are more prevalent in women experiencing IVF failure. No evidence was found for an association between inherited thrombophilia and MEA-f and failure to achieve pregnancy after IVF.

GSTO1 uncommon genetic variants are associated with recurrent miscarriage risk.

OBJECTIVE: To explore the role of the GSTO1 gene in the pathogenesis of recurrent miscarriage (RM). DESIGN: Genetic association study. SETTING: Rome, Italy. PATIENT(S): 123 women with RM and 130 women without pregnancy complications. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Genotyping of two single nucleotide polymorphisms (A140D and E208K) and a 3-bp deletion (E155del) of the GSTO1 gene. RESULT(S): We found a statistically significant association between GSTO1*E208K variants and RM risk. Specifically, we identified this uncommon genetic variant only in women with RM. None of the women with physiologic pregnancies were carriers of K208 allele. CONCLUSION(S): GSTO1 has a role in detoxification metabolism, and we hypothesize that a functional variation of GSTO1 is a RM risk factor that interacts with environmental conditions.

Uterine junctional zone at three-dimensional transvaginal ultrasonography in patients with recurrent miscarriage: a new diagnostic tool?

OBJECTIVE: To evaluate the characteristics of the uterine junctional zone (JZ) by three-dimensional (3D) transvaginal sonography (TVS) in women with recurrent miscarriage (RM) as compared to normal fertile controls. STUDY DESIGN: The thickness and the morphology of the JZ were evaluated in 75 women with a history of RM due to different causes and in 20 fertile women without a history of miscarriages or pelvic disease. All patients included in the study were selected among those who attended the outpatient clinic of "Tor Vergata" University. The JZ characteristics were evaluated in the midluteal phase of the cycle on the uterine coronal section obtained by 3D TVS. RESULTS: Patients with RM showed a JZ maximum thickness significantly increased when compared to that observed in control group (5.8±0.7 vs. 5.0±1.1mm). When grouped according to the different causes of RM, all groups of patients with RM showed an increased JZ thickness when compared to fertile women, with the exception of those with anti-phospholipid antibody syndrome, probably due to the small number of cases with this pathology. CONCLUSIONS: A thickened JZ could be an independent indicator of the risk of miscarriage and may represent an important contributing factor to some causes of RM. These observations may offer new perspectives for the screening and treatment of patients with RM. Although further studies are needed to ascertain if the reduction of the JZ thickness can determine a better pregnancy outcome, 3D TVS evaluation of the JZ could provide the opportunity to identify women in which appropriate therapeutic protocols can improve the possibility of successful pregnancy.

Lack of association between essential hypertension and GSTO1 uncommon genetic variants in Italian patients.

BACKGROUND AND OBJECTIVE: Essential hypertension (EH) is a complex phenotype that is affected by multiple genetic and environmental factors. Some authors have explored the role of genetic variability of the glutathione S-transferase (GST) enzymes in EH risk with contrasting results. In particular, our previous study investigated two GSTO common polymorphisms, but we did not find a significant outcome. The aim of this research was to analyze two GSTO1 uncommon variants (E155del and E208K) in 193 EH patients and 210 healthy controls. RESULTS: The genetic association analysis did not find significant outcome between GSTO1 uncommon variants and EH: both single-locus and haplotype investigations did not reach the statistical significance levels. Nevertheless, the correspondence analysis seems to highlight a difference between sexes: female EH patients seem to be more related to E155/del155 and E208/K208 genotypes than male patients. CONCLUSIONS: Our studies confirm the lack of association between GSTO1 variants and EH risk, also for two uncommon genetic variants with large functional effects. However, our study highlighted some hypotheses (sex-specific marker, antioxidant function, arsenic metabolism, and modulation of inflammation processes) that might help to clarify the potential role of GSTO1 in EH pathophysiology.

Further evidence on the role of thyroid autoimmunity in women with recurrent miscarriage.

It has been twenty years since the first paper reporting the association between thyroid antibodies (TAIs) and spontaneous miscarriage was published. Following this observation, several studies have clearly demonstrated an increased prevalence of TAI in patients with recurrent miscarriage (RM). However, the exact mechanism underlying this association remains a matter of debate. The aim of the present study was to evaluate the thyroid function, throughout a specific test, in patient with RM and TAI focusing on the hypothesis that TAI should be an indirect sign of a mild thyroid dysfunction. 46 patients with RM and TAI were included in the study. All patients underwent short TRH stimulation test showing an abnormal response in the vast majority of cases (65%). Normal FT4 and FT3 mean values were found whereas TSH values were in the upper normal range (2.64 ± 1.3 mUI/L). Our data support the hypothesis that in patients with RM the presence of TAI is an indirect sign of a subtle thyroid dysfunction detectable by a specific test. This test give the possibility to identify women with RM in which specific therapeutic approaches could effectively improve the possibility for a successful pregnancy.

Hypertension in pregnancy and endothelial activation: An emerging risk factor for cardiovascular disease.

OBJECTIVE: There is emerging evidence suggesting that women who develop hypertensive disorders of pregnancy should be considered at risk for cardiovascular disease (CVD). Our objective was to determine whether persistent endothelial activation, which represents the earliest step in atherogenesis, is present after delivery in women with a history of hypertensive pregnancies compared to women with normal pregnancies. STUDY DESIGN: Two matched case-control studies were conducted. In the first study, endothelial activation was assessed by the measurement of soluble intercellular adhesion molecules, namely, intercellular adhesion molecules-1 (ICAM-1), vascular cellular adhesion molecules-1 (V-CAM-1), E-selectin and P-selectin in 25 women with hypertensive pregnancies and in a matched control group with an uncomplicated pregnancy one month and three months after delivery. In the second study, adhesion molecules were measured in 20 patients with a history of HELLP syndrome several years after pregnancy and in 20 matched controls. RESULTS: Increased levels of soluble adhesion molecules were found in women with hypertensive complications compared to women with uncomplicated pregnancies shortly after delivery. Significant differences were still present, several years after delivery comparing levels of adhesion molecules in women with a history of HELLP syndrome with those found in control patients. CONCLUSIONS: Patients with hypertensive pregnancies showed an abnormal activation of the endothelium which persists after pregnancy. This activation was particularly marked in patients experiencing HELLP syndrome. These observations may represent an explanation to the increased risk of CVD later in life in patients experiencing hypertensive pregnancies, especially in women with a history of HELLP syndrome.

Glutathione S-transferase genes and the risk of recurrent miscarriage in Italian women.

OBJECTIVE: To investigate the role of glutathione S-transferases (GSTs) in the pathogenesis of recurrent miscarriage (RM). DESIGN: Genetic association study. SETTING: University of Rome, Tor Vergata and San Giovanni Calibita, Fatebenefratelli Hospital. PATIENT(S): One hundred twenty-one women with RM and 113 women without pregnancy complications. INTERVENTION(S): Genomic DNA extracted from buccal cells and screening of positive/null genotypes of GSTM1 and GSTT1 genes and single nucleotide polymorphisms of GSTA1, GSTO2, and GSTP1 genes. MAIN OUTCOME MEASURE(S): Occurrence of GST polymorphisms. RESULT(S): Women with at least one GSTA1*-69T allele are more frequent in the RM group than in the control group: 67% vs. 48%, respectively. Significant outcomes were obtained considering different genetic models: codominant, dominant, and log-additive. In addition, the combined analysis suggests that GSTA1 and GSTM1 variants have a significant interaction in RM risk. CONCLUSION(S): Our study highlighted a significant association between the GSTA1 gene and an increased risk of RM. In particular, the -69T allele in the GSTA1 gene may be considered as a predisposing factor of RM.

Low-dose aspirin and omega-3 fatty acids improve uterine artery blood flow velocity in women with recurrent miscarriage due to impaired uterine perfusion.

OBJECTIVE: To determine the effect of different therapeutic approaches on uterine artery blood flow in women with recurrent miscarriage (RM) and impaired uterine perfusion. DESIGN: Prospective, randomized study. SETTING: Department of Obstetrics and Gynecology, University of Rome "Tor Vergata," Italy. PATIENT(S): Sixty women with unexplained RM and impaired uterine perfusion. INTERVENTION(S): Patients were randomly assigned to three different therapeutic regimens: 20 patients received a daily dose of 100 mg of aspirin (LDA); 20 patients were treated with omega-3 fatty acids (Omega(3)), 4 g daily; and 20 patients received LDA plus Omega(3). MAIN OUTCOME MEASURE(S): Doppler measurement of uterine artery pulsatility index (PI) was performed, in the midluteal phase of the cycle, before and after 2 months of therapy. RESULT(S): All therapeutic regimens induced an improvement in uterine perfusion with a significant reduction of uterine artery PI values. LDA alone or in combination with Omega(3) was found to achieve the highest improvement of uterine blood flow. Omega-3 supplementation was less effective, as reflected by the lower PI values. CONCLUSION(S): LDA and Omega(3) are effective in improving uterine artery blood flow velocity in women with RM due to abnormal uterine perfusion. Further studies are needed to determine whether the improvement of uterine perfusion may lead to a better pregnancy outcome.

Midluteal phase Doppler assessment of uterine artery blood flow in nonpregnant women having a history of recurrent spontaneous abortions: correlation to different etiologies.

OBJECTIVE: To compare the impedance to uterine artery blood flow, during the midluteal phase, in women with recurrent spontaneous abortion (RSA) as compared to normal fertile controls. DESIGN: A prospective study involving women with a history of RSA and fertile controls. SETTING: University of Rome "Tor Vergata." PATIENT(S): Two hundred thirty women with RSA and 50 fertile controls referred for routine examination. INTERVENTION(S): Transvaginal Doppler examination of uterine arteries during the midluteal phase of untreated cycles. MAIN OUTCOME MEASURE(S): The mean pulsatility index (PI) of uterine arteries. RESULT(S): Uterine arteries PI values in RSA patients (2.42 +/- 0.79) were significantly higher with respect to those found in the control group (2.08 +/- 0.47). When patients were grouped according to the different RSA causes, the highest PI values were found among patients with uterine abnormalities (2.82 +/- 1.0), antiphospholipid antibodies syndrome (2.70 +/- 1.1), and unexplained RSA (2.60 +/- 0.7). These values were significantly higher with respect to that found in the control group. No differences were observed in PI values between fertile patients and those with RSA due to thyroid abnormalities (2.10 +/- 0.55), inherited thrombophilia (2.03 +/- 0.45), autoimmune pathology (2.34 +/- 1.18), and genetic anomalies (2.47 +/- 0.54). Similar results were observed when patients were grouped according to primary and secondary RSA. CONCLUSION(S): Increased resistance to uterine blood flow may be an important contributing factor to some causes of RSA and may represent an independent indication of the risk of pregnancy loss.

Hysteroscopic metroplasty improves gestational outcome in women with recurrent spontaneous abortion.

STUDY OBJECTIVE: To compare the reproductive outcome in women with recurrent spontaneous abortion (RSA) associated with septate uterus after hysteroscopic metroplasty compared with patients who did not undergo surgery. DESIGN: Longitudinal evaluation (Canadian Task Force classification II-2). SETTING: University of Rome, Tor Vergata-affiliated endoscopic unit. PATIENTS: Forty-eight consecutive women with septate uterus and RSA were enrolled in the study. INTERVENTIONS: Hysteroscopic metroplasty. MEASUREMENTS AND MAIN RESULTS: Reproductive outcome in terms of term pregnancy was significantly improved after hysteroscopic metroplasty compared with controls (76% vs. 20%). No differences were found in the prevalence of preterm delivery between groups (4% vs. 5%). CONCLUSION: Our data suggest that hysteroscopic septum incision can improve pregnancy outcome in patients with RSA associated with septate uterus.

Low fatty acid amide hydrolase and high anandamide levels are associated with failure to achieve an ongoing pregnancy after IVF and embryo transfer.

Human reproduction is a rather inefficient process, yet the molecular reasons for this inefficiency remain unknown. IVF and embryo transfer (IVF-embryo transfer) also results in a high frequency of implantation failures and early spontaneous abortions. Here we show that the anandamide (AEA)-degrading enzyme, fatty acid amide hydrolase (FAAH), had significantly lower activity (46 +/- 17 versus 161 +/- 74 pmol/min per mg protein) and protein content (0.10 +/- 0.03 versus 0.23 +/- 0.06 units) in lymphocytes of IVF-embryo transfer patients who failed to achieve an ongoing pregnancy than in those who become pregnant, and this was paralleled by a significant increase in blood AEA (4.0 +/- 2.2 pmol/ml and 0.9 +/- 1.0 pmol/ml respectively). The blood levels of the other endocannabinoid, 2-arachidonoylglycerol, or of the AEA congener, N-palmitoylethanolamine, which are metabolized by enzymes different from FAAH, was not different between the pregnant and nonpregnant women, nor was there any difference in the activity of the AEA membrane transporter or the amounts of cannabinoid receptors in lymphocytes. Taken together with the reported negative effects of AEA on embryo implantation, this study indicates that low FAAH activity and subsequent increased AEA levels in blood might be one of the causes of implantation failure or pregnancy loss, thereby leading to a better understanding of the pathophysiological and therapeutic implications of endocannabinoids in human fertility.