In this review, we discuss two very different types of environmental exposures: assisted reproductive technologies and in utero exposure to endocrine-disrupting chemicals.
We summarize the current literature on their effects on placental development in both rodent and human, and comment on the potential use of placental biomarkers as predictors of offspring health outcomes.
In subfertile patients, women exposed to higher concentrations of air pollutants while undergoing IVF showed lower live birth rates and higher rates of miscarriage.
After exposure to similar levels of air pollutants, comparable results have been found regardless of the mode of conception (IVF versus spontaneous conception), suggesting that infertile women are not more susceptible to the effects of pollutants than the general population.
In addition, previous studies have not observed impaired embryo quality after exposure to air pollution, although evidence for this question is sparse.
Fifteen babies a day in UK are stillborn or die within month of birth
Fifteen babies are dying every day in the UK from stillbirth, during labour or within four weeks of being born, according to a new report.
Perinatal Mortality Surveillance Reports for UK Births, MBRRACE-UK.
There has been slight fall in the rates of stillbirths and neonatal deaths in the UK compared with rates in 2013 which continues the downward trend in rates from 2003 onwards. However, the overall trend masks big variations in death rates across the UK from 4.1 to 7.1 per 1,000 births. Women from the poorest backgrounds and black and Asian mothers run a higher risk than others that their baby will die in the womb or soon after birth.
Fifteen babies a day in UK are stillborn or die within month of birth, the Guardian, 17 May 2016.
These variations remain despite the fact that a novel method of analysis introduced by MBRRACE-UK has been used to take into account aspects of case-mix to allow ‘fairer’ comparisons of mortality rates between services provided for high risk and low risk pregnancies. The new analytical method which divides the figures for Trusts and Health Boards into five groups based on the services they deliver, also takes into account the random variation in rates which can occur because of the small number of births which occur in some areas.
A global problem that need a global solution: time to act on a global scale
Video published on 1 Dec 2015 by PRHE UCSF‘s channel
Exposure to toxic environmental chemicals among women and men of reproductive age is ubiquitous and threatens healthy human reproduction.
The International Federation of Gynecology and Obstetrics (FIGO) World Congress attendees learned more about the science that links exposure to toxic environmental chemicals to poor health outcomes and what physicians and health care providers can do to prevent harm
Progesterone May Not Lower Risk of Repeated Miscarriage
2015 Study Abstract
Progesterone is essential for the maintenance of pregnancy. However, whether progesterone supplementation in the first trimester of pregnancy would increase the rate of live births among women with a history of unexplained recurrent miscarriages is uncertain.
We conducted a multicenter, double-blind, placebo-controlled, randomized trial to investigate whether treatment with progesterone would increase the rates of live births and newborn survival among women with unexplained recurrent miscarriage. We randomly assigned women with recurrent miscarriages to receive twice-daily vaginal suppositories containing either 400 mg of micronized progesterone or matched placebo from a time soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) through 12 weeks of gestation. The primary outcome was live birth after 24 weeks of gestation.
A total of 1568 women were assessed for eligibility, and 836 of these women who conceived naturally within 1 year and remained willing to participate in the trial were randomly assigned to receive either progesterone (404 women) or placebo (432 women). The follow-up rate for the primary outcome was 98.8% (826 of 836 women). In an intention-to-treat analysis, the rate of live births was 65.8% (262 of 398 women) in the progesterone group and 63.3% (271 of 428 women) in the placebo group (relative rate, 1.04; 95% confidence interval [CI], 0.94 to 1.15; rate difference, 2.5 percentage points; 95% CI, −4.0 to 9.0). There were no significant between-group differences in the rate of adverse events.
Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with a history of unexplained recurrent miscarriages.
Sources and more information
Progesterone May Not Help Women With History of Miscarriages, Study Finds, NYtimes, NOV. 25, 2015.
A Randomized Trial of Progesterone in Women with Recurrent Miscarriages, The New England Journal of Medicine, DOI: 10.1056/NEJMoa1504927, November 26, 2015.
Progesterone May Not Lower Risk of Repeated Miscarriage, livescience, NOV. 25, 2015.
New ambition to halve rate of stillbirths and infant deaths
The Health Secretary, Jeremy Hunt, has announced a new ambition to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50% by 2030.
The number of brain injuries occurring during or soon after birth will also be targeted as part of a new commitment by the government, in partnership with consultants, midwives and other experts across the country to make England one of the safest places to have a baby.
The government will work with national and international experts to ensure that best practice is applied consistently across the NHS and that staff can review and learn from every stillbirth and neonatal death.
Maternity services will be asked to come up with initiatives that can be more widely adopted across the country as part of a national approach – such as appointing maternity safety champions to report to the board and ensuring all staff have the right training to enable them to identify the risks and symptoms of perinatal mental health.
Trusts will receive a share of over £4 million of government investment to buy high-tech digital equipment and to provide training for staff already working to improve outcomes for mums and babies. This includes a £2.24 million fund to help trusts to buy monitoring or training equipment to improve safety, such as cardiotocography (CTG) equipment to monitor babies’ heartbeat and quickly detect problems, or training mannequins that staff can practise emergency procedures on.
A further £500,000 will be invested in developing a new system for staff to review and learn from every stillbirth and neonatal death. The new safety investigation unit will also be asked, once established, to consider a particular focus on maternity cases for its first year.
Over £1 million will be invested in rolling out training packages developed in agreement with the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, to make sure staff have the skills and confidence they need to deliver world-leading safe care.
This builds on previous government commitments to invest £75 million in improving perinatal mental health services and ensuring all maternity care is considered as part of ‘Ofsted style’ ratings for commissioners.
Over time this initiative will allow the money spent on caring for injured children or paid as compensation to be re-invested in improved front line services.
Health Secretary Jeremy Hunt said:
The NHS is already a safe place to give birth, but the death or injury of even one new baby or mum is a devastating tragedy which we must do all we can to prevent.
With more support and greater transparency in maternity services across England we will ensure every mother and baby receives the best and safest care, 24 hours a day, 7 days a week – this is at the heart of the NHS values we are backing with funding from a strong economy.
Countries like Sweden are proof that focusing on these issues can really improve safety – with the help of staff on the frontline, we can improve standards here at home.
The ambition is part of a wider government aim to reduce all avoidable harm by 50% and save 6,000 lives by 2017, and it will form a key part of the work of the patient safety campaign Sign up to Safety. The government will align next steps with the Independent Review of Maternity Services’ recommendations, which is already looking at ways to improve quality and safety.
Dr David Richmond, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:
We support this initiative and our important role in it as leaders of the profession. Good progress has been made but the fact is many of these incidents could be avoided with improvements to the care women and their babies receive.
The RCOG will continue to work closely with our clinical colleagues and the Royal College of Midwives to provide better multi-disciplinary training packages and promote more effective team working, so that this aspect of care can be improved. The challenges of reducing health problems and deaths in mothers and babies due to contributory factors such as smoking, obesity and alcohol also require similar commitment.
The age of the DES-exposed patients has varied from 7 to 34 years with the highest frequency from 14 to 22 years. The risk among the exposed is small and is on the order of 1 per 1,000.
Factors that may increase the risk are maternal history of prior miscarriage, exposure to DES in early gestation, a fall season of birth, and prematurity. Pregnancy does not appear to influence adversely the tumor characteristics or prognosis of patients who have developed these malignancies.
Criteria for appropriate local therapy of small clear cell adenocarcinomas of the vagina are presented. Recurrent CCA has been observed as long as 20 years after primary therapy emphasizing the importance of prolonged follow-up..
Sources and more information
Clear cell adenocarcinoma of the vagina and cervix secondary to intrauterine exposure to diethylstilbestrol, Herbst AL, Anderson D, Semin Surg Oncol. 1990;6(6):343-6. NCBI PMID: 2263810.
Significant association of epilepsy, exposure to antiepileptic drugs, and adverse outcomes exists in pregnancy
2015 Study Abstract
Antenatal care of women with epilepsy is varied. The association of epilepsy and antiepileptic drug exposure with pregnancy outcomes needs to be quantified to guide management. We did a systematic review and meta-analysis to investigate the association between epilepsy and reproductive outcomes, with or without exposure to antiepileptic drugs.
We searched MEDLINE, Embase, Cochrane, AMED, and CINAHL between Jan 1, 1990, and Jan 21, 2015, with no language or regional restrictions, for observational studies of pregnant women with epilepsy, which assessed the risk of obstetric complications in the antenatal, intrapartum, or postnatal period, and any neonatal complications. We used the Newcastle-Ottawa Scale to assess the methodological quality of the included studies, risk of bias in the selection and comparability of cohorts, and outcome. We assessed the odds of maternal and fetal complications (excluding congenital malformations) by comparing pregnant women with and without epilepsy and undertook subgroup analysis based on antiepileptic drug exposure in women with epilepsy. We summarised the association as odds ratio (OR; 95% CI) using random effects meta-analysis. The PROSPERO ID of this Systematic Review’s protocol is CRD42014007547.
Of 7050 citations identified, 38 studies from low-income and high-income countries met our inclusion criteria (39 articles including 2 837 325 pregnancies). Women with epilepsy versus those without (2 809 984 pregnancies) had increased odds of spontaneous miscarriage (OR 1·54, 95% CI 1·02–2·32; I2=67%), antepartum haemorrhage (1·49, 1·01–2·20; I2=37%), post-partum haemorrhage (1·29, 1·13–1·49; I2=41%), hypertensive disorders (1·37, 1·21–1·55; I2=23%), induction of labour (1·67, 1·31–2·11; I2=64%), caesarean section (1·40, 1·23–1·58; I2=66%), any preterm birth (
A small but significant association of epilepsy, exposure to antiepileptic drugs, and adverse outcomes exists in pregnancy. This increased risk should be taken into account when counselling women with epilepsy.