Monday, 20 October 2014

New DNA test offers miscarriage clues

New research shows an alternative DNA test offers clinically relevant genetic information to identify why a miscarriage may have occurred years earlier. Researchers were able to identify chromosomal variants and abnormalities in nearly 50 percent of the samples. This first-of-its-kind study was conducted by researchers from Montefiore Medical Center and the Albert Einstein College of Medicine of Yeshiva University. The results were published in the March issue of Reproductive Biology and Endocrinology.

The technique used in this study, called rescue karyotyping, allows physicians to obtain important genetic information from tissue that had not been tested at the time of the miscarriage. As part of standard hospital protocol, tissue from miscarriages is embedded in paraffin for archival use and the karyotyping test is performed on DNA extracted from this tissue.

In this retrospective study of 20 samples from 17 women, genetic testing was successfully performed on 16 samples that had been archived for as long as four years. Of those samples, eight showed chromosomal variants and abnormalities. This is an important alternative when conventional karyotyping is not available or cannot be used for a specific sample.

"Given the ease of obtaining results, even if a delay in testing occurs, this new test may provide a useful technique to gain a better understanding as to why miscarriage occurs in some women," said Zev Williams, M.D., Ph.D., director, Program for Early and Recurrent Pregnancy Loss (PEARL), Montefiore and Einstein, assistant professor of obstetrics & gynecology and women's health and of genetics at Einstein, and corresponding author of the study. "I have seen women in tears because testing was not done at the time of the miscarriage and they feared they would never learn why it happened. Now we are able to go back and often get the answers we need."

One in five pregnancies ends in miscarriage, with the vast majority occurring in the first trimester. Recurrent miscarriage, which is defined as two or more miscarriages, occurs in up to 5 percent of couples attempting to conceive. Led by Dr. Williams, PEARL is comprised of a team of expert physicians, scientists, genetic counselors, nurses, technicians and staff members who work together to help these women maintain their pregnancies.

"Montefiore and Einstein have worked together to develop an innovative model based on research, which allows us to create novel diagnostic and treatment options and, in parallel, to quickly bring new advances to the clinic," said Dr. Williams. "This represents a new and emerging model in medicine - where the lab and clinic are brought closer in order to speed the pace of discovery and treatment."

"Most miscarriages are caused by an abnormal number of chromosomes in the embryo, accounting for up to 75 percent of first trimester losses," continued Dr. Williams. "This new test can help guide future treatment options but, more importantly, can also help alleviate some of the guilt and self-blame often associated with unexplained miscarriage and can close a door on a painful chapter in a woman's and couple's life."

Dr. Williams is a board certified obstetrician gynecologist with specialty training in reproductive endocrinology and infertility. He received his M.D. and Ph.D. degrees from the Mount Sinai School of Medicine and trained in Obstetrics and Gynecology at Harvard Medical School's Brigham and Women's Hospital and the Massachusetts General Hospital. Dr. Williams completed a fellowship in Reproductive Endocrinology and Infertility at Weill-Cornell Medical Center.


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Saturday, 18 October 2014

Risk of miscarriages not increased by NSAIDs

Women who take nonsteroidal anti-inflammatory drugs (NSAIDs) during pregnancy are not at increased risk of miscarriages, confirms a new study published in CMAJ (Canadian Medical Association Journal).

NSAIDs, which include ibuprofen, naproxen, diclofenac and others, are increasingly used by pregnant women in the first trimester to combat pain, fever and inflammation. However, it is unclear whether they increase the risk of pregnancy loss because previous studies have shown inconsistent results.

To determine whether there is an association between the use of NSAIDs in pregnancy and miscarriage (spontaneous abortion), researchers looked at data on 65 457 women aged 15 to 45 years who were admitted to Soroka Medical Center in Beer-Sheva, Israel, between January 2003 and December 2009 to give birth (90% of women) or for a miscarriage (10%). Of the total group, 4495 (6.9%) of women took NSAIDs during the first trimester of pregnancy. Women who took NSAIDs were older, were more likely to smoke and had more inflammatory diseases. As well, more pregnant women in the exposed group had undergone in-vitro fertilization (IVF) than in those who did not take NSAIDs.

About 8.2% of women in the group exposed to NSAIDs - general anti-inflammatories - had miscarriages compared with 10% of women in the group that did not take NSAIDs. In the group of women who took COX-2 selective inhibitors, which target specific inflammation, 17% had a miscarriage, although this group was small and the question needs further research.

"We found no important associations between exposure to NSAIDs, either by group or for most specific NSAID drugs, and risk of spontaneous abortion," write Dr. Sharon Daniel and Prof. Amalia Levy, Department of Public Health, Ben-Gurion University of the Negev and Soroka Medical Center, with coauthors. "However, we found an increased risk of spontaneous abortion following exposure to indomethacin."

The authors believe that this may be due to "reverse causation bias" because indomethacin was dispensed at the end of pregnancy, likely to treat preterm labour, an indication different than that for other NSAIDS.

"The fact that the study was based on large proportion of the district population, was adjusted to nearly all known risk factors for miscarriages (tobacco use, obesity, IVF, uterine malformations, hypercoagulable conditions, intrauterine contraceptive device etc.) and used advanced statistical methods strengthens the validity of the results," states the principal investigator, epidemiologist Prof. Levy.


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Friday, 17 October 2014

Strong association between pollutants from coal-burning stoves and miscarriages in Mongolia

Burning coal for domestic heating may contribute to early fetal death according to a new study by experts from The Saban Research Institute of Children's Hospital Los Angeles and Ulaanbaatar, Mongolia - the coldest capital city in the world.

In a paper published in the journal BMC Pregnancy and Childbirth, researchers report "alarmingly strong statistical correlations" between seasonal ambient air pollutants and pregnancy loss in Ulaanbaatar (UB), Mongolia.

UB has one of the highest levels of air pollution of all world capitals, with sulfide dioxide and particulate matter levels during winter months, which are up to 23 times World Health Organization standards. Air pollution in winter is largely caused by coal burning in Ger stoves (Ger refers to the traditional round, felt tent used as a portable residence by nomadic Mongolian people, but such stoves are also used in wooden houses within the Ger district.)

The scientists, led by David Warburton, OBE, DSc, MD, MMM, FRCP, FRCS, FRCPCH, professor of Pediatrics and Surgery at The Saban Research Institute of Children's Hospital Los Angeles and Keck School of Medicine at the University of Southern California, examined the association between spontaneous abortion (miscarriages) and seasonal variation of air pollutants. The measurements were gathered near the National Center for Maternal and Child Health (NCMCH) - which provides the majority of obstetric and gynecological services in UB - and compared to the medical records of 1,219 women in the region who had been admitted to the hospital between 2009 and 2011 due to fetal death prior to 20 weeks gestational age.

"We found that the incidence of miscarriage revealed a striking seasonal pattern of variation," said Warburton.

While the overall rate of miscarriages (occurring in approximately 15 to 20 percent of pregnancies) reported in UB is similar to that of Western countries, including the United States, the study showed that spontaneous abortion incidence per calendar month increased from 23 per 1,000 live births in May to 73 per 1,000 live births in December 2011.

Monthly average ambient levels of air pollutants showed increases in relation to the duration of hours of darkness, as well as the coldest temperatures - when Ger heating stoves are used most.

"We and our colleagues in government and academia in Mongolia are expending concerted efforts to improve stove efficiency and to educate the public about correct and more efficient lighting and heating methods," Warburton said, adding that a similar, strong correlation between air pollutants and miscarriages may also occur elsewhere in the world where similar levels of air pollution exist.

"The disturbingly strong correlation between air pollution indices and fetal death that we found suggests that much more needs to be done to further ameliorate the toxic effects of air pollution on the human unborn," Warburton concluded.


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Wednesday, 15 October 2014

Surprising findings regarding political polarization and knowledge about abortion and health

A new national survey reveals that the political divide among red-versus-blue states does not support the hypothesis that knowledge about abortion and health is shaped by the state in which one lives. Research led by Danielle Bessett, a University of Cincinnati assistant professor of sociology, was presented at the 109th Meeting of the American Sociological Association in San Francisco.

Bessett says that regardless of political viewpoints, only 13 percent of the 569 people polled in the national survey demonstrated high knowledge of abortion, correctly answering four or five questions. Seven percent mistakenly thought that abortion until 12 weeks gestation was illegal (another 11 percent didn't know if it was illegal or not).

More than half the sample (53 percent) reported living in a blue (considered liberal) state; 26 percent reported living in a red (considered conservative) state and 20 percent reported living in a "purple" state - swing states such as Ohio, in which Democrats and Republicans have strong support.

Although initial results showed some support for the red-versus-blue state divide when it came to abortion health knowledge (but not legal knowledge), this difference between states disappeared when researchers took into account individual-level characteristics, including respondents' political beliefs, their beliefs about whether abortion should be permitted and whether or not they knew someone who had an abortion."Because the issue of abortion is an exemplar of polarization, it provides a useful way to test the red states v. blue states hypothesis," write the authors. Bessett says she and her co-researchers found that their "data does not support the red-versus-blue state hypothesis: geography does not dictate the world views of Americans. Some individuals in all settings do have accurate information about abortion, regardless of political context."

An online questionnaire was administered to 586 randomly selected men and women ages 18 to 44 via SurveyMonkey Audience. The findings focused on answers from 569 respondents (91.7 percent of the sample) who were born in the U.S.

Participants responded to five survey items related to knowledge about abortion health and one exploring legal knowledge about abortion:

Survey Questions

What percentage of women in the U.S. will have an abortion by age 45?

Correct answer: 33 percent

Percentage of respondents with correct answer: 41 percent

Which has a greater health risk: An abortion in the first three months of pregnancy or giving birth?

Correct answer: giving birth

Percentage of respondents with correct answer: 31 percent

A woman who has an abortion in the first three months of pregnancy is more likely to have breast cancer than if she were to continue the pregnancy.

Correct answer: disagree somewhat/disagree strongly

Percentage of respondents with correct answer: 37 percent

A woman who has an abortion in the first three months of pregnancy is more at risk of a serious mental health problem than if she were to continue that pregnancy.

Correct answer: disagree somewhat/disagree strongly

Percentage of respondents with correct answer: 31 percent

A woman having an abortion in the first three months of pregnancy is more likely to have difficulty getting pregnant in the future.

Correct answer: disagree somewhat/disagree strongly

Percentage of respondents with correct answer: 35 percent

Abortion during the first three months of pregnancy is legal in the U.S.

Correct answer: true

Percentage of respondents with correct answer: 83 percent

Based on their findings, the researchers conclude that men and women making sexual and reproductive health decisions may not be well informed about the relative safety and consequences of their choices, highlighting a need for the provision of better, more comprehensive and evidence-based sexual and reproductive health education.

Survey Demographics

Fifty-three percent (313) of the respondents were male; 47 percent (273) female; 49 percent reported an age between 18-29 and 51 percent reported being between 30-44; the majority of the respondents (78 percent) identified as white; 11 percent Hispanic; four percent black and seven percent identified as "other" race or ethnicity.

Thirty-seven percent described themselves as very or somewhat liberal, 38 percent felt they were moderate and 25 percent identified as somewhat or very conservative.

Forty-one percent did not affiliate with any religion, 16 percent identified as Catholic and 35 percent identified as Protestant. Twelve percent reported they had a personal experience with abortion and 65 percent reported knowing someone who had an abortion. Eighty-seven percent believed that in most instances, abortion should not be restricted.


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Tuesday, 14 October 2014

Research reveals more than half of young women who have abortions were using contraception when they fell pregnant

Reproductive health charity Marie Stopes UK has launched the findings of the first research in the UK into the contraceptive use of women aged 16-24 having one or more abortions. It found that more than half (57%) of women were using contraception when they became pregnant, with short-term methods like the pill or condoms the most commonly used instead of the more reliable long acting methods.

Researchers analysed five years of the charity's patient data, surveying 430 women - 121 of whom had previously had an abortion - to gain an insight into how post-abortion contraception services can be strengthened and reduce the numbers of women seeking subsequent abortions. Although the total number of abortions in England and Wales has gradually declined in recent years, the number of women seeking abortion who had one or more previous abortions is increasing[i].

Key findings include:

The majority were using short-term methods, such as the pill (54%) or condoms (40%) Only 12% of women had used emergency contraception 28% of women had had one or more previous abortions, and the older a women is, the more likely she is to have more than one abortion Uptake of contraception at four weeks post-abortion was extremely high at 86%, but 67% used their chosen method for less than a year. Reasons for stopping included menstrual irregularities for long-acting reversible contraception (LARCs) and not renewing supply in time for pills and injections 63% of all young women received a post-abortion LARC from Marie Stopes (compared to 30% in England as a whole). Women are more likely to choose a LARC method if they've had a previous abortion, or had a surgical rather than a medical abortion.

Genevieve Edwards, Director of Policy at Marie Stopes UK said:
"Women have three fertile decades to manage, but too many women are being let down by a lack of on-going support in choosing and using the most effective method of contraception.

"If we tackled the lack of sex and relationships education in schools, invested in contraceptive training for health professionals and bridged the gap between abortion, contraception and sexual health services, we'd see the rates of unwanted pregnancies plummet."

Not all methods provide the same protection. With typical use, around 9 in 100 women will become pregnant each year on the pill, while condoms have a failure rate of 18%, compared to less than 1% for long-acting methods like intrauterine contraceptives and implants[ii].

Genevieve added: "We have got to get better at talking about contraception and abortion. One in three women will have an abortion and one in four of them will go on to have another. Our research shows there is no particular demographic group who are more likely to have abortions - it can happen to any of us. But for the majority of women, it was more often the short-term methods that failed them.

"Getting this right is also good for the public purse. Fitting a coil costs about £40 and lasts ten years - that's less than 8p a week and it repays the NHS many times over in abortion or maternity costs[iii]."

The research also found that while uptake of contraception post-abortion was very high[iv], what suits women at one time, may not always be the best option, making an ongoing conversation so important.

Genevieve added: "We are particularly concerned about low awareness of emergency contraception. Family planning doesn't start and stop with condoms or the pill and much more needs to be done to support women on choosing and using the contraception that suits their lifestyle and stage of life."


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Monday, 13 October 2014

Study Finds Unique 'Anonymous Delivery' Law Effective In Decreasing Rates Of Neonaticide In Austria

Rates of reported neonaticide have more than halved following the implementation of a unique 'anonymous delivery' law in Austria, finds a new study published on the 5th December in BJOG: An International Journal of Obstetrics and Gynaecology.

Researchers, from the Medical University of Vienna, looked at the rates of reported neonaticide (where a child is killed within the first 24 hours of birth) in Austria prior to and after the implementation of the 'anonymous delivery' law which was introduced in 2001. The law allows women access to antenatal care and to give birth in a hospital anonymously and free of charge.

Rates of neonaticide were obtained from police records pre and post the introduction of the law between 1991-2001 and 2002-2009. This data was then compared to data from Finland and Sweden, who also have a register for neonaticide but have no such law for anonymous delivery. Currently neonaticide is only governed by a specific law, separately from infanticide, in a few European countries.

Results from the study showed a reduction of more than half in the reported incidence of neonaticide from the pre to post-law data, decreasing from 7.2 per 100,000 births prior to the passage of the law (1991-2001) to 3.1 per 100,000 births after the passage of the law (2002-2009). The data from Finland and Sweden showed no such change over the same time period.

Importantly, the researchers noted that during this time there were no other known socioeconomic changes in Austria that could have impacted on the observed rates, such as passage of abortion laws or changes to childbirth benefits.

The researchers also investigated other preventative measures such as 'baby hatches' and 'safe havens', which allow for the safe handover of a newborn to government authorities and have been used in Austria and other countries around the world (including the US, Germany, Japan, South Africa). They estimated that in Austria there are 2-3 cases of babies being left in baby hatches reported per year, whereas cases of anonymous birth are in the range of 30-40 cases per year.

Claudia Klier, Associate Professor of Child & Adolescent Psychiatry at the Medical University of Vienna and co-author of the study, said:

"Neonaticide is usually the result of an unwanted pregnancy, and a resulting denial of that pregnancy, so it is often hard to gauge as those who commit neonaticide tend to evade the healthcare system.

"The passage of the anonymous delivery law and the subsequently major reduction in reports of neonaticide during this study period indicate that this has been a very effective tool in the prevention of this crime in Austria.

"It is clear that more research into neonaticide and its associated factors is needed to accurately identify and implement long-term solutions. However, we want to raise awareness of this option for women as we know this is a hidden crime and there may be many more cases than previously thought."

John Thorp, BJOG Deputy-Editor-in-Chief added:

"The results of this study are very compelling and highlight the benefits of anonymous birth. While preventative measures like baby hatches are good in theory, they still do not provide adequate support for the woman who is on her own not only during pregnancy but during the potentially dangerous delivery.

"It is therefore important to raise awareness of anonymous delivery as this approach could lead to a reduction in neonaticide rates."


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Saturday, 11 October 2014

The Gap Between Policy And Practice In Maternal Health And Maternal Mortality

As the UN Special Rapporteur on maternal mortality in India points out there is a 'yawning gulf between ... commendable maternal mortality policies and their urgent, focused, sustained, systematic and effective implementation.' Reproductive Health Matters explores the causes and impact of this gap, but also highlights hopeful signs of progress.

Two papers from India included in the issue capture both the good and bad news that characterise the gap between rhetoric and reality in maternal health and maternal mortality. In India a range of provisions to support better maternal nutrition and access to subsidised health care are required by law, but there is a wide gap between policy and practice. Preventable deaths are caused by several factors including a shortfall in antenatal care, delays in emergency obstetric care and inappropriate referral. Detailed case studies of women who died point to lack of accountability, discrimination on the grounds of poverty and caste, and according to Subha Sri Balakrishnan, author of one of the papers, "In some cases...quality of care (that) was so poor that it may be considered negligent."

Both papers follow subsequent action taken to seek government accountability and justice. In one paper, author Jameen Kaur, reports on the way in which a women's family sought redress in the courts, supported by human rights lawyers. The second paper details an investigation lead by Subha Sri Balakrishnan into maternal deaths in response to a public protest about local maternal deaths in Madhya Pradesh. The researchers presented their findings to district and state level health officials which led to some improvements in care.

Examples of using law to promote accountability and good practice are described in a paper from Latin America reporting on landmark decisions by the UN Committee on the Elimination of Discrimination Against Women (CEDAW) calling for appropriate maternal health care (Brazil) and decriminalisation of abortion to safeguard women's health (Peru). These are promising examples of the application of human rights to demand government responsibility for maternal deaths and to assert the rights of women not to die in pregnancy, childbirth and unsafe abortion.

Furthermore a new emphasis on evidence-based practice is described in several papers, providing grounds for optimism. It suggests there is a real desire to improve outcomes and the hope that new initiatives may have a greater chance of success in saving women's lives. Without the political commitment to addressing equity, however, important initiatives will continue to fail the poorest and most marginalised women. As one author notes, "The death of a woman due to pregnancy complications is not just a biological fact it is also a political choice."

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