A recent study has identified a number of risk factors for first trimester miscarriages. The study, conducted at the London School of Hygiene and Tropical Medicine (London, UK), found that high maternal or paternal age, previous miscarriage, infertility, assisted conception, low body mass index (BMI), regular or high alcohol intake, high stress levels and changing partners are associated with an increased risk of first trimester miscarriage.
This study set out to explore links between biological, behavioral and lifestyle risk factors and the risk of miscarriage. While a number of these factors, such as increased maternal age and previous miscarriage, are known to be associated with an increased risk of miscarriage, this study found a number of factors that had not been identified previously. Approximately 250,000 women in the UK are affected by miscarriage each year.
A total of 6719 women in the UK aged 18–55 years old were questioned by the researchers regarding sociodemographic, behavioral and other factors in their most recent pregnancy. Of these, 603 had had their last pregnancy end in first trimester miscarriage and 6116 women’s pregnancies had progressed beyond 12 weeks.
One crucial finding was the link between low BMI and a 72% increased chance of miscarriage. However, the study also identified a decreased risk associated with supplement intake, in particular folic acid or iron, eating fresh fruit, vegetables and chocolate.
Other novel findings include an increased risk of miscarriage if a woman was single or had changed her partner recently and a 60% increased risk if she had had a termination previously. In addition, ‘planned’ pregnancies and morning sickness saw a 40% and 70% decrease in the odds of miscarriage, respectively, and no association was found with educational level, socioeconomic circumstances or working during pregnancy.
Lead author of the study, Noreen Maconochie, commented: “An estimated one in five pregnancies in the UK will end in miscarriage. It can be a very distressing experience for women, and any advice on how they can improve their chances of achieving a full-term pregnancy is likely to be welcome”.
She continues: “Our study confirms the findings of previous studies which suggest that following a healthy diet, reducing stress and looking after your emotional well being may all play a role in helping women in early pregnancy, or planning a pregnancy, to reduce their risk of miscarriage. The findings related to low-pregnancy weight, previous termination, stress and change of partner are noteworthy, and we suggest further work be initiated to confirm these findings in other study populations”.
Source: Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage – results from a UK population-based case–control study. Br. J. Obstet. Gynaecol. doi: 10.1111/j.1471-0528.2006.01193.x (2006).
Abortion pill may help prevent breast cancer
The antiprogesterone drug, Mifepristone, works by blocking progesterone receptors in the uterus and thus by competitively inhibiting endogenous progesterone. Progesterone is required for the maintenance of implantation of the fertilized egg in the womb. The drug is speculated to be able to prevent the growth of mammary breast tumors by inhibiting progesterone present in breast tissue cells.
“We found that progesterone plays a role in the development of breast cancer by encouraging the proliferation of mammary cells that carry a breast cancer gene,” said Eva Lee, the lead author of the study.
Mifepristone could be effective in women with a genetic disposition to cancer carrying the mutated BRCA-1 gene. Women who have the BRCA-1 gene have more than a 50% chance over the age of 70 years of developing breast or ovarian cancer. So far, studies on mice are promising, but experts warn that scientists are still a long way from recommending Mifepristone as a breast cancer drug in humans.
Source: Poole AJ, Li Y, Kim Y et al. Prevention of BRCA-1-mediated mammary tumorigenesis in mice by a progesterone antagonist. Science 314, 1467–1470 (2006).
What is the best way to prevent fetal exposure to isotretinoin?
Isotretinoin is an effective treatment for severe acne. With over 1.4 million prescriptions dispensed annually in the USA, the drug provides a great benefit to patients with this physically, emotionally and socially disabling condition. However, isotretinoin is also highly teratogenic, associated with a risk of birth defects if taken by pregnant women.
Since the introduction of the drug in 1982, several risk management programs have been implemented in an attempt to reduce fetal exposure, but with suboptimal levels of success. The latest program, iPLEDGE™, was introduced by the manufacturers of isotretinoin in March 2006 at the request of the US FDA; however, concerns remain over its utility.
In a paper published in the November 2006 issue of PLoS Medicine, Lorien Abroms and colleagues discuss the advantages and disadvantages of the iPLEDGE system.
iPLEDGE is the most rigorous risk management program to date. All patients and all parties involved in isotretinoin distribution, including wholesalers, pharmacies and health-care professionals, are required to register in an online database at www.ipledgeprogram.com.
Previous interventions have failed to sufficiently reduce the number of pregnancies exposed to isotretinoin, perhaps due to lack of motivation or education on the part of patients and a lack of compliance by providers of the drug.
To try to improve compliance and motivation, under the iPLEDGE program pharmacists may now dispense isotretinoin only when the iPLEDGE database indicates that the following requirements have been met:
- Physicians must provide results of two negative pregnancy tests and two agreed forms of contraception to be used throughout treatment;
- Each month, physicians must provide negative results of additional pregnancy tests, re-identify the patient’s contraceptive choices and provide pregnancy prevention counseling;
- Patients must sign a consent form, identify their two chosen forms of contraception and answer questions demonstrating their understanding of the risks of isotretinoin.
iPLEDGE has the advantages of being able to prevent pregnant patients from beginning treatment, identify unplanned pregnancies earlier and increase awareness of the risks.
However, although widely adopted, many dermatologists complain that the system is inflexible and confusing. Moreover, it is still unknown whether the program actually reduces the number of exposed pregnancies, since there has been no formal evaluation of the system to date. Writing in the PLoS Medicine article, Steven Feldman comments: “A lesson from the history of past programs is that new programs should be tested before implementation. Until then, physicians must continue to use isotretinoin with great caution. Isotretinoin should be a last-line acne treatment for women of child-bearing potential”. Sources: Abroms L, Maibach E, Lyon-Daniel K, Feldman SR. What is the best approach to reducing birth defects associated with isotretinoin? PLoS Medicine 3(11), e483 (2006).
iPLEDGE™ Program
www.ipledgeprogram.com
Postpartum depression is a major public health problem
More needs to be done to help sufferers of postpartum depression, according to a recent editorial. Written by KL Wisner and colleagues from the University of Pittsburgh (PA, USA), the editorial states that postpartum depression is a major public health problem that needs additional resources, such as effective screening, education and treatment.
The editorial was written in response to a study by Trine Munk-Olsen and colleagues. Munk-Olsen’s large-scale epidemiological Danish study examined perinatal psychiatric episodes and found that at 3 months postpartum, women were at a much greater risk of hospitalization for psychiatric disorders than at 12 months after birth, especially after the birth of a first-born.
Owing to the importance and risk of postpartum depression – one in seven women will experience some form of depression after giving birth, of which many will be undiagnosed or untreated – Wisner proposes a universal screening and treatment program 2–12 weeks after birth.
Previous studies have identified a negative association between postpartum depression and the relationship between a mother and child, the mother’s ability to function and the child’s mental and motor development.
Wisner concluded: “Postpartum depression not only affects the mother. It touches the father, other children in the family and most importantly, the newborn. Knowing what we do about the risks of postpartum depression, we must recognize our responsibility to address this illness through improved research and greater access to care and services”. Sources: Wisner KL, Chambers C, Sit DK. Postpartum depression: a major public health problem. JAMA 296(21), 2616–2618 (2006).
Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Mortensen PB. New parents and mental disorders: a population-based register study. JAMA 296(21), 2582–2589 (2006).
Pregnant women with placental infection have doubled risk of recurrence during second pregnancy
A total of 10% of women who have vaginal births with their first child will develop chorioamnionitis, which will result in double the chance of them developing the infection again in a second pregnancy.
Chorioaminionitis, an infection in the placenta and the surrounding membranes, can cause bleeding and widespread infection in the mother and fetus. It is also believed that the type of bacteria involved may play a role in secondary infection, “Certain women could be colonized with bacteria that are more virulent and more likely to cause infection,” commented Vanessa Laibl, from the University of Texas Southwestern (TX, USA).
Longer labor, labor induction, long second stages of labor and use of medical equipment, such as internal monitors, also appeared to be factors present in those with the infection.
“Circumstances do play an important role,” said Laibl, who also added: “the women who got the infection the first time were still more prone to getting it in their second pregnancy”.
Source: Laibl VR, Sheffield JS, Roberts S et al. Recurrence of clinical chorioamnionitis in subsequent pregnancies Obstet. Gynecol. 108(6), 1493–1497 (2006).