Uterine stem cells deficiency linked to Recurrent Pregnancy Loss (RPL).

Stem cells have the potential to treat a myriad of diseases and have acted as a powerful tool to treat many life threatening diseases. Researchers have opened up a new avenue in stem cell therapy by tying stem cell deficiency in endometrium to recurrent pregnancy loss.

According to a recent paper published in February issue of Stem cells by Lucas E S et al researchers postulated that stem cell deficiency in the endometrial tissue and accelerated stromal aging is responsible for RPL by limiting the endometrial capacity to decidualize. Most miscarriages are sporadic and are due to chromosomal aberration in the conceptus, but RPL is a distinct entity.  In about 50% of RPL, the etiology is not defined. It is estimated that roughly 5% of women suffer from 2 clinical miscarriage and 1% ending up with 3 or more losses. While many factors seems to play role in RPL, the underlying endometrial pathology is not yet explored.

It is indicated that RPL is associated with impaired differentiation of endometrial stromal cells (HESCs) into specialized decidual cells. The differentiation termed as decidualization, predicts the end of implantation window and confers endometrium the ability to recognize, respond to and eliminate implanting compromised embryos, theory of natural selection. The theory suggests that it is the response of the decidualized endometrium to embryonic signals, which decides the future implantation and development of the  embryo or its rapid demise through menstruation-like shedding. Current evidence suggests that it is the abnormal decidualization which causes the loss of selectivity leading to implantation without further progress leading to pregnancy loss. So, the endometrium acts as a ‘biosensor’ detecting the embryo derived signal and deciding the fate of the embryo.

It is already known that decidualization of the endometrium in not dependent on embryo. It happens in post ovulatory phase of every cycle due to increase in progesterone levels and cAMP. It is because of cyclic activation of mesenchymal stem cells which differentiate into stromal cells in regenerating endometrium.

The authors hypothesized that defect in cyclic regeneration of endometrium in RPL patients is impacted due to defect in DNA methylation status of human endometrial stromal cells (HESCs).

A total of 183 endometrial biopsies were taken from patients with  normal women and those with RPL, except 8 random samples, all other were timed between 6 and 10 days after the preovulatory luteinizing hormone surge.  HESCs were isolated from the samples and cultured in laboratory. They were further tested for epigenetic markers for recurrent pregnancy loss.

It was seen that endometrial lining in patients with RPL showed loss of plasticity, with included increased senescence, deficiency and limited capacity to differentiate. Epigentic signature was lacking in women who experienced RPL as compared to their normal counterparts.

The endometrium also had decreased number of stem cells that had limited capacity to renew the endometrium, resulting in aging. Aging cells mount an inflammatory response that is enough for implantation but not for development and sustaining the embryo.

In an interview with medscape  Dr. Brosens said “"We also found that the greater the number of miscarriages a woman had experienced...the more depleted the lining was."

"Cultured cells from women who had had three or more consecutive miscarriages showed that aging cells in the lining of the womb don't have the ability to prepare adequately for pregnancy," Dr. Brosens notes.

He futher explained hat medicine usually regards recurrent miscarriage as being associated with an underlying disease, and normal practice is to investigate clotting abnormalities, hormonal imbalances, or immune responses. In the United States, patients are referred to specialist care after two consecutive losses; patients are referred after three losses in the United Kingdom. "It is often stated that a cause for recurrent miscarriage can be found in 50% of patients. However, for every woman with an apparent known 'cause' of miscarriage, there will be 50 to 100 women who have the same disorder but do not experience miscarriage. So current tests completely lack specificity."

With sporadic miscarriages, the majorities are caused by chromosomal abnormalities in the fetus, but with recurrent miscarriages, the majority involves normal fetuses. The more miscarriages a woman has, the greater the likelihood pregnancy loss involves a fetus with normal chromosomes. "Also, as the number of miscarriages increases, there is a higher chance of recurrent miscarriage," Dr. Brosens added.

According to Dr. Brosens, the real challenge lies in translating these findings into something clinically meaningful. He believes that this could further lead to development of some sort of screening tests, eventually ending up with some sort of treatment for women at risk. "The abnormalities we have identified all precede pregnancy, so it is possible to test the uterine lining for these markers and help predict if a patient is at risk of recurrent miscarriages."

He also pointed that stem cells in the uterine lining were highly dynamic and active pool, that are undergoing  cyclic shedding and regeneration, so intermittently the defects in the uterine lining could undergo self-repair, changing from an unsupportive environment to a supportive one. This explains why many women have a successful pregnancy even after recurrent miscarriages.

The authors concluded that “These findings open up new avenues to screen women prior to pregnancy for the risk of miscarriage and point to the potential of cell-based therapies in the prevention of RPL.”

References:

Lucas, E. S., Dyer, N. P., Murakami, K., Hou Lee, Y., Chan, Y.-W., Grimaldi, G., Muter, J., Brighton, P. J., Moore, J. D., Patel, G., Chan, J. K.Y., Takeda, S., Lam, E. W.-F., Quenby, S., Ott, S. and Brosens, J. J. (2016), Loss of Endometrial Plasticity in Recurrent Pregnancy Loss. STEM CELLS, 34: 346–356. doi: 10.1002/stem.2222

http://www.ncbi.nlm.nih.gov/pubmed/22835448

http://www.ncbi.nlm.nih.gov/pubmed/1975862

http://www.ncbi.nlm.nih.gov/pubmed/20847090

FDA announces a proposal to ban most powdered medical gloves in USA.

In a press release on March 21, 2016 US Food and Drug Administration (FDA) announced a proposal to ban most powdered medical gloves in USA. The ban includes powdered surgeon’s gloves, powdered patient examination gloves and absorbable powder for lubricating a surgeon’s glove. Both synthetic gloves and natural rubber latex (NRL) are covered in the ban, only powdered radiographic examination gloves are exempt.

A ban was only option to FDA as the risks associated with the use of powdered gloves cannot be corrected through new or updated labeling.

“This ban is about protecting patients and health care professionals from a danger they might not even be aware of,” said Jeffrey Shuren, M.D., director of FDA’s Center for Devices and Radiological Health. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”

Surgical gloves made a room in doctor’s armamentarium in the year 1889, and have played an important role in protecting both patients and health care personnel in medical field since than. Various types of powder lubricants have been used so that they can be donned easily. The first was powder made from Lycopodium spores (club moss spores) and later replaced by talcum powder (chemically hydrous magnesium silicate). Both of these were replaced by modified cornstarch as they were recognized to cause wound granulomas and adhesion formation.  Cornstarch is currently the most commonly used type of absorbable glove powder.

Before proposing the ban, FDA considered all available scientific evidence in disease causation due to powder which included a through review of literature. FDA has also received several public petitions from 1997 to 2011, requesting a ban due to multiple health issues in doctors and healthcare workers.

The level and type of risks due to use of powdered gloves vary according to the composition of gloves (synthetic versus NRL) and its intended use (surgeon’s glove versus patient examination glove). It is known that powdered synthetic patient examination gloves present less risk than powdered NRL surgeon’s gloves.

The identified risks of powdered gloves according to composition and intended use are:

1) Risks of Absorbable Powder for Lubricating a Surgeon's Glove.

This powder, often referred to as Absorbable Dusting Powder or ADP, has been shown to cause acute severe airway inflammation, granulomas, and adhesions. When used on NRL gloves, powder has the ability to adhere to latex allergenic proteins that, when aerosolized and inhaled, present significant risks to patients, including inflammatory responses, hypersensitivity reactions, and allergic reactions. Additionally, the latex sensitive individuals experience cutaneous reactions upon skin exposure to the latex allergenic proteins adherent to the powder.

2) Risks of Powdered Natural Rubber Latex Gloves.

The powder used to lubricate these gloves bind to the natural rubber latex protein, causing latex aerosol which causes allergic and inflammatory responses to NRL. Allergic reactions include asthma, allergic rhinitis, conjunctivitis, and dyspnea.

3) Risks of Powdered Synthetic Surgeon’s Gloves.

These gloves do not pose the risk of allergic reaction due to aerosolized powder, but exposes individuals to powder by inhalation leading to airway inflammation. Additionally surgeries and invasive examinations deposits the powder could then results in granuloma formation in any exposed site, as well as peritoneal and other tissues adhesions. Additional studies show that powder may promote infection in wounds, which can lead to wound healing complications.

4) Risks of Powdered Synthetic Patient Examination Gloves.

The patient examination gloves does not expose the patient’s internal organs  to powder but the internal tissue  are exposed  during procedures such as oral, vaginal, gynecological, and rectal examinations. In female patients the reproductive tracts is exposed to powder leading to tubal adhesions and infertility in animal and human studies.

Over the years organizations such the American Academy of Allergy, Asthma, and Immunology(ACAAI), the National Institute for Occupational Safety and Health (NIOSH), the American College of Surgeons (ACS), and the American Nurses Association have all issued statements against the use of powdered gloves. CDC also joined the team, issuing a statement on NRL sensitization and recommending that non powdered rubber latex gloves would be more efficient.

Moreover, health care systems such as the Cleveland Clinic network of nine hospitals, the Johns Hopkins Hospital and University of Virginia Healthcare systems have all restricted or banned the use of powdered NRL gloves in their systems. In Europe, Germany and the United Kingdom have also taken steps against use of powdered NRL gloves.

The FDA published a request for comments in its notice to include the public in Federal decision making.  Comments will be accepted for 90 days from the date of publication. The full notice and the way to post comments can be viewed here.

FDA further proposes that the ban will not incur any additional economical or environmental burden. The proposed rule is expected to provide a positive net benefits range between $26.6 million and $29.3 million due to reduced adverse effects.

It further added that the policy will also not affect the medical practice as several non powdered alternatives are already available in the market.

References:

https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-06360.pdf

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm491466.htm

https://www.regulations.gov/#!documentDetail;D=FDA-2011-N-0027-0001

Stillbirths and the ACOG 39 weeks rule----Does it need to be revisited?

The 39-week rule – was established in 2009 that restricts labor induction in the 37^th and 38^th week of pregnancy (i.e., in the “early-term period”) unless an accepted/approved “indication” is present.

The 39-week rule is now a strict clinical guideline that is enforced by professional organizations, governmental agencies and the medical insurance industry in US. 

In November 2013, ACOG  and Society for Maternal and Fetal medicine(SMFM)  made a recommendation of  replacing the use of “ term”  pregnancy which accommodated gestations between 37 wks to 42 wks with the following designations:

•  Early term: 37 weeks through 38 weeks and 6 days
 •  Full term: 39 weeks through 40 weeks and 6 days
 •  Late term: 41 weeks through 41 weeks and 6 days
 •  Postterm: 42 weeks and beyond

These changes were made by growing research evidence, a part of which has been led by Eunice Kennedy Shriver National Institute of Child Health and Human Development, indicating that key developmental process for the fetus continue well beyond 37 wks till 39 wks. They also advocated that “Babies born at or after 39 weeks have the best chance at healthy outcomes compared to those born before 39 weeks.”

It was seen that the percentage of infants born preterm declined for the seventh straight year in 2013. The NIH  also published a report that shows a decline in induction of labor for singleton birth in year 2011 (23.7%) and 2012 (23.3%),after 20 years of consecutive increases. There was also a decline in Early Elective Deliveries across the United States, from 17% of babies in the United States were delivered before 39 weeks in 2010 to a sharp decline to 4.6% in 2013. 

But, two recent studies, one by Dr. Nicholson presented at Society for Maternal-Fetal Medicine (SMFM) 2016 Pregnancy Meeting and the other by Dr Jason Salemi, assistant professor of family and community medicine at Baylor and lead author of the study advise caution against the universal application of the rule.  

According to  paper presented at SMFM 2016 Pregnancy Meeting Dr Nicholson said that  “Investigators found that the proportion of term stillbirths rose from 1.103 per 1000 deliveries before the rule was adopted to 1.177 per 1000 after. He further added "This study raises the possibility that the 39-week rule may be causing serious unintended harm."

According to Dr Nicholson "Term stillbirth is clearly one of worst obstetrical outcomes, and it occurs with relatively high frequency — in one per 1000 deliveries that reach 37 weeks," he explained. "We should place a high priority on determining the causes, developing preventive interventions, and studying factors suspected of producing this truly horrible outcome.

He advocated an urgent need of high quality research in this area, and until we get the evidence the forced imposition of the 39-week rule should be looked into. The 39 weeks rule was put into action after results of many studies, but he said that all those studies were flawed; they suffered from incorrect modeling, were retrospective cohort studies and the confounders were not corrected for.

He further went to add that "the studies failed to consider ecological fallacy, which is that we should not determine the treatment of an individual patient based on studies that examine population-based data," he said. "Ecological cohort studies should rarely be used to generate policy, yet that's what I think we did."

Dr. Nicholson and his colleagues requested the state health department to provide them with data on term still births and term births segregated according to the weeks of gestation for 3 years before and 3 years after the rule was in enforced. The data clearly showed an increase in deliveries at 39 weeks. He said that "The greatest increases in term stillbirth occurred at 37, 38, and 39 weeks of gestation," he noted, which is "right where the 39-week rule is working."

The team observed a clear increase in number of stillbirths when the rule  was  implemented,  1.103 per 1000 deliveries in 2007-2009 to 1.177 per 1000 in 2011-2013. He further estimated that it accounts for additional 335 more term stillbirths in 2013 than in 2007. He acknowledged some shortcoming of his retrospective cohort study, saying it only identifies association, not causation.

A study published in JAMA paediatric, documented that  during this period admission to NICU increased sharply.

The paper was a topic of hot debate and some physicians suggest that benefit of the rule outweigh the risk. 
Dr. Baxi from New York University Langone Medical Center in New York City Opined that timing of delivery is refined decision depending on many variable and it should be individualized according to the circumstances and not governed by a rule .

She also emphasized the need to understand more about the pathophysiology of the stillbirths. "Unless we know the cause, we can't say it's related to the 39-week rule," Dr Baxi pointed out. "Over time, we have fewer 'unrecognized causes,' but there still are some.

Dr Jason also saw limitations in many studies used to justify the 39-week rule. They conducted a retrospective cohort study, used state health data on  675,000 infants and found equivocal results in elective cesarean sections at 37-38 weeks and those delivered after  39 weeks.

“Each pregnancy is unique,” He said. “I cannot overstate the importance of open and ongoing communication between pregnant women and their healthcare providers so that the potential risks and benefits of any pregnancy-related decision are understood fully.”

Many other studies also have challenged the “39 weeks rule”. A study by Hart et al published in ACOG challenged the application of rule in Women who had prior C-sections. They conclude that their findings suggest the optimal time for scheduled delivery of women with 2 previous cesarean section deliveries is between 38 wks 0 and 38wk 6 days and between 37 wks 0 and 37 wks 6 days for women with ≥ 3 previous cesarean section deliveries

Some physicians said that they do not think that the rule should be dropped entirely but needs to be revisited.

 References:

http://www.cdc.gov/nchs/data/databriefs/db155.htm

http://www.nih.gov/news/health/jul2015/nichd-10.htm

http://www.cmaj.ca/content/early/2014/04/14/cmaj.109-4766.short?rss=1

https://www.nichd.nih.gov/Pages/index.aspx

https://www.bcm.edu/news/reproductive-health/research-goes-against-39-week-pregnancy-rule

Hart L, Refuerzo J, Sibai B, Blackwell S. Abstract 40: Should the “39 week rule” apply to women with multiple prior cesarean deliveries? American Journal of Obstetrics & Gynecology 2014; 210(1 Supplement): S27, January 2014

 

Is the age at natural menopause predictable using Ovarian Reserve Tests or Mother's Age at Menopause? A systemic review.

The first signs of aging are ineludible. The decrease of ovarian function is an important turning point in a woman’s life. But, with current increase in life expectancy women will be expected to live one-third of there lives in this hormone deficient stage.

The average age at final menstruation period (FMP) is 51 years, but menopause occurs between 40-60 years. There is discrepancy between the ability to maintain a normal ovulatory cycle and actual cessation of fertility potential, which is largely  controlled by a set of genes. These genes carry heritable variants, modifying the wide range of ovarian and reproductive aging seen in population based studies.  But, there is a fixed interval of 10 years between the end of fertility and the natural menopause.

 

In recent years we have seen an increase in age- related infertility in women because of postponement of childbirth due to career choices, education, control over fertility, financial concerns, late and second marriages, and infertility.  So, researchers are looking for markers which can accurately predict the end of fertility life span, limiting the number of women unknowingly facing age related infertility. This prediction could also help in timely planning the family or cryopreservation, and decreasing involuntary childlessness.

Currently, no marker has been yet identified that can accurately predict the end of human fertility, hence the final menstrual period is taken as a proxy variable to signify the end of fecundity. Personalized forecast regarding the approximate age at menopause is usually predicted based on age in relation to regularity of cycles.

According to the stages of Reproductive Aging Workshop (STRAW) FSH is very accurate in determining the current state of reproductive aging, but it does not predict the timing of final menstrual period (FMP). Similarly other parameters of Ovarian reserve tests such as antimüllerian hormone (AMH) and antral follicle count (AFC) and levels of inhibin-B lack standardized assays limiting their incorporation and utility as clinical tools for staging reproductive aging.

Researchers also turned towards identifying genetic markers responsible predicting age at natural menopause, but despite identifying potential genetic loci, no dominant alleles responsible for ovarian depletion have been discovered to date. Mother’s age at menopause seems promising to the researchers as it has demonstrated high degree of heritability. Pedigree analysis has shown a dominant pattern of inheritance of natural menopause.

This systemic review was published in February issue of Journal Menopause, aims to evaluate data on prediction of age at natural menopause based on antimüllerian hormone (AMH), antral follicle count (AFC), and mother's ANM so as to use in clinical practice and future research.

The authors conducted three searches and systemic review and included studies up to September 2014, which met the inclusion criteria.

.

Six studies were selected for AMH, out of which 5 were prospective studies and 1 was cross sectional study. These studies had limitations as the levels of AMH were determined by three different assays, and different laboratories making pooling of data impossible. Furthermore, smoking affects the levels of AMH and most of the studies did not correct for it.

For correlating the AFC and predicting age at natural menopause 2 studies were found that met the criteria. AFC measurement was performed on cycle days 2 to 4. It was seen that although in univariate regression AFC showed be promising predictor, when corrected for age and smoking the results were statistically non significant (P=0.13)

Mothers’s ANM is a promising variable in predicting ANM, studies of mother’s ANM consistently stated that among women who had early menopause, their mothers or daughters are highly likely to have early menopause. Daughters of mothers with early menopause also have low levels of AMH and low follicular count.

The studies included have many limitations as only including women with regular cycles, dominance of studies with women of  particular ethnicity,  lack of  including women taking external hormones  and  women with chronic illnesses, such as malignant diseases, genetic diseases, and autoimmune diseases.

The main rationale for predicting ANM is to prevent unwanted childlessness, knowledge of which would encourage women to start family early or to timely cryopreserve eggs.

Knowing mother's age at menopause may be pivotal information for the daughter. Further implications of knowing the ANM will also help in earlier treatment of bone loss and CVDs.

This systematic literature review is the first to use variables AMH, AFC, and mother's ANM in predicting menopause. This review has shown that AMH and mother’s ANM are the most promising variables to be used in daily clinical practice. The models used to predict ANM lack precision at both end of the spectrum and provide wide intervals. A single reading is not capable of predicting the exact age. A large cohort of women with variable age, corrected for smoking and other chronic diseases are followed for a long time with repeated measurements for   AMH and AFC and incorporating mother ANM than a firm conclusion can be drawn. However, all these markers need further research and improvement before they can be applied into day to day clinical practice. At present mother’s ANM seems to be most promising for future research.

References:

http://www.ncbi.nlm.nih.gov/pubmed/8582512

http://www.medscape.com/viewarticle/858678

http://www.ncbi.nlm.nih.gov/pubmed/12099629

http://www.ncbi.nlm.nih.gov/pubmed/9922101

http://www.ncbi.nlm.nih.gov/pubmed/9871906

http://www.ncbi.nlm.nih.gov/pubmed/3536609

http://depts.washington.edu/endolab/Publications_2012/Harlow_etal_2012.pdf

http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/News_and_Publications/Journals_and_Newsletters/Menopausal_Medicine/2011/MenMed_0511.pdf

http://newsroom.ucla.edu/releases/researchers-find-a-way-to-predict-244164

Differentiating between intrauterine pregnancy and cesarean scar pregnancy in the early first trimester by Ultrasongraphy.

Cesarean scar pregnancy (CSP) consists of implantation of the gestational sac in the previous hysterotomy scar, with some serious complications as the pregnancy progresses. 

CSP was first described by Larsen and Salomon in 1978. The incidence currently is 1/1800 to 1/2200 pregnancies with 0.15% of women with previous Caesarean sections ending in CSP. But, as the rates of cesearean section rates are increasing world wide, with some countries reporting as high as 50%, the incidence of CSPs is bound to increase!

Risk factors for  CSPs are those  with a history of multiple Caesarean sections and Caesarean breech delivery but scar pregnancies have also been reported after dilation and curettage, myomectomy, metroplasty, hysteroscopy, and manual removal of the placenta.

In fact up to 72% of cesarean scar pregnancies occur in women who have had 2 or more cesarean deliveries.

Transvaginal Sonography and color Doppler are the best diagnostic tools at present, but the clinician should have a high index of suspicion to use them.

According to a paper by Osborn D.A et al the following sonographic criteria have been put forward for early diagnosis of cesarean scar pregnancies in the first trimester.

1. Empty uterus with a clearly visualized endometrium;
2. Empty cervical canal;
3. Gestational sac within the anterior portion of the lower uterine segment at the presumed site of the cesarean scar; and
4. Thinned or absent myometrium between the gestational sac and bladder (<5 mm in two-thirds of cases).
5. Other findings include marked peritrophoblastic color Doppler flow around the sac with low-impedance (pulsatility <1), high-velocity flow (>20 cm/s), a resistive index of less than 0.5, and a peak systolic to diastolic blood flow ratio of less than 3.

MRI being useful as a troubleshooting tool when sonography is equivocal or inconclusive before intervention or therapy.

This paper by  Timor-Tritsch I.E et al in the forthcoming issue of American Journal of Obstetrics & Gynecology describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation.

The study tests the hypothesis that in a first trimester sonography between 5-10 weeks of pregnancy the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs.

This is a retrospective study reviewing the electronic record of 242 ultrasound images from 20004- 2015 were analyzed. A total of 57 cases of CSP diagnosed. The following measurements were made for each case:

1. distance from the external cervical os to the uterine fundus,
2. the midpoint axis of the uterus,
3. the distance from the external cervical os to the center of gestational sacs, and
4. the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix.

It was seen that the location of the center of gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs –10.6 mm, respectively, P = .0001).

Most CSPs are located proximally to the midpoint axis of the uterus and most IUPs are located distally to the midpoint axis.

The diagnostic accuracy of the method:  accuracy: sensitivity 93.0% and specificity 98.9%.

The authors strongly believe that the mounting anecdotal evidence supports instituting a simple, relatively inexpensive very early transvaginal screening ultrasound of every pregnant patient with a previous history of cesarean delivery.

References:

https://med.stanford.edu/news/all-news/2015/12/optimal-c-section-rate-may-be-as-high-as-19-percent-to-save-lives.html

http://www.jultrasoundmed.org/content/31/9/1449.full

http://www.ajog.org/article/S0002-9378%2816%2900316-1/abstract

Abnormal Vaginal Microbiota: Could it hinder IVF success rates?

Human vaginal microbiota (VMB) plays an important role in women’s health. Since the report (and discovery) of Lactobacillus (Döderlein Bacillus) as common inhabitants of the human vagina in 1892 by Gustav Döderlein,it  is known to play an important role in urogenital health. It has been known since quite long that most vaginal microbiota (VMB) undergoes compositional changes thought out lifetime of women from puberty to menopause, and sex hormone steroids play an important in its stability and composition.

It contributes to low vaginal pH (<4.5) by production of lactic acid, which limits the growth of pathogenic bacteria.

The development of culture-independent profiling methods to detect fastidious or non-cultivable organisms through the analysis of the sequence of marker genes, such as the 16S rRNA gene, has precipitated a revolution in biology and medicine, by spurring projects such as the National Institutes of Health (NIH)-funded Human Microbiome Project, the European MetaHit project and the creation of the International Human Microbiome Consortium.

Culture-independent characterization of bacterial communities have established that at least six types of vaginal microbiota exist, referred to as community state types (CSTs). Four of these CSTs are most often dominated by one of four Lactobacillus spp. commonly found in the vagina (L. crispatus, L. iners, L. jensenii and L. gasseri), while the remaining two lack substantial numbers of Lactobacillus spp.

Disruption of Lactobacilli predominant VMB can lead to growth of abnormal vaginal pathogens. Bacterial vaginosis (BV) represents the most common vaginal syndrome characterized by  lactobacilli being  replaced by Gardnerella vaginalis, Atopobium vaginae, Prevotella , Sneathia, Ruminococcaceae, Parvimonas, Mobiluncus , Veillonella, Megasphaera and other anaerobic microorganisms  which are difficult to culture. BV is not highly inflammatory and is therefore often asymptomatic; this is why it is referred to as a vaginosis and not vaginitis.The clinical symptoms are minimum or insignificant, so BV is often overlooked.

In clinical settings, BV is typically diagnosed using Amsel criteria (three of the following four criteria should be present: 1) clue cells on wet mount microscopy; 2) a ‘fishy’ odour after adding 10% KOH to vaginal secretions; 3) vaginal pH>4.5; and 4) thin, homogenous vaginal discharge) .In research settings, BV is also often defined by Gram stain Nugent scoring, which is based on microscopic visualization of three bacterial morphotypes (a Nugent score of 0–3 is considered normal, 4–6 intermediate microbiota, and 7–10 BV) .

According to a recent paper published online in Journal of Human Reproduction Haahr T et al, the principal author and an MD/PhD student at Aarhus University in Denmark,postulated that Abnormal Vaginal Microbiota may be contributing factor for negative outcome in IVF patients. He further added that about 1 in 5 women suffer from BV and it could affect the fertility.

A total of 130 women were recruited who were seeking IVF treatment, vaginal swab collected from posterior fornix, gram stained and analyzed according to Nugent’s criteria. Real-time polymerase chain reaction (qPCR) to identify the type of bacteria was also used. The researchers compared the results of Nugent scores and results of qPCR to identify abnormal vaginal microbiota and its possible role in IVF success rates.

According to Nugent criteria the prevalence of BV was 21%( 27/130), whereas qPCR identified  abnormal VMB in 28% (36/130) patients with a predominance of  Gardnerella vaginalis and/or Atopobium vaginae. The qPCR have a sensitivity and specificity of 93%.

A total of 84 patients completed the treatment with clinical pregnancy rate of 35% (29/84). Interestingly, only 9% (2/22) with qPCR defined abnormal vaginal microbiota obtained a clinical pregnancy (P = 0.004).

The study is limited by small sample size and Caucasian only subjects. Dr. Haahr says that it is very early to draw any conclusion from the study, but physicians who have patients of recurrent pregnancy loss should investigate them for BV.

Dr. Haahr told Reuters health that “"Several attempts to find the right clinical management or treatment for bacterial vaginosis has shown that this is very difficult, because it seems that a biofilm is growing in the presence of these bacteria,” He and his colleagues are planning a clinical trial in which they will test the effects of treating BV with antibiotics, followed by probiotics, on IVF success. "Hopefully with this new study we might offer these patients help in bettering their pregnancy rates," he said.

Dr. Peter Humaidan of the Fertility Clinic at Skive Regional Hospital and Aarhus University, senior author of the new study was very hopeful of the results of the study and told Reuters Health in a telephonic interview “Probiotic treatments are gaining a wide usage all over the body. So maybe probiotics will be the future, rather than antibiotic treatment." It's possible, he added, that the health of the vaginal microbiome could also influence natural fertility rates.

Other study results suggest that BV infection is associated with infertility and its absence leads to pregnancy, emphasizing its screening and treatment.

According to a paper published in Seminars in Reproductive Medicine by Sirota et al  Studies that characterize the vaginal microbiome in assisted reproductive technology support the hypothesis that colonizing the transfer-catheter tip with Lactobacillus crispatus at the time of embryo transfer may increase the rates of implantation and live birth rate while decreasing the rate of infection.

However, antibiotic treatment before IVF has been shown to be positively disadvantageous for IVF by encouraging other organisms.

Exogenous strains of lactobacilli have been suggested as a means of re-establishing a normal healthy vaginal flora. Carefully selected probiotic strains can eliminate BV and also exert an antiviral effect, thus reducing viral load and preventing foetal and neonatal infection. The administration of beneficial microorganisms (probiotics) can aid recovery from infection and restore and maintain a healthy vaginal ecosystem, thus improving female health also in relation to reproductive health.

References:

http://journals.lww.com/co-clinicalnutrition/Abstract/2009/11000/Targeting_the_vaginal_microbiota_with_probiotics.5.aspx

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0105998#abstract0

http://www.ncbi.nlm.nih.gov/pubmed/19833694

http://www.ncbi.nlm.nih.gov/pubmed/?term=abnormal+vaginal+microbiota+and++pregnancy

http://jcm.asm.org/content/45/9/3145.short

http://journals.lww.com/co-clinicalnutrition/Abstract/2009/11000/Targeting_the_vaginal_microbiota_with_probiotics.5.aspx

Maternal ZIKA virus infection linked to fetal and placental malformations, apart from Microcephaly.

The World Health Organization has declared the Zika virus an international public health emergency, with a prediction of about four million people being infected at the end of the year.

WHO has issued a travel warning for pregnant women advising them not to travel to areas with continuing outbreaks of Zika virus due to the potential risk of birth defects.

Sexual transmission appears to be more common than previously thought of. "Pregnant women whose sexual partners live in or travel to areas with Zika virus outbreaks should ensure safe sexual practices or abstain from sex for the duration of their pregnancy," the WHO said, based on advice from its Emergency Committee of independent experts.

According to a preliminary report of case series  from Rio de Janeiro, Brazil, published online March 4 issue of the New England Journal of Medicine, ZIKA is also linked to fetal death, placental insufficiency, IUGR and Nervous system malformation.

Dr. Patrícia Brasil, MD, the principal investigator of the study  “our findings provide further support for a link between maternal ZIKV infection and fetal and placental abnormalities that is not unlike that of other viruses that are known to cause congenital infections characterized by intrauterine growth restriction and placental insufficiency.”

In September, 2015 researchers in Brazil identified dengue like fever, which was later identified as ZIKV. In the same month the ZIKV was linked to microcepahy, cases in Brazil rocketed to 3,500 from 147, the average for the same time last year (2014).

The link was first detected when Brazilian health authorities found traces of the Zika virus in a deceased infant born with microcephaly or in amniotic fluid of mothers delivering microcephalic infants.

In the present study, the researchers enrolled pregnant women of any gestation, who presented with a rash that had developed within the previous 5 days. Out of 88 women, 72 (82%) women tested positive ZIKV in blood and/or urine by reverse-transcriptase polymerase chain reaction assays. The researchers followed the women prospectively with clinical examinations and serial ultrasound. All the study participants were generally healthy with no h/o congenital malformations.

Clinically the women presented with a macular or maculopapular rash, pruritus (94%) arthalgia (65%), conjuntival redness (58%). Fever was not a significant symptom with only one third of women reporting it.

All the ZIKV negative as well as positive women had ultrasound. USG showed abnormalities in 12 of ZIKV positive women while those women who are negative showed normal USG.  Sonographically detected abnormalities include:

• intrauterine growth restriction, with or without accompanying microcephaly(5)
• cerebral calcification (4)
• CNS alterations (n = 2)
• Oligohydramnios and anhydramnios (2)
• Abnormal arterial flow in the cerebral or umbilical arteries(4)
• additional malformations, including agenesis of the vermis, Blake’s pouch cyst, and potentially a club foot, in addition to cerebral calcifications, intrauterine growth restriction, and microcephaly(1)

Abnormalities were present in fetuses of women irrespective of there gestational age at ZIKV infection, although those women infected in first trimester show signs of insult during embryogenesis. CNS abnormalities seen in fetuses infected as late as 27 weeks.

Six live births and two still births occurred during the follow up and confirmed the Sonography findings.

The authors suggest that “many aspects of ZIKV infection are similar to those of rubella, particularly rash, arthralgias, pruritus, and lymphadenopathy in the mother without high fever.” But, it is worrisome that there is no population immunity for ZIKV as compared to rubella U.S. pandemic of 1959–1965, when only 17.5% of women of childbearing age lacked rubella antibodies.

In summary the study findings provide support to the hypothesis of link between maternal ZIKV infection and fetal and placental abnormalities. The women infected with ZIKV should be followed up closely with serial ultrasonography to evaluate for signs of placental insufficiency, given the risks of fetal death and intrauterine growth restriction.

References:

http://www.who.int/mediacentre/news/statements/2016/zika-ec/en

http://www.nejm.org/doi/full/10.1056/NEJMoa1602412?query=featured_home#t=articleDiscussion

 

Managing Menopause: Is it time to take a second look at the Women's Health Initiative (WHI) study results?

Menopause is an important life event for a woman that signifies the end of her reproductive era and transitioning into a period of increasing health risk from cardiovascular disease, osteoporosis, and other chronic diseases.

According to a census in 1998, there were more than 477 million postmenopausal women in the world, and the number is going to rise to approximately 1.1 billion by 2015. Life expectancy for women worldwide was 65 years in 1998 which has currently increased to 73.2 years (81 years in developed countries).  With increasing life expectancy women spend one third of life in this phase of life.  

In the year 2000, there were an estimated 45.6 million postmenopausal women in the United States, out of which about 40 million were older than age 51, the average age of natural menopause in the Western world.                                    

According to a book chapter by Dr.  JoAnn E. Manson, MD, DrPH professor of medicine at Harvard Medical School and Brigham and Women's Hospital “Aging of the female reproductive system begins at 20 weeks gestation with regard to follicle atresia and proceeds as a continuum. It consists of a steady loss of oocytes from atresia or ovulation, and does not necessarily occur at a constant rate. Because of the relatively wide age range (40-58 y) for natural menopause, chronologic age is a poor indicator of the beginning or the end of the menopause transition.

This article is based on a perspective by JoAnn E. Manson, M.D., Dr.P.H., and Andrew M. Kaunitz, M.D. in March 03, 2016 edition of  The New England Journal of Medicine( NEJM).

Menopausal symptoms are well tolerated by some women, but may be very troublesome to other women. Often there is underreporting of menopausal symptoms due to cultural taboos. The attitude towards menopause varies according to culture and ethnicity, with 80% African women reporting symptoms versus very few Asian women reporting symptoms.

There has been an ongoing confusion regarding the findings of WHI study and prescription of hormonal therapy to relieve the symptoms of menopause.

The Women's Health Initiative (WHI) was launched in 1991 and consisted of a set of clinical trials and an observational study, which together involved 161,808 generally healthy postmenopausal women.

The clinical trials were designed to test the effects of postmenopausal hormone therapy, diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer. The trials were specifically designed to address questions about effect of initiating menopausal hormone therapy for the prevention of chronic disease in postmenopausal women across a broad range of ages, including many women in their 60s and 70s?

In 2002, the study results ripped the widely held belief that hormone replacement therapy protected women from heart disease and other chronic illnesses.  Instead, the Women's Health Initiative study found concluded that taking estrogen plus progestin hormone replacement therapy — HRT — actually increased a woman's risk of heart disease and breast cancer.

Within months of the results, number of women using HRT dropped by half. 

The results of the study were extrapolated to women in 40s and 50s who had severe vasomotor symptoms disrupting quality of life. In-fact, these women had trouble finding clinician who could prescribe them with HRT.  

But, studies conducted during Extended Poststopping Phases of the Women’s Health Initiative Randomized Trials when broken down according to age groups showed entirely different outcomes. Subgroup analysis stratified according to age and time since menopause onset modified the effect of HRT on some of the outcomes. The study concluded that HRT is a reasonable option for the management of moderate to severe menopausal symptoms among generally healthy women during early menopause.

In-fact, the USPSTF in its recommendation made a specific mention that “This recommendation applies only to postmenopausal women who are considering hormone therapy for the primary prevention of chronic medical conditions. This is not a recommendation about the use of hormone therapy to treat menopausal symptoms, such as hot flashes or vaginal dryness; the USPSTF did not review the evidence related to this possible indication because it falls outside of the mission and scope of the USPSTF. This recommendation also does not apply to women younger than 50 years who have had surgical menopause”.

The North American Menopause Society (NAMS), the Endocrine Society, the American College of Obstetricians and Gynecologists (ACOG) endorse the use of HRT in younger women for treating postmenopausal symptoms, who do not have specific contraindication for the therapy.

This will definitely improve the quality of life and it is quite likely that the benefit would outweigh the risks.

These organizations have many resources that help clinicians in decision making, the NAMS have a MenoPro Mobile App, which helps in personalization of treatment to individual patient and help patient in shared decision making.

The MenoPro app has several unique features, including the ability to calculate your 10-year risk of heart disease and stroke, which is important in deciding whether a treatment option is safe for you. It also has links to online tools that assess your risk of breast cancer and osteoporosis and fracture.

Photo courtesy: NAMS

Finally Dr. JoAnn E. Manson emphasized the need of training young healthcare providers to keep up with the variety of options in treating postmenopausal women. This will certainly help in improving the quality of life of a growing population.

References:

Manson JE, Kaunitz A. Menopause management: getting clinical care back on track. N Engl J Med. 2016;374:803-806.

https://www.google.com/?gws_rd=ssl#q=current+life+expectancy++in+world+

http://www.menopause.org/docs/2012/cg_a.pdf?sfvrsn=2

http://www.npr.org/sections/health-shots/2013/10/04/229171477/the-last-word-on-hormone-therapy-from-the-womens-health-initiative

http://jama.jamanetwork.com/article.aspx?articleid=1745676

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Cleveland Clinics performs first Uterine Transplant from deceased donor in U.S.

The surgeons at Cleveland clinic performed first uterine transplant in U.S. this week.

Earlier in November 2015, Cleveland clinic announced a clinical trial that involved performing 10 uterine transplants in women with Uterine Factor Infertility (UFI).

About 1 in 4,500 women in the United States is born without a uterus - a condition known as Mayer-Rokitansky-Küster-Hauser syndrome, according to the NIH.

UFI is an irreversible condition affecting 3-5% of pregnancies worldwide. "Women who are coping with UFI have few existing options," Tommaso Falcone, chairman of the Department of Obstetrics-Gynecology at Cleveland Clinic, said when the clinical trial was announced. "Although adoption and surrogacy provide opportunities for parenthood, both pose logistical challenges and may not be acceptable due to personal, cultural or legal reasons."

The first two International attempts on Uterine Transplant were unsuccessful due to organ rejection. Finally a team of Doctors in Sweden were able to treat the mild organ rejection. The University of  Gothenburg team  led by Dr. Mats Brännström   achieved its first birth in September 2014. To date, the Swedish group has performed nine uterus transplants, achieving five pregnancies and four live births.

In the Brännström case report, the woman who became pregnant following uterus transplantation took tacrolimus and azathioprine to prevent organ rejection both before and during her pregnancy.

Uterine Transplant is a complex process involving multiple steps. Each Candidate selected for the transplant undergo a extensive medical evaluation and psychological counseling, and her candidature has to be approved unanimously by the team of experts in the field.

According to the team at Baylor hospital, Dallas:

 

 

The selection criteria for the recipient are :

· Women with uterine infertility
· Ages 20-35, with working ovaries
· Body mass index of less than 30
· Cancer-free for at least five years
· No history of diabetes
· Non-smoker

The criteria to be a donor are:

  Ages 65 and younger
· At least one full-term delivery
· Body mass index of less than 30
· Cancer-free for at least five years
· Test negative for HIV, herpes and hepatitis B and C

According to the Cleveland clinic, once a woman is selected for the transplant she has to follow the following protocols:

• Her ovaries are stimulated to produce multiple eggs, starting the in vitro fertilization (IVF) process.
• Her eggs are retrieved, fertilized with sperms in a laboratory, and 6-8 embryos are frozen.
• Lifebanc, an organ procurement agency, begins the search for a donor between 18-40 years of age.
• The donor’s next-of-kin signs an informed consent for uterus donation.
• The donor uterus is removed along with the uterine arteries and   transplanted within six to eight hours into the patient’s pelvis.
• Over 12 months, the transplanted uterus fully heals.
• Women who receive the uterus transplants will not be able to become pregnant without ARTs, because the transplanted uterus will not be connected to their fallopian tubes, where normal fertilization takes place.
• One year after transplant, the frozen embryos are then thawed and implanted, one at a time, into the patient until she becomes pregnant.
• During her pregnancy, she takes immunosuppressant drugs.
• She is monitored by a high-risk obstetrics team throughout pregnancy and delivery.
• She has a monthly cervical biopsy to check for organ rejection.
• The baby is delivered by cesarean section.
• After one to two babies, she has a hysterectomy to remove the transplanted uterus.
• Her anti-rejection drugs are stopped after hysterectomy to reduce long-term exposure to transplant medications.

Andreas Tzakis, MD, the transplant surgeon at the Cleveland clinic says “It is critical that the risks for uterus transplant, which is not lifesaving, are no greater than the risks for other transplants. Like transplants of the face and extremities, uterus transplant is considered life-enhancing rather than lifesaving.”

He further adds “Unlike any other transplants, they are ‘ephemeral,” he says. “They are not intended to last for the duration of the recipient’s life, but will be maintained for only as long as is necessary to produce one or two children.”

References:

http://www.livescience.com/52799-uterus-transplants-cleveland-clinic.html

http://www.dallasnews.com/lifestyles/health-and-fitness/health/20160129-baylor-dallas-to-become-one-of-first-u.s.-hospitals-to-offer-uterine-transplants.ece

http://www.reuters.com/article/us-ohio-transplant-idUSKCN0VZ0O7

Induction of labor in older mothers does not hike the Caesarean section rate! The 35/39 Trial.

Since last 30 years, we have seen a trend of increasing number of women delaying childbirth till later in life, especially in industrialized nation . In a span of 10 years, births to women 35 years and older increased from 12% to 20% in UK.

Women 35 years and  older are at increased risk of antepartum, intrapartum and postnatal complications  like hypertensive disease, gestational diabetes mellitus, placenta previa, and placental abruption and perinatal deaths. They are also at risk of delivering macrosomic or low birth weight infants.

The rate of obstetrical intervention and caesearean deliveries also rises with maternal age, being 38% in nulliparous women over 35 and nearly 50% in those over 40 years of age.

According to Smith GCS et al the gestational week of delivery associated with the lowest cumulative risk of perinatal death was 38 weeks' gestation and the risk of death increased more sharply among primigravid women after 38 weeks' gestation because of a greater risk of antepartum stillbirth.

Currently, in the absence of maternal and fetal complication, routine induction is available to all women in U.K at 41-42 weeks when the risk of still birth is 2-3/1000 live births. However, based on many observational studies, it is a general consensus among obstetrician that induction leads to increased rate of caesarean deliveries and increased perinatal complications.

Trials of induction of labour at term are mostly in women with complications like hypertension, prelabor rupture of membranes, fetal growth restriction, diabetes, or fetal macrosomia. Only few trials involving women with no complications are found in literature, but lack power and are in 1970s. Trials of induction of labour due to advanced maternal age are lacking 

This 35/39 trial was designed to test the hypothesis that induction of labour at 39 weeks in older nulliparous women reduces the risk of operative delivery. The results of the trial was published in March 3, 2016 issue of New England Journal of medicine.

The investigators performed a multicenter, randomized, controlled trial to compare the rate of cesarean section between  women who were induced at 39 weeks and 0 days – 39 weeks and 6 days ( n= 304) with  those who were managed expectantly(n=314). Inclusion criteria were nulliparity, age 35 years or older and carrying a single fetus in cephalic presentation.

The primary outcome was cesarean section and the secondary outcome being other form of vaginal deliveries, onset of labour, augmentation of labour , intrapartum , postpartum and neonatal complications.

The induction of labour was done according to the protocols of the units, but most used prostaglandin ripening followed, if necessary, by amniotomy and oxytocin infusion.

It was seen that there was no significant difference in the rate of cesarean sections between the induction group (98 of 304 women [32%]) vs. (103 of 314 women [33%]) in the expectant group. Also a total of 115 of 304 women (38%) in the induction group delivered vaginally as compared with 104 of 314 women (33%) in the expectant-management group.

The results were also comparable across different maternal age group according to a sub group analysis.

The authors acknowledge the limitations of the trials "the results may not be generalizable to older multiparous women and may not apply to all nulliparous pregnant women who are 35 years of age or older."

The authors further say that “Our trial did not address whether induction of labor at 39 weeks of gestation can prevent stillbirths. It does, however, provide support for the safety of performing a larger trial to test the effects of induction on stillbirth and uncommon adverse neonatal outcomes in women 35 years of age or older, although such a trial would need to be extremely large.”

The journal article was also accompanied by an editorial by William A. Grobman, M.D, from the Northwestern University Feinberg School of Medicine in Chicago, Illinois,  he emphasized that “it would be premature to alter recommendations regarding the timing of delivery in uncomplicated pregnancies. Although the study did not show evidence of harm from induction at 39 weeks of gestation, it also did not show evidence of benefit, and one could argue that medical interventions in general, and intervention in the natural progress of gestation specifically, should be performed only when benefit has been shown.”

He also stressed that the study lacked sufficient power to analyze differences in perinatal outcomes, whether labor induction at 39 weeks of gestation affects these outcomes remains unknown!

He further added “The trial makes an important contribution to medical knowledge. It is the largest trial of its type to be completed, and it suggests that a belief that guides decisions about the timing of delivery — namely, that induction of labor at term increases the risk of cesarean delivery — may not be true after all.”

In summary,the authors concluded “ in women of advanced maternal age, induction of labor at 39 weeks of gestation, as compared with expectant management, had no significant effect on the rate of cesarean section and was not associated with adverse short-term effects on maternal or neonatal outcomes.”

Currently Dr. Groban is the principal investigator for a larger trial to test the effects of induction on stillbirth and uncommon adverse neonatal outcomes. The trial is currently under way within the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. This trial, which has a targeted enrollment of 6000 women, is designed to identify differences in perinatal outcomes among nulliparous women with uncomplicated singleton pregnancies who are randomly assigned to induction between 39 weeks 0 days and 39 weeks 4 days of gestation or to expectant management.

References:

Walker KF, Bugg GJ, Macpherson M, et al. Randomized trial of labor induction in women 35 years of age or older. N Engl J Med 2016;374:813-822

Smith GCS. Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies. Am J Obstet Gynecol 2001;184:489-496