Treatment efficacy for idiopathic recurrent pregnancy loss - a systematic review and meta-analyses.

INTRODUCTION: Medical treatment of women with idiopathic recurrent pregnancy loss is controversial. The objective was to assess the effects of different treatments on live birth rates and complications in women with unexplained recurrent pregnancy loss. MATERIAL AND METHODS: We searched MEDLINE, Embase and the Cochrane Library, and identified 1415 publications. This systematic review included 21 randomized controlled trials regarding acetylsalicylic acid, low-molecular-weight heparin, progesterone, intravenous immunoglobulin or leukocyte immune therapy in women with three or more consecutive miscarriages of unknown cause. The study quality was assessed and data was extracted independently by at least two authors. RESULTS: No significant difference in live birth rate was found when acetylsalicylic acid was compared with low-molecular-weight heparin or with placebo. Meta-analyses of low-molecular-weight heparin vs. control found no significant differences in live birth rate [risk ratio (RR) 1.47, 95% CI 0.83-2.61]. Treatment with progesterone starting in the luteal phase seemed effective in increasing live birth rate (RR 1.18, 95% CI 1.09-1.27) but not when started after conception. Intravenous immunoglobulin showed no effect on live birth rate compared with placebo (RR 1.07, 95% CI 0.91-1.26). Paternal immunization compared with autologous immunization showed a significant difference in outcome (RR 1.8, 95% CI 1.34-2.41), although the studies were small and at high risk of bias. CONCLUSION: The literature does not allow advice on any specific treatment for idiopathic recurrent pregnancy loss, with the exception of progesterone starting from ovulation. We suggest that any treatment for recurrent pregnancy loss should be used within the context of a randomized controlled trial.

Thromboembolism and in vitro fertilization - a systematic review.

INTRODUCTION: There is no accepted consensus on thromboprophylaxis in relation to in vitro fertilization (IVF). We aimed to study the frequency of thromboembolism and to assess thromboprophylaxis in relation to IVF. MATERIAL AND METHODS: We performed a systematic review. All study designs were accepted except single case reports. Language of included articles was restricted to English. RESULTS: Of 338 articles, 21 relevant articles (nine cohort studies, six case-control studies, three case series, and three reviews of case series) were identified. The antepartum risk of venous thromboembolism (VTE) after IVF is doubled (odds ratio 2.18, 95% CI 1.63-2.92), compared with the background pregnant population. This is due to a 5- to 10-fold increased risk during the first trimester in IVF pregnancies, in turn related to a very high risk of VTE after ovarian hyperstimulation syndrome (OHSS), i.e. up to a 100-fold increase, or an absolute risk of 1.7%. The interval from embryo transfer to VTE was 3-112 days and the interval from embryo transfer to arterial thromboembolism was 3-28 days. No robust study on thromboprophylaxis was found. CONCLUSIONS: The antepartum risk of VTE after IVF is doubled, compared with the background pregnant population, and is in turn related to a very high risk of VTE after OHSS in the first trimester. We recommend that IVF patients with OHSS be prescribed low-molecular-weight heparin during the first trimester, whereas other IVF patients should be given thromboprophylaxis based on the same risk factors as other pregnant women.

Randomized controlled study in pregnancy on treatment of marked hyperglycemia that is short of overt diabetes.

INTRODUCTION: A randomized multicenter study was conducted in the Stockholm-Örebro areas in Sweden to evaluate how treatment aiming at normoglycemia affects fetal growth, pregnancy and neonatal outcome in pregnant women with severe hyperglycemia. MATERIAL AND METHODS: Pregnant women with hyperglycemia defined as fasting capillary plasma glucose <7.0 mmol/L and a two-hour plasma glucose value ≥10.0 and <12.2 mmol/L following a 75-g oral glucose tolerance test (OGTT) diagnosed before 34 weeks of gestation were randomized to treatment (n = 33) or controls (n = 36). Women assigned to the control group were blinded for the OGTT results and received routine care. The therapeutic goal was fasting plasma glucose 4-5 mmol/L, and <6.5 mmol/L after a meal. Primary outcomes were size at birth and number of large-for-gestational age (>90th percentile) neonates. Secondary outcomes were pregnancy complications, neonatal morbidity and glycemic control. RESULTS: The planned number of participating women was not reached. There was a significantly reduced rate of large-for-gestational age neonates, 21 vs. 47%, P < 0.05. Group differences in pregnancy complications and neonatal morbidity were not detected because of limited statistical power. In total, 66.7% of the women in the intervention group received insulin. Of all measured plasma glucose values, 64.1% were in the target range, 7.2% in the hypoglycemic range and 28.7% above target values. There were no cases of severe hypoglycemia. CONCLUSIONS: Aiming for normalized glycemia in a pregnancy complicated by severe hyperglycemia reduces fetal growth but is associated with an increased rate of mild hypoglycemia.

Maternal and fetal outcomes if gestational impaired glucose tolerance is not treated.

OBJECTIVE: To evaluate whether there is increased maternal or neonatal morbidity in connection with impaired glucose tolerance (IGT) during pregnancy when the condition is not treated. RESEARCH DESIGN AND METHODS: During the study period of 1997-2001, in a defined geographical area in Sweden, the diagnostic criteria for gestational diabetes mellitus (GDM) were limited to the criteria for diabetes. Prospectively, 213 women who were identified with IGT during pregnancy were undiagnosed and untreated. Data on maternal and fetal outcome was collected from records. For each case subject, four control subjects were taken from the same delivery department. RESULTS: The proportion of women who underwent cesarean section was significantly higher in the case subjects than in the control subjects and was independently associated with IGT. The adjusted odds ratio (OR) was 1.9 (95% CI 1.2-2.9). The proportion of infants who were large for gestational age (LGA), defined as birth weight >2 SDs greater than the mean for gestation and sex, was independently significantly associated with untreated IGT during pregnancy (OR 7.3, 95% CI 4.1-12.7). Admission to a neonatal intensive care unit (NICU) for 2 days or longer was more common (adjusted OR 2.0, 95% CI 1.1-3.8). However, 71.3% of the children in the IGT group and 87.3% of the control subjects had no neonatal complications. CONCLUSIONS: There is increased independent association between cesarean section rate, prematurity, LGA, and macrosomic infants born to mothers with untreated IGT. Most of the children were healthy, but there is still increased morbidity. Therefore, to evaluate the effects of treatment, there is a need for a randomized study.

Well-being and sense of coherence during pregnancy.

BACKGROUND: Our knowledge of how a woman as an individual experiences, evaluates and copes with pregnancy is limited. The concept of 'sense of coherence' as described by Antonovsky may be an important factor in how people deal with stressful situations in life. The aim of this study is to describe pregnant women's perception of well-being during pregnancy and after delivery and to explore its relationship to their sense of coherence. METHODS: Participants (n = 177) were recruited from four Maternal Health Care Centers (MHCCs) in the Stockholm area. Three standard instruments were used in the study: the Sense of Coherence (SOC) scale, the Health Index (HI) and the Hospital Anxiety and Depression (HAD) scale. These instruments were filled in at pregnancy weeks 10-12 and 34-36 and also 8 weeks after delivery. RESULTS: One hundred and twenty women completed the study. At weeks 34-36 the pregnant women scored significantly worse for well-being than at weeks 10-12 and after delivery. A strong predictor for well-being is the women's degree of SOC. With regard to anxiety and depression no differences were found between the measurements. Neither demographic data such as age or financial status nor degree of complications influenced the results. CONCLUSIONS: Our study shows that the SOC scale measures the capacity to cope with the unforeseeable process that child-bearing still implies today. The SOC scale questionnaire and the HI can complement the midwife's subjective evaluation of the pregnant woman's need for psychosocial support during pregnancy. If this is correct, the SOC scale and the HI could be of great value in clinical work within maternal health care.