Risk of breast cancer after miscarriage or induced abortion: a Scottish record linkage case-control study.

STUDY OBJECTIVE: To assess the risk of breast cancer in patients with a previous history of miscarriage or induced abortion. DESIGN: Case-control study relating "exposure" to outcome by linkage of national hospital discharge and maternity records, the national cancer registry, and death records. SETTING: Scotland. PARTICIPANTS: Miscarriage analysis-2828 women with breast cancer and 9781 matched controls; induced abortion analysis-2833 women with breast cancer and 9888 matched controls. MAIN RESULTS: After stratification for age at diagnosis, parity, and age at first birth, the odds ratio (95% confidence intervals) of breast cancer was 1.02 (0.88 to 1.18) in women with a previous miscarriage, and 0.80 (0.72 to 0.89) in women with a previous induced abortion. Further adjustments for age at bilateral oophorectomy, socioeconomic status (based on small area of residence), and health board area of residence had only minor effects on these odds ratios. CONCLUSION: These data do not support the hypothesis that miscarriage or induced abortion represent substantive risk factors for the future development of breast cancer.

Relations of gestational length and timing and type of incomplete pregnancy to ovarian cancer risk.

While the protective nature of parity with respect to ovarian cancer has been well documented, whether a history of incomplete pregnancy affects ovarian cancer risk is uncertain. Data collected from 739 epithelial ovarian cancer cases and 1,313 community controls in the Delaware Valley from 1994 to 1998 were used to evaluate the relation between gestational length and timing of first induced or spontaneous abortion and ovarian cancer risk. Incomplete pregnancy was not associated with ovarian cancer among nulliparous women or among ever-pregnant women either before or after adjustment for relevant confounders (for nulliparous women, odds ratio (OR) = 1.12, 95% confidence interval (CI): 0.66, 1.89; for ever-pregnant women, OR = 0.95, 95% CI: 0.76, 1.18). Among unigravid women, one full-term pregnancy was more protective than an incomplete pregnancy (adjusted OR = 0.29, 95% CI: 0.15, 0.57). These results were independent of the type of pregnancy loss. Among ever-pregnant women, a spontaneous abortion before a first birth provided significant protection (adjusted OR = 0.47, 95% CI: 0.30, 0.75), while no significant effect was found for an induced abortion prior to a first birth (adjusted OR = 0.80, 95% CI: 0.44, 1.47). These data do not support an independent association between incomplete pregnancies, either spontaneous or induced, and ovarian cancer risk.

Sonographic versus clinical evaluation as predictors of residual trophoblastic tissue.

BACKGROUND: The study aims to compare the diagnostic accuracy of sonographic evaluation versus clinical estimation in women suspected to have retained trophoblastic fragments. METHODS: The study group consisted of 68 consecutive patients admitted to our department due to suspected residual trophoblastic tissue. Each woman underwent ultrasound and physical examination by expert clinicians. The clinicians performing the physical examination were not informed of the sonographic findings, and vice versa. RESULTS: Patients were divided into three subgroups: clinical suspicion only of residual trophoblastic tissue (n = 8), sonographic suspicion only (n = 44) and combined sonographic and clinical suspicion of residual trophoblastic tissue (n = 16). In the latter group, in 14 out of 16 women (87.5%) retained trophoblastic tissue was confirmed by histological examination, a significantly higher rate compared to ultrasonographic (45.5%, P < 0.002) or clinical suspicion only (62.5%, P = 0.07). The specificity and positive predictive value of the clinical examination were significantly higher compared to ultrasonographic evaluation (P < 0.05), while the sensitivity of the ultrasonographic evaluation was higher than the clinical estimation (P < 0.05). There was no statistically significant difference in the negative predictive value or in diagnostic accuracy between the two methods. CONCLUSIONS: Based on our current experience, it seems that the combination of both clinical and ultrasonographic evaluation is recommended before uterine curettage is performed, thus lowering the rate of unnecessary invasive procedures.

Does underlying infertility aetiology impact on first trimester miscarriage rate following ICSI? A preliminary report from 1244 singleton gestations.

BACKGROUND: We evaluated the impact of using ICSI for assisted fertilization on first trimester survival rates of singleton gestations among an unselected infertile population. METHODS: The 1244 singleton gestations achieved by ICSI were segregated according to underlying infertility aetiology, with 55.0% having male factor, 3.6% endometriosis, 4.3% polycystic ovarian disease, 9.1% tubal factor, 24.3% unexplained and 3.3% other. None of the patients had coexisting infertility factor. RESULTS: The survival rate of all ICSI singleton gestations during the first trimester was 72.2%. There were no differences in early pregnancy loss (EPL) rate by infertility factor. Among patients undergoing ICSI because of male factor, there were no differences in EPL using ejaculated or non-ejaculated sperm. Regardless of aetiology, women aged >40 years had significantly higher EPL (42.1%). CONCLUSION: Our preliminary results demonstrate that first trimester miscarriage rates of ICSI gestations are not affected by underlying infertility aetiology but are affected by maternal age.

Is previous aberrant reproductive outcome predictive of subsequently reduced fecundity?

BACKGROUND: Effect of past reproductive performance on subsequent fecundity is uncertain. METHODS: A total of 2983 consecutive pregnant women self-completed questionnaires about time to pregnancy (TTP), pregnancy planning, previous pregnancies, contraceptive use, age, and individual/lifestyle variables. Outcome measures were: TTP, conception rates (CR) and, subfecundity odds ratio (OR; with 95% confidence intervals) before and after each outcome of last pregnancy. RESULTS: After miscarriage, TTP was longer than before miscarriage [2.1 (1.4-3.0), P < 0.001] and than TTP after livebirth [OR = 2.1 (1.6-2.6), P < 0.001]. Also subfecundity OR after miscarriage increased [1.7 (1.2-2.4), 1.8 (1.2-2.5), P = 0.001, 0.002 respectively]. This effect was more evident in older and obese women. Compared with livebirth, time to ectopic pregnancy (EP) was longer [OR = 13.8 (1.8-108.5), P = 0.001] but TTP after EP was not significantly different. Subfecundity OR relative to livebirth were 12.8 (3.6-45.0) (P<0.001) before, and 3.9 (1.4-11.0) (P=0.01) after, EP. The CR after EP increased 3-fold (1.1-8.3) over those prior to EP. Time to the terminated pregnancies even without contraceptive failures was shorter than that to livebirth [OR = 0.5 (0.3-0.7), P = 0.001] and than TTP after termination [0.35 (0.1-0.8), P = 0.001]. Also subfecundity OR increased after termination [7.2 (1.8-29.7), P = 0.02]. CONCLUSIONS: Miscarriers should be counselled about short-term reduction in subsequent fecundity, and earlier investigations should be considered in those who have other potential risk factors for reduced fertility. Further studies are required to clarify the relatively favourable effect on fecundity following EP and the relative reduction in fecundity after termination of pregnancy.

Factor V Leiden mutation in relation to fecundity and miscarriage in women with venous thrombosis.

BACKGROUND: Factor V Leiden mutation (Arg506Gln) increases the likelihood of venous thrombosis; it may also have a positive effect through facilitation of embryo implantation. This may manifest itself as a reduced time to pregnancy (increased fecundity) and fewer miscarriages in the first trimester. METHODS: From March 1999 onwards, consecutive patients with a first venous thrombosis (VT) were recruited. The first 115 female VT patients with factor V Leiden and 230 age-matched female VT patients without factor V Leiden were included. All patients, unaware of their genotype, received a structured questionnaire. RESULTS: Of the 297 (86%) women who returned the questionnaire, 220 had been pregnant at least once. Time to first pregnancy was unaffected by carrier status: 58% factor V Leiden carriers reported a pregnancy within 3 months compared to 54% non-carriers. The miscarriage proportion was 14%, similar in both groups. First trimester miscarriage was less frequent among carriers (46%) than among non-carriers (95%) (relative risk 0.5, 95% confidence interval 0.3-0.9). CONCLUSIONS: Factor V Leiden mutation may support embryo implantation, as factor V Leiden carriers had fewer miscarriages in the first trimester with a similar overall miscarriage rate. Miscarriage of embryos with poor viability may be postponed until the second trimester in factor V Leiden carriers. Fecundity was not influenced by factor V Leiden status.

Potential pathogens in the lower genital tract at manual vacuum aspiration for incomplete abortion in Korle Bu Teaching Hospital, Ghana.

OBJECTIVES: To determine the carriage rates of potential pathogens in the lower genital tract and factors associated with colonization among women with incomplete abortion. DESIGN: A cross-sectional study. SETTING: The Manual Vacuum Aspiration room of the Korle-Bu Teaching Hospital, Accra, Ghana. SUBJECTS: Two hundred women undergoing Manual Vacuum Aspiration at the Korle-Bu Teaching Hospital. METHODS: Eligible patients were screened for the presence of organisms in the lower genital tract by microscopy and culture of high vaginal and endocervical swabs. RESULTS: Nearly two-thirds of the patients (64.2%) had potential pathogens in the lower genital tract. Bacterial vaginosis alone was present in 47% and a combination of bacterial vaginosis and Candida albicans was present in 17.2%. Residence in an urban slum showed a significant association with the presence of potential pathogens (Odds ratio 2.6; p-value 0.04). CONCLUSION: Organisms responsible for bacterial vaginosis were the most frequently isolated potential pathogens in the cervical canal of patients with incomplete abortion at the Korle-Bu Teaching Hospital. Management of these patients should therefore include antibiotic prophylaxis against bacterial vaginosis.

Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an "empty uterus".

OBJECTIVE: The purpose of this study was to compare clinical outcomes of conservative management versus surgical evacuation of retained products of gestation after misoprostol treatment for first trimester spontaneous miscarriage using less restrictive transvaginal ultrasound criteria for diagnosing "empty uterus," which were managed conservatively. STUDY DESIGN: This was a prospective, randomized, controlled trial. RESULTS: Forty-six patients who had sonographic features previously regarded as significant retained products of gestation after misoprostol treatment, ie, homogenous intrauterine dimension of more than 11 cm 2 in combined transverse and sagittal plane, or those with heterogeneous intrauterine contents were consented to randomization. The short-term complication rates of those managed conservatively were significantly higher than surgical evacuation ([9/24] 37.5% vs [0/21] 0%, P < .05). CONCLUSION: Our previously reported transvaginal ultrasound criteria of homogenous intrauterine dimension of less than 11 cm 2 in combined transverse and sagittal planes for defining "empty uterus," which requires no further treatment, cannot be "relaxed" without incurring additional complications.

Hyperemesis gravidarum: outcomes and complications with and without total parenteral nutrition.

OBJECTIVE: To evaluate the obstetric and medical complications with hyperemesis gravidarum, comparing those who were supported with total parenteral nutrition (TPN group) and those who did not receive TPN (non-TPN group). STUDY DESIGN: The medical records of women with a diagnosis of hyperemesis gravidarum (ICD-9 code 643) admitted to Crouse Hospital, Syracuse, New York, between January 1995 and December 1998, were reviewed. A total of 166 subjects were identified and 192 admissions reviewed. Information was gathered for age, gestational age, gravity and parity, marital status, length of stay and number of admissions, and a review of electrolyte, albumin and thyroid function was performed. An assessment of pregnancy complications and outcomes was undertaken. RESULTS: Of the cases reviewed, 16% (27/166) were treated with TPN. The 2 groups were similar regarding incidence of pregnancy-related and maternal medical complications. The groups were similar when comparing objective measures, such as serum potassium, bicarbonate, albumin and thyroid function. The TPN group had a significantly increased incidence of complications directly attributable to parenteral therapy. Among multiparous patients in both groups, 69% had a prior pregnancy that had ended in spontaneous or induced abortion. CONCLUSION: The TPN group had a marked and significant increase in serious complications directly related to TPN use. These data suggest that great care should be taken to assess the need for parenteral therapy in patients with hyperemesis gravidarum. A history of loss in the antecedent pregnancy may be a risk factor for a subsequent pregnancy complicated by hyperemesis gravidarum.

Miscarriage but not fecundity is associated with progression of joint destruction in rheumatoid arthritis.

OBJECTIVE: To determine whether reproductive history before disease onset is associated with severity of joint destruction in rheumatoid arthritis. METHODS: A special early arthritis clinic (EAC) was established at the department of rheumatology of Leiden University Medical Centre. General practitioners were encouraged to refer patients with joint complaints to this clinic, where the diagnosis of rheumatoid arthritis was made by a rheumatologist. In all, 113 female patients with definite rheumatoid arthritis were included in this study. A structured questionnaire was administered and joint damage was assessed by sequential x rays of the hands and feet, using the modified Sharp score. RESULTS: The length of time of unprotected intercourse until first pregnancy (fecundity) was comparable with data from earlier studies, with 16% of the patients reporting a time to first pregnancy of more than 12 months. Fecundity did not reflect the extent of joint damage over time. The miscarriage rate was 15% per pregnancy, comparable to population figures (12-15%). A significant increase in joint damage over a two year follow up was found in patients with rheumatoid arthritis who had experienced at least one miscarriage compared with those who had never had a miscarriage (mean modified Sharp scores at 2 years, 24 (95% confidence interval, 15 to 32) and 16 (10 to 23), respectively; p<0.05). At baseline, the Sharp scores were similar in the two subgroups. CONCLUSIONS: Miscarriage before disease onset but not fecundity is associated with the progression of joint damage in rheumatoid arthritis.

Risk factors for preterm birth in Vietnam.

OBJECTIVE: To identify the risk of preterm birth and possible determinants among women in Hanoi, Vietnam. METHOD: Prospective cohort study of 1709 women with singleton live births at Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam, June-October 2002. Logistic regression analysis was used to examine predictors of preterm birth (<37 weeks' gestation). RESULT: The risk of preterm birth was 11.8%. Physically demanding work during pregnancy, two or more prior spontaneous abortions, history of preterm birth, vaginal bleeding, inadequate prenatal care during the first 20 weeks of gestation, and history of intrauterine device use with removal less than 12 months before the current pregnancy were associated with increased risk of preterm birth (adjusted odds ratios between 1.8 and 2.6). CONCLUSION: Preterm birth is relatively frequent in this population. Beyond established risk factors, these data implicated agricultural work and physical work demands with preterm birth, as well as history of recent IUD use.

Does speculum examination have a role in assessing bleeding in early pregnancy?

OBJECTIVES: To assess to what extent a speculum examination after a bimanual examination influences the accuracy of diagnosis and subsequent management of women with bleeding in early pregnancy in an accident and emergency (A&E) department. METHOD: A prospective study over a five month period included women presenting to A&E with vaginal bleeding at <20/40. Exclusion criteria were haemodynamic instability or known cervical carcinoma. The clinician recorded a diagnosis and management plan on a standard questionnaire after bimanual examination and after subsequent speculum examination. RESULTS: 236 women were included in the study. Of these, a total of three (1.3%) had a change of management plan and 10 (4.2%) patients had a change of diagnosis after speculum examination. CONCLUSION: The results suggest that speculum examination contributes to a minority of management decisions. The need for speculum examination should be assessed on a case by case basis depending on whether the findings on bimanual are conclusive.

Pregnancy interval and delivery outcome among HIV-seropositive and HIV-seronegative women in Kisumu, Kenya.

OBJECTIVE: A short pregnancy interval (PI) has been associated with increased child mortality, but mechanisms are unclear. We studied factors associated with PI and the effect of PI on birthweight and haemoglobin. METHODS: Information was analysed from 2218 multigravidae who were recruited at the prenatal clinic (1758) or in the labour ward (460) of the Provincial Hospital in Kisumu between June 1996 and July 2000 for a study to assess the interaction between placental malaria and vertical HIV transmission. RESULTS: The HIV prevalence was 28.9%. HIV seropositivity, older age, being unmarried, and <8 years of education were associated with a prolonged PI; among all women, a stillbirth, abortion, or death of a liveborn child as outcome of the previous pregnancy, and death of a child other than the last born among HIV-seronegative women, were associated with a shortened PI. No significant effect of short PI (an interval <24 months) on low birth weight (LBW), prematurity, small-for-gestational-age infants or maternal anaemia was evident. An abortion, stillbirth, or death of a liveborn child as outcome of the previous pregnancy was associated at the present delivery with LBW among HIV-seronegative women [adjusted odds ratio (AOR) 3.33, 95% confidence interval (CI) 1.63-6.81], and a low haemoglobin (<11 g/dl) among HIV-seropositive women (AOR 2.01, 95% CI 1.05-4.03 in the third trimester). CONCLUSION: Public health efforts to ensure 'adequate' birth spacing may run contrary to family planning decisions to replace a deceased child and may be spent on prenatal issues like prevention of anaemia, and vertical HIV transmission.

[Relation between neuroticism and low educational level and the risk of post-traumatic stress disorder in women after miscarriage or stillbirth]. / Verband tussen neuroticisme en laag opleidingsniveau en de kans op posttraumatische stressstoornis bij vrouwen na een miskraam of doodgeboorte.

OBJECTIVE: To determine whether neuroticism and educational level are predictive variables for post-traumatic stress disorder (PTSD) in women following an unsuccessful pregnancy. DESIGN: Prospective. METHOD: In the period June-September 1999, via advertisements in national newspapers, pregnant women with a gestation period shorter than 12 weeks were asked to participate in a study into their perception of the pregnancy. After they had agreed to participate they were given the 'Eysenck personality questionnaire' (EPQ) for neuroticism and other questionnaires, including a scale to determine their highest attained level. Every other month during the pregnancy and one month after the expected date of birth the participants were given brief questionnaires about the pregnancy, in which they were also asked to report miscarriage or stillbirth if such had occurred. Participants in whom the pregnancy had in fact ended unsuccessfully were contacted by telephone and asked to participate in a follow-up study with the 'Post-traumatic symptom scale' (PSS), among others. RESULTS: Of the 1339 women studied, 126 (9%) experienced an unsuccessful pregnancy; 8 of these dropped out of the study (response rate: 94%); one had not indicated her educational level. The remaining 117 women filled out the PSS after about one month. The average age was 31 years (SD: 4). The average duration of gestation at the moment of loss was 12 weeks (SD: 6; range 5-40). The average EPQ-score was 7.3 (SD: 4.6) and the average PSS-score was 18.1 (SD: 9.1). On the basis of the DSM IV, 31 women (26%) fulfilled the criteria for PTSS and 86 women did not. The average PSS-score was 28.2 (SD: 7.0) for the group with PTSS and 14.7 (SD: 6.7) for the group without PTSS. Logistic regression analysis revealed that a later diagnosis of PTSS was significantly associated with a higher score for neuroticism (RR = 4.49; p = 0.004; 95% CI: 1.60-12.60), a lower educational level (RR = 0.65; p = 0.009; 95% CI: 0.48-0.90) and a longer duration of gestation (RR = 2.48; p = 0.001; 95% CI: 1.45-4.25). CONCLUSION: In patients with a high educational level and a low score for neuroticism the risk of developing PTSS was negligible, while with a low educational level and a high score for neuroticism the estimated risk was about 70%. Care and guidance should be concentrated primarily on this group.

The effect of caffeine consumption and nausea on the risk of miscarriage.

Evidence for a harmful effect of caffeine intake on risk of miscarriage (spontaneous abortion) is inconsistent and nausea during pregnancy has been claimed to explain any association seen. The objective of this analysis was to determine whether caffeine consumption both before and during pregnancy influenced the risk of miscarriage in a group of pregnant women in the UK. We examined the association with maternal caffeine intake in a case-control study of 474 nulliparous women. Participants were recruited during the years 1987-89 from the Royal Berkshire Hospital in Reading and from a large group practice situated within the hospital's catchment area. Cases were 160 women with a clinically diagnosed miscarriage and controls were 314 pregnant women attending for antenatal care. Information on coffee/tea/cola consumption and potential confounders was collected by interview and caffeine content was assigned to individual drinks according to published data on caffeine content of beverages. Compared with a maternal caffeine intake of < 151 mg/day, we found evidence that caffeine consumption > 300 mg/day doubled the risk of miscarriage. Adjusted odds ratios were 1.94 [95% CI 1.04, 3.63] for 301-500 mg/day and 2.18 [95% CI 1.08, 4.40] for > 500 mg/day. This effect could not be explained by nausea in pregnancy. Nausea appeared to be strongly independently associated with a reduced risk of miscarriage (test for trend P < 0.0001). There was no evidence that prepregnancy caffeine consumption affected the risk. Our results indicate that high caffeine consumption during pregnancy (>300 mg/day), in particular coffee consumption, is an independent risk factor for increased risk and nausea is an independent protective factor for a lower risk of miscarriage.

Bony fragments in the uterus: an association with secondary subfertility.

Bone within the uterine cavity is an unusual finding in women with secondary subfertility, and is usually associated with a past history of termination of pregnancy. The etiology is unknown, but theories include retained fetal bone and osseous metaplasia of endometrial tissue. We describe the cases of three subfertility patients, all with a history of surgical termination of pregnancy. Each patient underwent a hysteroscopy after highly echogenic foci were seen in the uterus on transvaginal ultrasound examination. During hysteroscopy, several coral-like bony fragments were seen and removed by sharp curettage. On histological examination, these fragments were found to be mature, necrotic bone. This case report confirms the importance of routine baseline evaluation of the endometrium in subfertile women with a history of termination of pregnancy.

Vaginal bleeding in the first 20 weeks of pregnancy.

The first and foremost diagnosis to exclude in the pregnant patient presenting with vaginal bleeding is ectopic pregnancy. Once ectopic pregnancy is ruled out, miscarriage should be considered as a clinical spectrum. Its management is directed according to the integrity of the internal cervical os and patient hemodynamic status. Treatment with anti-D immune globulin is warranted for all Rh-negative patients. Urgent obstetric consultation is necessary for most miscarriage presentations.