cd4/cd8 ratio and miscarriage , abortion

 It is difficult to make a general statement without looking at the subgroups. But  one study suggests that an increased ration ( cd4 increased and cd8 decreased) may be indicative of an increased risk of miscarriage.

"A significantly higher CD4/CD8 ratio was found in the postabortion group in relation to the control group (1.65 vs. 1.24) (P = .01). Women with pregnancy complications in their next pregnancy had a lower absolute value for total lymphocytes (P = .02), T lymphocytes (P = .04), absolute CD8 lymphocytes (P = .01) and percentage of CD8 lymphocytes (P = .02) and a higher percentage of CD4 lymphocytes (P = .03) and higher CD4/CD8 ratio (P = .02) than women who had not experienced any pregnancy complications."

Women with previous spontaneous abortions have a tendency to have an immunologic profile expected in a rejection phenomenon with an increased cd4/cd8 profile.

find reference here

Slow Embryonic Heatbeat / fetal heart rate/ fetal heart beat in early pregnancy: what is a normal heartbeat rate?

 One of the most difficult moments for a patient who has suffered for either infertility or miscarriages is to find out ,  at the first pregnancy ultrasound ,that something is not entirely normal.

An example of this is  when on , one of the early ultrasounds,  the heart beat of the embryo ( baby) is observed as being too slow.

Fetal heart rate  ( or embryonic heart rate) in the first trimester depends on the gestational week. It increases since 6 to 9 weeks and decreases after 10 weeks. The highest values of fetal heart rate  are observed between 9 and 10 weeks of gestation. The risk of early pregnancy loss increases significantly in case of detecting slow FHR.

but what is a normal value for embryonic heart rate / fetal heart rate?

In one study  At 6 weeks, mean embryonic heart rate was 116 +/- 21 beats per minute , then slowly increased, reaching mean 172 +/- 9 beats per minute  at 10 weeks. At 11 weeks the mean fetal heart rate  achieved the level of 165 +/- 7 beats per minute.

Embryonic heart rates below 90 beats per minute at 6 to 8 weeks of gestation have been shown to be associated with a high likelihood of subsequent first trimester demise.

what the actual risk of  risk of pregnancy  loss or miscarriage  was quantified in one study as:  first trimester survival rate was 61.6% for slow early heart rates ( less than  100 beats per minute  at  6.2 weeks or less ,  less than120 beats per minute at 6.3 to 7.0 weeks), lower than the survival rate  with normal heart rates.

In another study the rates of first-trimester demise were 60.6% for pregnancies with slow heart rates at 6.0-7.0 weeks), 17.4% for those with borderline heart rates , and 9.1% for those with normal heart rates.

As mentioned above  boundary between slow and normal heart rates has not been established, however, and different studies have yelded different numbers. But these studies  suggest that lower limit of normal is 100 beats per minute up to 6.2 weeks' gestation and 120 bpm at 6.3-7.0 weeks.

Can Progestrone Supplementation Prevent Miscarriages?

Based on the Chocrane Database Review the answer is : probably not. But is does seem to prevent further losses in women with 3 or more miscarriages. This is why in the end we end it prescribing it quite liberally. The review states quite clearly that the type of progesterone (vaginal vs injectable) makes no difference in therms of outcome. So don't believe it if they tell you that the oil injection is any better. Abstract is below

Abstract

Background

Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilised egg. It has been suggested that a causative factor in many cases of miscarriage may be inadequate secretion of progesterone. Therefore, progestogens have been used, beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage.

Objectives

To determine the efficacy and safety of progestogens as a preventative therapy against miscarriage.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to June 2006), EMBASE (1980 to June 2006), CINAHL (1982 to June 2006), NHMRC Clinical Trials Register (June 2006) and Meta-Register (June 2006). We searched references from relevant articles, attempting to contact authors where necessary, and contacted experts in the field for unpublished works.

Selection criteria

Randomised or quasi-randomized controlled trials comparing progestogens with placebo or no treatment given in an effort to prevent miscarriage.

Data collection and analysis

Two review authors assessed trial quality and extracted data.

Main results

Fifteen trials (2118 women) are included. The meta-analysis of all women, regardless of gravidity and number of previous miscarriages, showed no statistically significant difference in the risk of miscarriage between progestogen and placebo or no treatment groups (Peto odds ratio (Peto OR) 0.98; 95% confidence interval (CI) 0.78 to 1.24) and no statistically significant difference in the incidence of adverse effect in either mother or baby.

In a subgroup analysis of three trials involving women who had recurrent miscarriages (three or more consecutive miscarriages), progestogen treatment showed a statistically significant decrease in miscarriage rate compared to placebo or no treatment (Peto OR 0.38; 95% CI 0.20 to 0.70). No statistically significant differences were found between the route of administration of progestogen (oral, intramuscular, vaginal) versus placebo or no treatment.

Authors' conclusions

There is no evidence to support the routine use of progestogen to prevent miscarriage in early to mid-pregnancy. However, there seems to be evidence of benefit in women with a history of recurrent miscarriage. Treatment for these women may be warranted given the reduced rates of miscarriage in the treatment group and the finding of no statistically significant difference between treatment and control groups in rates of adverse effects suffered by either mother or baby in the available evidence. Larger trials are currently underway to inform treatment for this group of women.

Source: Cochrane Database

Caffeine and Miscarriages

Today the International Herald Tribune had an article on caffeine and miscarriages. Parts of the article are below.

Too much caffeine during pregnancy may increase the risk of miscarriage, a new study says, and it suggests that pregnant women may want to reduce their intake or cut it out entirely.

Many obstetricians already advise women to limit caffeine, though the subject has long been contentious, with conflicting studies, fuzzy data and various recommendations given over the years.

The new study, being published Monday in the Journal of Obstetrics and Gynecology, finds that pregnant women who consume 200 milligrams or more of caffeine a day - the amount in 10 ounces of coffee or 25 ounces of tea - may double their risk of miscarriage. Ten ounces is equivalent to about 300 milliliters.

Professional groups like the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine have not taken official positions on caffeine, representatives said.

On Friday, the March of Dimes Web site said most experts agreed that the amount of caffeine found in 8 to 16 ounces of coffee a day was safe. It noted that some studies had linked higher amounts to miscarriage and low birth weight, but stated: "However, there is no solid proof that caffeine causes these problems. Until more is known, women should limit their caffeine intake during pregnancy."

Now, having reviewed the new study, the March of Dimes plans to change its message, to advise women who are pregnant or trying to conceive to limit their daily caffeine intake to 200 milligrams or less, said Janis Biermann, its senior vice president of education and health promotion.

Li's study included 1,063 pregnant women who were interviewed once about their caffeine intake. At the time of the interview, their median length of pregnancy was 71 days. But 102 had already miscarried - not surprising, because most miscarriages occur very early in pregnancy. Later, 70 more women miscarried, for an overall miscarriage rate of 16 percent for the group, a typical rate.

Of 264 women who said they used no caffeine, 12.5 percent had miscarriages. But the miscarriage rate was 24.5 percent in the 164 women who consumed 200 milligrams or more per day. The increased risk was associated with caffeine itself and not with other known risk factors like the mother's age or smoking habits, the researchers said.

Li said the study had answered an important question that previous research had left unresolved. Women who have morning sickness are less likely to miscarry than those who do not, possibly because the same hormonal changes that cause nausea and vomiting contribute to a healthy pregnancy. But some researchers said morning sickness could lead to misleading results in caffeine studies.

These researchers argued that because they feel ill, some women may consume less caffeine. That tendency may make it appear that they are less likely to miscarry because they avoid caffeine, when the real reason is actually that they started out with healthier pregnancies.

Li said he and his colleagues had carefully analyzed the data and determined that the risk from caffeine was real and could not be explained away by different rates of morning sickness.

Dr. Carolyn Westhoff, a professor of obstetrics and gynecology, and epidemiology, at Columbia University Medical Center in New York, had reservations about the study, noting that miscarriage is difficult to study or explain.

She said most miscarriages resulted from chromosomal abnormalities, and there was no evidence that caffeine could cause those problems.

Of course Dr. Westhhoff is dead on with her comments. The study is at best mildly indicative of an effect . The main reason is that it is a retrospective study . To believe that cutting caffeine would reduce miscarriages by 50% is simply ludicrous.
Nevertheless i would say that it is prudent to reduce caffeine intake to 2 cups per day of regular coffee. That's 1 espresso or 1 "tall latte" for the starbucks drinkers.