A causal link has long been described between estrogen and systemic lupus erythematosus activity. Contraceptive and pregnancy management is now common for lupus patients, but pregnancy continues to ...be associated with higher maternal and fetal mortality/morbidity in systemic lupus erythematosus patients than among the general population. Potential complications include lupus flares, obstetric complications (fetal loss, in utero growth retardation, premature birth) and neonatal lupus syndrome. Association with antiphospholipid antibodies or antiphospholipid syndrome increases the risk of obstetric complications. Anti-SSA and/or anti-SSB antibodies put fetuses at risk for neonatal lupus. Improving the outcome of such pregnancies depends upon optimal systematic planning of pregnancy at a preconception counseling visit coupled with a multidisciplinary approach. Absence of lupus activity, use of appropriate medication during pregnancy based on the patient's medical history and risk factors, and regular monitoring constitute the best tools for achieving a favorable outcome in such high-risk pregnancies. The aim of this review is to provide an update on the management of contraception and pregnancy in systemic lupus erythematosus, cutaneous lupus and/or antiphospholipid syndrome in order to reduce the risk of complications and to ensure the best maternal and fetal prognosis.
Abstract
Study question
Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in hormonal replacement therapy (HRT) cycles?
Summary answer
...Body Mass Index (BMI), parity, and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles.
What is known already
While the detrimental impact of low serum P concentrations on HRT-FET outcomes is unanimously recognized, the factors accounting for P levels disparities among patients receiving the same luteal phase support treatment remain to be elucidated, in order to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation.
Study design, size, duration
Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020.
Participants/materials, setting, methods
Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤ 9.8 ng/mL, according to a previous published study) were analyzed using univariate and multivariate logistic regression models.
Main results and the role of chance
The live birth rate was 31.5% (288/915) in the overall population. Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Univariate analysis showed that BMI (p < 0.001), parity (p = 0.001), non-European geographic origin (p = 0.001), and the duration of infertility (p = 0.018) were significantly associated with low serum P levels. Moreover, the proportion of active smokers was significantly lower in the “low P concentrations” group (p = 0.002). After multivariate analysis, BMI (OR 1.06 95%CI 1.02-1.11, p = 0.002), parity (OR 1.31 95%CI 1.04-1.65, p = 0.024), non-European geographic origin (OR 1.67 95%CI 1.19-2.35, p = 0.003), and active smoking (OR 0.43 95%CI 0.21-0.85, p = 0.016) remained independent factors associated with serum P levels ≤ 9.8 ng/mL.
Limitations, reasons for caution
The main limitation of our study is linked to its observational design. Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated.
Wider implications of the findings
There is urgent need for future research on clinical factors affecting P concentrations to help clinicians predicting which subgroups of patients would benefit from individualized luteal phase support. More data are also needed on the underlying mechanisms explaining the relationship between patients’ characteristics and serum P levels in HRT-cycles.
Trial registration number
NA
Oral estrogen increases the risk of venous thromboembolism (VTE) in postmenopausal women, particularly in those with a prothrombotic mutation. Transdermal estrogen may be safe with respect to VTE. We ...investigated the impact of the route of estrogen administration on the association between a prothrombotic mutation (factor V Leiden or prothrombin G20210A mutation) and VTE risk.
We performed a multicenter case-control study of VTE among postmenopausal women who were enrolled in 1999 through 2004 at 7 clinical centers in France. We recruited 235 consecutive patients with a first documented episode of idiopathic VTE and 554 controls. Factor V Leiden was associated with a 3.4-fold-increased risk of VTE (95% confidence interval CI, 2.0 to 5.8), and a prothrombin mutation was associated with a 4.8-fold-increased risk of VTE (95% CI, 2.5 to 9.4). Oral but not transdermal estrogen was associated with an increased risk of VTE (odds ratio OR, 4.3; 95% CI, 2.6 to 7.2; and OR, 1.2; 95% CI, 0.8 to 1.7, respectively). After adjustment for potential confounding factors, the combination of either factor V Leiden or prothrombin G20210A mutation and oral estrogen gave a 25-fold-increased risk of VTE compared with nonusers without mutation (95% CI, 6.9 to 95.0). However, the risk for women with prothrombotic mutation using transdermal estrogen was similar to that of women with a mutation who were not using estrogen (OR, 4.4; 95% CI, 2.0 to 9.9; and OR, 4.1; 95% CI, 2.3 to 7.4, respectively).
In contrast to oral estrogen, transdermal estrogen does not confer additional risk on women who carry a prothrombotic mutation. The safety of transdermal estrogen has to be confirmed in randomized trials.
Oral contraceptive (OC) use is associated with an increased risk of venous thromboembolism. Previous data reported higher thrombotic risk in women using third‐generation combined OC than in those ...using second generation OC. The difference could be explained by differential effects of progestagens on plasma sensitivity to activated protein C (APC). The main purpose of this cross‐sectional study was to assess the influence of a progestagen‐only OC (chlormadinone acetate) as well as the effect of several combined OC with different progestagen components on APC resistance. The effect of APC on endogenous thrombin potential (ETP) was investigated in the plasma of healthy women using either combined OC (n = 82) or progestagen‐only OC (n = 28), and in non‐users (n = 64). Carriers of factor V Leiden were excluded. Compared with non‐users, there was no significant change in APC resistance in women using progestagen‐only OC. Women who used combined OC were less sensitive to APC than non‐users (P < 0.001) and the difference was significantly more pronounced in women using third‐generation OC (n = 41) than in those who used second‐generation OC containing levonorgestrel (n = 22) (P < 0.05). Compared with OC containing levonorgestrel, use of norethisterone‐containing OC (n = 9) was associated with an increased resistance to APC (P < 0.05). Women who used cyproterone‐containing OC (n = 10) were less sensitive to APC than those using third‐generation OC (P < 0.05) or second‐generation OC containing levonorgestrel (P < 0.05). Protein S, factor II and FVIII levels explained in part the OC‐related changes in APC sensitivity variations. ETP‐based APC resistance may contribute to explain why different brands of OC can be associated with different levels of thrombogenicity.
The use of anatomic model is particularly suitable for teaching gynecological examination. Although simulation training was proved to be effective in improving medical students' technical skills, its ...interest in reducing their apprehension about pelvic examination was poorly evaluated. The aim of the present study was to evaluate low-fidelity simulation sessions to reduce the discomfort and apprehension of medical students towards gynecological examination. The secondary objective was to appreciate student satisfaction with these sessions.
Descriptive analysis of simulation-based teaching of breast and pelvic examination on Ilumens platform at the university Paris 5 among 3rd and 4th year medical students. It consisted in a before/after evaluation, using an anonymous questionnaire of self-evaluation and satisfaction at the beginning and at the end of the session.
Four hundred and thirty-two students answered both questionnaires. Seventy-two percent apprehended the pelvic examination initially and 62% were uncomfortable with the idea of performing it. Among the students who had never performed pelvic examination, more than 80% felt less uncomfortable with the idea of performing pelvic examination and were less apprehensive about it at the end of the simulation session.
The benefits of low-fidelity simulation in gynecology extend to the well-being of medical students who are less apprehensive about performing gynecological examination.
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