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Objective Transabdominal cerclage (TAC) is an effective intervention to prevent spontaneous mid-trimester loss and preterm delivery when a transvaginal cerclage has failed. A TAC may be inserted during the first trimester of pregnancy or preconceptually. The objective of this study was to determine whether or not preconceptual transabdominal cerclage (TAC) confers any benefit over first trimester TAC insertion in terms of associated surgical and pregnancy-related morbidity and subsequent pregnancy outcome. Study design This was a retrospective and prospective cohort study of 161 consecutive women who underwent preconceptual (PC) TAC versus first trimester (T1) TAC over a 22-year period from January 1993 to January 2015 at a tertiary referral miscarriage clinic. Data was obtained from case note review retrospectively from 1993 to 2006 and prospectively between 2006 and 2015. Inclusion criteria comprised a history of at least one previous spontaneous mid-trimester loss coupled with at least one failed transvaginal cerclage and screening for antiphospholipid syndrome and bacterial vaginosis. Of 144 patients who conceived, 121 had complete pregnancy outcomes; 62 in the preconceptual group and 59 in the first trimester group. Both groups had similar previous pregnancy losses and previous transvaginal cerclage history. Results Successful pregnancies >24 weeks occurred in 97% of PC TACs compared to 93% in the T1 group. Furthermore, a successful pregnancy >34 weeks occurred in 90% (56/62) in the PC group compared to 74% (44/59) in the T1 group (OR 3.18; CI 1.14–8.8). Significantly fewer patients needed emergency caesarean section for preterm delivery in the PC group (7/62 (12%) versus 21/59 (36%); OR 4.34; CI 1.68–11.32). All 6 failures before 24 weeks gestation (T1 = 4, PC = 2) were associated with antiphospholipid syndrome or bacterial vaginosis. In the T1 group 3/65 (5%) of patients suffered serious surgical complications and haemorrhage >500 mls occurred in 32/65(50%) of cases whereas no surgical complications occurred in the PC group. Conclusions Preconceptual TAC is more successful in preventing repeat spontaneous mid-trimester loss and preterm labour, and is associated with less surgical and pregnancy-related morbidity compared to first trimester TAC insertion.

BACKGROUND: 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.METHODS: 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.RESULTS: 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.CONCLUSIONS: 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. (Funded by the United Kingdom National Institute of Health Research; PROMISE Current Controlled Trials number, ISRCTN92644181.).

Objective To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. Design A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). Setting 86 participating Early Pregnancy Units. Population All women diagnosed in the participating units with CSP between November 2013 and January 2015. Methods Cohort study of women identified through the UKEPSS monthly mailing system. Main outcome measures Incidence, clinical outcomes and complications. Results 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. Conclusions Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. Tweetable abstract Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

Background and objectivesProgesterone is essential to maintain a healthy pregnancy. Guidance from the Royal College of Obstetricians and Gynaecologists and a Cochrane review called for a definitive trial to test whether or not progesterone therapy in the first trimester could reduce the risk of miscarriage in women with a history of unexplained recurrent miscarriage (RM). The PROMISE trial was conducted to answer this question. A concurrent cost-effectiveness analysis was conducted.Design and settingA randomised, double-blind, placebo-controlled, international multicentre study, with economic evaluation, conducted in hospital settings across the UK (36 sites) and in the Netherlands (nine sites).Participants and interventionsWomen with unexplained RM (three or more first-trimester losses), aged between 18 and 39 years at randomisation, conceiving naturally and giving informed consent, received either micronised progesterone (Utrogestan®, Besins Healthcare) at a dose of 400 mg (two vaginal capsules of 200 mg) or placebo vaginal capsules twice daily, administered vaginally from soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) until 12 completed weeks of gestation (or earlier if the pregnancy ended before 12 weeks).Main outcome measuresLive birth beyond 24 completed weeks of gestation (primary outcome), clinical pregnancy at 6–8 weeks, ongoing pregnancy at 12 weeks, miscarriage, gestation at delivery, neonatal survival at 28 days of life, congenital abnormalities and resource use.MethodsParticipants were randomised after confirmation of pregnancy. Randomisation was performed online via a secure internet facility. Data were collected on four occasions of outcome assessment after randomisation, up to 28 days after birth.ResultsA total of 1568 participants were screened for eligibility. Of the 836 women randomised between 2010 and 2013, 404 received progesterone and 432 received placebo. The baseline data (age, body mass index, maternal ethnicity, smoking status and parity) of the participants were comparable in the two arms of the trial. The follow-up rate to primary outcome was 826 out of 836 (98.8%). The live birth rate in the progesterone group was 65.8% (262/398) and in the placebo group it was 63.3% (271/428), giving a relative risk of 1.04 (95% confidence interval 0.94 to 1.15;p = 0.45). There was no evidence of a significant difference between the groups for any of the secondary outcomes. Economic analysis suggested a favourable incremental cost-effectiveness ratio for decision-making but wide confidence intervals indicated a high level of uncertainty in the health benefits. Additional sensitivity analysis suggested the probability that progesterone would fall within the National Institute for Health and Care Excellence’s threshold of £20,000–30,000 per quality-adjusted life-year as between 0.7145 and 0.7341.ConclusionsThere is no evidence that first-trimester progesterone therapy improves outcomes in women with a history of unexplained RM.LimitationsThis study did not explore the effect of treatment with other progesterone preparations or treatment during the luteal phase of the menstrual cycle.Future workFuture research could explore the efficacy of progesterone supplementation administered during the luteal phase of the menstrual cycle in women attempting natural conception despite a history of RM.Trial registrationCurrent Controlled Trials ISRCTN92644181; EudraCT 2009-011208-42; Research Ethics Committee 09/H1208/44.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 41. See the NIHR Journals Library website for further project information.

Thyroid disorders have been associated with recurrent miscarriage. Little evidence is available on the influence of subclinical hypothyroidism on live birth rates. In this cohort study, women who had experienced miscarriage and subclinical hypothyroidism (defined as thyroid-stimulating hormone >97.5th percentile mU/l with a normal thyroxine level) were investigated; the control group included women who had experienced recurrent miscarriage and normal thyroid function. Multivariable logistic regression was used to investigate the association of subclinical hypothyroidism. Data were available for 848 women; 20 (2.4%) had subclinical hypothyroidism; 818 women (96%) had euthyroidism; and 10 (1.2%) had overt hypothyroidism. The live birth rate was 45% in women with subclinical hypothyroidism and 52% in euthyroid women (OR 0.69, 95% CI 0.28 to 1.71). The ongoing pregnancy rate was 65% versus 69% (OR 0.82, 95% CI 0.32 to 2.10) and the miscarriage rate was 35% versus 28% (OR 1.43, 95% CI 0.56 to 3.68), respectively. No differences were found when thyroid stimulating hormone 2.5 mU/l was used as cut-off level to define subclinical hypothyroidism. In women with unexplained miscarriage, no differences were found in live birth, ongoing pregnancy and miscarriage rates between women with subclinical hypothyroidism and euthyroid women.

Acquired and inherited thrombophilia is an important research avenue in the recurrent miscarriage field. The optimum treatment for patients with recurrent miscarriage and a confirmed thrombophilia remains a contentious issue. We aim to appraise and explore the latest research in the field of thrombophilia and recurrent miscarriage in this review.Antiphospholipid syndrome (APS) is the only proven thrombophilia that is associated with adverse pregnancy outcomes. Research involving inherited thrombophilia and recurrent miscarriage is limited to small observational studies with small and heterogeneous populations. Aspirin and heparin therapy are frequently prescribed for APS, yet there is no robust evidence for the most efficacious regime. The combination of inherited hypercoagulability and environmental factors in association with recurrent miscarriage has recently been explored as an aid to identify high-risk individuals.The cause of recurrent miscarriage is multifactorial and appropriate treatment continues to be a challenge. Laboratory tests need to be standardized and well designed multicentre research trials are essential to expand on the current knowledge base with the aim to produce strong evidence-based medicine.

Please cite this paper as: Quenby S, Matthew A, Zhang J, Dawood F, Wray S. In vitro myometrial contractility reflects indication for caesarean section. BJOG 2011;118:1499–1506. Objective To assess the extent to which in vitro measurements of myometrial contractility reflect the clinical indication for caesarean section. Design A prospective, observational hypothesis-generating study. Setting Women were recruited from Liverpool Women’s NHS Foundation Trust and experiments were performed in the Physiology Department at the University of Liverpool. Population Myometrial samples were taken from women undergoing a caesarean section during labour (n = 50) or from women having a repeat nonlabouring caesarean section (n = 70). Methods The demographic characteristics of the women and indications for current and previous caesarean sections were recorded. The force, frequency and duration of spontaneous contractions of myometrial strips, and changes in the intracellular calcium concentration of the strips, were measured. Kruskall–Wallis and post hoc tests were used to assess the significance of differences between groups. Results Samples from women whose caesarean section was for fetal distress/acidosis (scalp pH

Aims: To critically evaluate the hypothesis that cervical weakness could be another risk factor in patients with uterine anomalies for the adverse pregnancy outcome related with their presence. Brief description of the reviewed data: The prevalence of congenital uterine anomalies (CUA) has been variably reported, as there is no universally agreed classification system. Moreover cervical weakness is a difficult entity to diagnose with certainty. However, despite the heterogeneity in definitions and study populations, there is evidence that women with CUA are at increased risk of spontaneous mid-trimester losses and preterm delivery. Since the latter are inversely related to cervical length and ensuing cervical weakness, there does appear to be a correlation between CUA and cervical weakness. Furthermore, adverse pregnancy outcomes may be obviated with interventions such as cerclage. Clinical implications: Patients who have a history of mid-trimester loss or preterm delivery should be thoroughly evaluated to exclude the presence of CUA based on a well-defined classification. Tests to assess underlying cervical weakness should also be conducted. Open issues for further research: Consensus on CUA classification will yield a framework for the comparison of future studies. Robust, well-designed studies are required to delineate a more definitive association between cervical weakness and CUA.

BACKGROUND: Recurrent miscarriage has been associated with antiphospholipid syndrome (APS) and other prothombotic conditions. We tested the hypothesis that women diagnosed as having APS as an aetiological factor for their miscarriages were at higher risk of thrombosis than those with idiopathic recurrent miscarriage. METHODS: A retrospective case–control study was performed using validated questionnaires. A total of 141 women with recurrent miscarriage and APS alone were matched with 141 women with idiopathic recurrent miscarriage for age, number and type of pregnancy loss and number of years of follow-up. A subgroup of eight women included those who initially presented with recurrent miscarriage, thrombosis and APS. RESULTS: The mean length of follow-up was 7.3 years and response rate 74%. The incidence of thrombosis was similar in the recurrent miscarriage and APS women (6/1000 women-years) and in the idiopathic recurrent miscarriage women (2/1000 women-years) (P 5 0.18). All eight women who presented with recurrent miscarriage, APS and thrombosis reported further thrombotic events. CONCLUSIONS: Both idiopathic and APS-associated recurrent miscarriage were associated with a similar long-term risk of thrombosis.

Recurrent miscarriage (RM) is a clinical condition of heterogeneous aetiology. Classification of recurrent pregnancy loss is a crucial tool in the investigation and exploration of pathophysiological mechanisms. Some of the previous causes of RM, such as polycystic ovaries, and endocrinopathies are now viewed with scepticism, paving the way for a modern, refined and evidence-based approach. While the antiphospholipid syndrome continues to be a prominent feature in RM, the traditional thrombotic pathogenetic mechanism has been extrapolated, encompassing the direct effect of anticardiolipin antibodies on trophoblast invasion. Furthermore, the emergence of other thrombophilias, have gained more consideration as aetiological factors. At the molecular and biological phases, more light has been shed on immunological influences and the role of a hostile endometrium. The fate of normal and abnormal embryos has challenged traditional concepts of RM, giving birth to the paradigm of nature’s quality control.

Introduction: Multiple trials of immunotherapy for reproductive failure have failed to demonstrate significant benefit. A reason for this may be the lack of a test that selects which women will benefit from treatment. High density of uterine naturak killer (uNK) cells has been associated with recurrent miscarriage (RM) and prednisolone was shown to reduce this uNK cell density. Hence we carried out a double blind randomised placebo controlled trial of prednisolone versus placebo in early pregnancy for women with RM and increased uNK cell density. The aim of this pilot trial was to assess the feasibility of recruitment, integrity of trial procedures and potential efficacy for future power calculations.

Mid-trimester pregnancy loss (MTL) occurs between 12 and 24 weeks' gestation. The true incidence of this pregnancy complication is unknown, because research into MTL in isolation is scarce, although the estimated incidence has been noted to be 2% to 3% of pregnancies. A comprehensive preconceptual screening protocol is recommended, because the cause for an MTL may be present in isolation or combined (dual pathology), and is often heterogeneous. Patients with a history of MTL are at an increased risk of future miscarriage and preterm delivery. This risk is increased further depending on the number of associative factors diagnosed.

Background Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately reduce the duration of the labour. It has also been suggested that intravenous fluids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous fluids to labouring women has not been adequately elucidated although it is a widely-adopted policy, and there is no consensus on the type or volume of fluids that are required, or indeed, whether intravenous fluids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral fluids during labour. Furthermore, excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks. Objectives To evaluate whether the routine administration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013). Selection criteria Randomised controlled trials of intravenous fluid administration to spontaneously labouring low-risk nulliparous women. Data collection and analysis The review authors independently assessed trials for inclusion, trial quality and extracted data. Main results We included nine randomised trials with 1781 women. Three trials had more than two treatment arms and were included in more than one comparison. Two trials compared women randomised to receive up to 250 mL/hour of Ringer's lactate solution as well as oral intake versus oral intake only. For women delivering vaginally, there was a reduction in the duration of labour in the Ringer's lactate group (mean difference (MD) -28.86 minutes, 95% confidence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringer's lactate group (risk ratio (RR), 0.73 95% CI 0.49 to 1.08). Three trials compared women who received 125 mL/hour versus 250 mL/hour of intravenous fluids with free oral fluids in both groups. Women receiving a greater hourly volume of intravenous fluids (250 mL) had shorter labours than those receiving 125 mL (MD 23.87 minutes, 95% CI 3.72 to 44.02, 256 women). There was no statistically significant reduction in the number of CS in the 250 mL intravenous fluid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women). In one study the number of assisted vaginal deliveries was lower in the group receiving 125 mL/hour (RR 0.47, 95% CI 0.27 to 0.81). Four trials compared rates of intravenous fluids in women where oral intake was restricted (125 mL/hour versus 250 mL/hour). There was a reduction in the duration of labour in women who received the higher infusion rate (MD 105.61 minutes, 95% CI 53.19 to 158.02); P < 0.0001, however, findings must be interpreted with caution as there was high heterogeneity amongst trials (I2 = 53%). There was a significant reduction in CS in women receiving the higher rate of intravenous fluid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identified in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17). Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no significant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups. Authors' conclusions Although the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy of 'nil by mouth'. One trial raised concerns about the safety of dextrose and this needs further exploration. None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported.

Thrombophilic disorders encompass a diverse group of coagulation disorders that potentiate a predisposition for thrombotic events. Amongst the known thrombophilias are antithrombin III deficiency, prothrombin G20210A gene mutation, protein S and protein C deficiency, activated protein C resistance and the antiphospholipid syndrome. Thrombophilia and its influence on pregnancy have been studied for the past 50 years. Both inherited and acquired thrombophilia have been associated with an increased risk of thrombo-embolism as well as an increased risk of pregnancy loss and adverse obstetric outcomes. Some thrombophilias (antiphosphoplipid syndrome, factor V Leiden mutation and antithrombin III deficiency confer a higher risk of both venous thrombo-embolism and obstetric complications. There is still no consensus on the optimal management of thromboprophylaxis in future pregnancies. Clearly large well designed and adequately powered multicenter randomised trials are required to clarify the management of thrombophilia in pregnancy especially with a history of adverse obstetric outcome.

Aims/hypothesis The prevalence of births worldwide complicated by diabetes mellitus is increasing. In the UK, for example

The thrombophilia represent a spectrum of coagulation disorders associated with a predisposition for thrombotic events (deep vein thrombosis (DVT) and pulmonary embolism (PE)) (Kaandorp et al, 2009). Inherited thrombophilia include a single-point mutation on the Factor V gene (factor V Leiden (FVL), prothrombin (PT) G20210A gene mutation, deficiencies in protein C and protein S as well as antithrombin (AT) deficiency. The most entrenched acquired thrombophilia is the antiphospholipid syndrome (APS). APS is a non-inflammatory auto-immune disease characterised by thrombosis or pregnancy complications in the presence of antiphospholipid antibodies (Urbanus et al, 2008). Recognized obstetric complications include fetal loss, recurrent miscarriage, intrauterine growth restriction (IUGR), pre-eclampsia and preterm labour (Lassere and Empson, 2004). The association between the diverse group of thrombophilias and adverse pregnancy outcome has been studied for over 40 years with numerous studies identifying varying coagulation defects. A meta-analysis assessing the impact of thrombophilia and fetal loss described varying outcomes and concluded that positive or negative associations were dependent on the type of thrombophilia (Rey et al, 2003). This chapter will focus on inherited and acquired thrombophilia in pregnancy, except for the antiphospholipid syndrome, which is extensively described in other chapters.

Early pregnancy problems form a major part of all gynaecological emergencies. Approximately one in five pregnancies will end in pregnancy loss. The model of care for all early pregnancy events and complications provides the timeline base along which the core standards of care elements, care pathways and clinical protocols can support the care provision for best patient experience. Many agents, including prostaglandins, mifepristone, potassium chloride and dactinomycin, have all been used for the medical management of ectopic pregnancy. It is vital that only appropriately trained and competent staff should perform transabdominal and transvaginal early pregnancy scans. As an essential component of clinical governance, all early pregnancy assessment units and recurrent miscarriage clinics should have regular meetings to review clinical guidelines and protocols. This would provide an ideal opportunity to discuss audits, to generate research ideas and discuss recruitment to national or international multicentre trials.

BACKGROUND: Recurrent miscarriage (RM) has been associated with the thrombophilia, activated protein C resistance (APCR). The factor V Leiden mutation located on the B domain of the factor V gene, causes 95% of APCR and since the B domain is pivotal to APCR, it seemed plausible that other mutations or polymorphisms affecting this active domain may instigate acquired APCR. The objective of this study was to determine whether other polymorphisms exist on the parts of the gene encoding the B domain of the factor V in women with acquired APCR and RM. METHODS: There were 51 women with RM and acquired APCR, 24 parous women (with no history of miscarriage and at least one normal full-term delivery) and 15 women with a history of idiopathic RM, who formed the study and two control groups, respectively. Six exons of the B domain of the factor V gene were intensely analysed using polymerase chain reactions, single-strand conformation polymorphism, genetic sequencing and restriction enzyme digestion analysis to identify single-nucleotide polymorphisms (SNPs). RESULTS: A significantly increased frequency of some SNPs on the factor V gene were observed in the women with acquired APCR and RM when compared with the control groups. CONCLUSIONS: The presence of some of these SNPs may predispose these women to acquired APCR and RM.

We have every confidence in the clinical safety of our services. There is no evidence in the trust’s adverse clinical event reporting system to support allegations made in the article by Gornall about poor clinical practices allegedly witnessed by Peter Bousfield.1 Mr Bousfield would have had a duty to report through this system in the course of his practice, …

Abstract 2971 Poster Board II-947 Introduction: Women with antiphospholipid syndrome (APS) are at increased risk of recurrent miscarriage. Remarkably, the outcome of a successive pregnancy in women with APS and recurrent miscarriage is merely unknown. Patients and methods: We performed a cohort study including all women with 2 or more consecutive miscarriages who attended the recurrent miscarriage clinic of Liverpool Women's Hospital, Liverpool, UK between 1988 and 2006. All women underwent a systematic diagnostic work up including testing for APS. Women with proven APS (according to the SAPPORO criteria) were studied, and outcomes were compared to women with unexplained recurrent miscarriage. We excluded all women from couples with other reasons for recurrent miscarriage. Results: 737 women were included, of whom 220 (30%) had APS. Mean age (32 years) and obstetric history (mean number of prior losses: 3) did not differ between women with and without APS. Of women with APS, 148 (67%) had a successful pregnancy outcome as compared to 324 women without APS (63%), OR=1.2 (95%CI 0.9 to 1.7). No differences were found for birth weight, gestational age, and intra-uterine growth retardation. Women with APS who received aspirin and heparin more often had a successful pregnancy 53/67 (79%) as compared to women without treatment 26/44 (59%); OR=2.6 (95%CI 1.0 to 6.6). Combined use of aspirin and heparin was not associated with an increased success rate in women without APS: 25/43 (58%) vs 204/305 (67%); OR=0.7 (95%CI 0.3-1.4). Conclusions: The prognosis of a successive pregnancy in women with recurrent miscarriage and APS was comparable to women with unexplained recurrent miscarriage. However, the combined use of heparin and aspirin was associated with a significantly increased chance of a successful pregnancy in women with APS. Disclosures: No relevant conflicts of interest to declare.

We set out to assess the association between antiphospholipid antibodies, acquired activated protein C resistance (factor V Leiden negative), and type of pregnancy loss. This was a retrospective case–control observational study at a tertiary miscarriage clinic. Two hundred and eighty consecutive women with a history of recurrent miscarriage underwent testing for antiphospholipid antibodies (APA) and acquired activated protein C resistance (APCR). The Dilute Russell Viper Venom Time, a standardised enzyme link immunosorbent assay, the Coatest kit and a polymerase chain reaction were used to detect lupus anticoagulant, IgG and IgM, APCR and factor V Leiden mutation, respectively. High resolution ultrasound was used to define fetal loss. Obstetric outcome was also recorded. Of the 280 women tested, 51 were found to have acquired ACPR, and were matched for age and previous number of pregnancy losses with a control group of 102 women with no evidence of APCR or APA. The fetal loss rate was significantly raised...

Activated protein C resistance is a thrombophilia with an established role in producing thrombosis which more recently has been implicated in the pathogenesis of pregnancy loss. This review will analyse recent literature to evaluate this association and address the gestation and type of pregnancy loss.