Midluteal Assessment of Uterine Artery Doppler and Serum Progesterone Level in Women with Unexplained Recurrent Miscarriage

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Introduction:
Abortion is described as the loss of a pregnancy before 20 weeks of pregnancy or with a foetal weight of less than 500 grams.
Both ectopic pregnancies and molar pregnancies, according to the majority of researchers, should not be included in the definition [1].
As unpleasant disorder, recurrent miscarriage (RM) affects approximately one percent of couples who are trying to get pregnant.It can be extremely disappointing for both clinicians and patients when, despite extensive workup, no identifiable underlying disease is discovered in at least half of all couples with this condition [2].
There is no agreement on the number of miscarriages that must occur before a woman is considered to have recurrent miscarriage.The Royal College of Obstetricians and Gynecologists (RCOG) in the United Kingdom defines recurrent miscarriage (RM) as "the loss of three or more successive pregnancies".In addition, the Austrian and Swiss Societies of Gynecology and Obstetrics define RM as three or more consecutive losses [3].
However, the American Society for Reproductive Medicine defines recurrent abortion as two or more failed clinical pregnancies with exclusion of biochemical pregnancies but requiring only two losses in order to be considered RM [4]

Aim of the work:
To investigate the blood flow and progesterone levels in non-pregnant women with a history of unexplained recurrent pregnancy loss (RPL) in comparison to normal fertile women.

Subjects and Methods:
This case-control study was done in obstetrics and gynecology department in Beni-Suef University Hospital from October 2020 to April 2021 and was applied on non pregnant women.

Subjects:
Group I (Cases Group): Included women with recurrent pregnancy loss .

Methods:
All women were subjected to the following: for significance using a P-value, which was divided into two categories: non-significant when the P-value was greater than 0.05 and significant when the P-value was less than or equal to 0.01.

Ethical consideration:
The current study was conducted approval by the research ethics committee of faculty of medicine in Beni-Suef University.No one obliged to participate in this study.Informed consent was obtained from all participants.

Discussion:
In the current study it was found that there was statistically insignificant difference between both groups as regards age (P-value =0.721) (table 1).In the current study, it was found that there was no statistically significant difference between the BMI of women in the RPL group and the control group P= 0.352 (table 1).

Sugiura-Ogasawara
[16] found that obesity might increase the danger of spontaneous miscarriage.Body mass index more than 30 kg/m 2 increases the risk of abortion with odds ratio 1.7-3.5 in patients with early recurrent abortion.
In addition, King and Casanueva [17] and Lashen et al.,[18] reported that obese women have a 20 percent higher chance of spontaneous abortion than women with a normal BMI.
Because all women in this study were selected with normal BMI, we can't document the controversy between our results and the previous studies. In


Group): Included healthy fertile non-pregnant women (20-35 years) with no history of previous miscarriage and had at least one child born at term.They did not receive any hormonal contraception or use IUCD at the time of study with the same exclusion criteria as the study group.Cases were selected according to the following inclusion/exclusion criteria:  Inclusion criteria: Women with age: 20-35 years, with history of recurrent miscarriage (defined as ≥ 3 previous miscarriages at < 20 weeks' gestation) fathered by the same partner, with regular menstrual cycles at least for the Exclusion criteria: Women with one or more of the following conditions as https://ejmr.journals.ekb.failure to obtain consent were excluded from the study.

Full history taking : 
Personal history: their names, ages, addresses, occupations, special habits, and history of consanguinity. Menstrual history: asking about regularity of cycles, frequency, duration and amount of bleeding of each cycle, and date of the last menstrual period. Obstetric history: asking about parity and method of previous deliveries, time at which previous abortions had been occurred and whether they had been followed by surgical evacuation or not, and ask about date of the last delivery or abortion.Past history: past history of systemic diseases such as diabetes mellitus, hypertension, renal disease, past history of infants with chromosomal abnormalities such as trisomy 21, and past history of thyroid troubles.Pelvic examination: to assess uterine size and the presence or absence of adnexal masses.Laboratory investigations:  Random blood sugar was done for the study group and the control group. IgG and IgM titre for anti-cardiolipin antibodies, Lupus anticoagulant were done for the study group. Measurement of TSH for the study group. Evaluation of serum progesterone level: was done during the mid-luteal phase (Day 21 of regular menstrual cycle) in https://ejmr.journals.ekb.eg/women of the study group and the control group.color Doppler and by the same examiner in the mid-luteal phase of menstrual cycle for all women of the study and control group. Pelvic ultrasound examination with abdominal probe was done to exclude the presence of large adnexal or pelvic masses. Transvaginal ultrasound examination was done to exclude any uterine or adnexal abnormalities.Transvaginal bilateral uterine artery Color Doppler assessment of Pulsatility index (PI) and Resistance index (RI) was done.A pulsed colour Doppler examination of the right uterine artery (located at the lateral border of the uterine isthmus) was performed first, followed by an evaluation of the left uterine artery.Because there was no discernible difference between the right and left sides, it appeared possible to confirm that the most accurate way to interpret Doppler data for uterine arteries would be to utilise the mean PI and RI of both sides combined, as previously reported [13].So, the average pulsatility index (PI) and resistance index (RI) of the bilateral uterine arteries were calculated.Analysis of data was performed using SPSS v. 25.The mean and standard deviation of quantitative variables served as the basis for their description (SD).Nouns and percentages were used to describe qualitative variables in the quantitative data https://ejmr.journals.ekb.eg/collection (percent).Data was explored for normality using Shapiro/ Kolmogorov tests of normality.Data was normally distributed.Comparison between the scale variables of the two groups was assessed by the independent t-test.Comparison between both groups regarding categorical variables was conducted by Chi-Squared test.Receiver operating characteristic curve was used to assess the optimal cut off point of uterine artery RI and PI for prediction of unexplained recurrent miscarriage.Pearson correlation was conducted to assess the linear correlation between uterine arteries' PI and RI and patient's age, BMI and progesterone level.Results were evaluated

Table ( 1
) showed that there was no statistically significant difference between cases and controls regarding their age and BMI (both groups were well matched) (P-value > 0.05).

Table ( 2
) showed that there was no statistically significant difference between cases and controls regarding their progesterone level (as cases group had unexplained recurrent abortion) (P-value > 0.05).
Table (3)showed that there was a significant higher uterine artery PI and RI among cases than controls (P-value<0.001).

Table ( 4
) showed that the uterine artery PI and RI have a significant role in prediction of unexplained recurrent abortion (P-value <0.001).

Table ( 5): Correlation between uterine artery Doppler parameters and patients' age, BMI and progesterone level:
Table (5)showed that there was no statistically significant linear correlation between the uterine arteries' PI and RI and patient's age, BMI and progesterone level (P-value >0.05).