VIDEO
Separation of miscarriage tissue from maternal decidua for chromosome analysis Gayathree Murugappan, M.D., Stephanie Gustin, M.D., and Ruth B. Lathi, M.D. Department of Reproductive Endocrinology and Infertility, Stanford Hospital & Clinics, Stanford, California
Objective: To demonstrate a technique for separation of miscarriage tissue from maternal decidua to reduce maternal cell contamination for chromosome analysis. Design: Retrospective. Setting: University-based infertility center. Patient(s): Not applicable. Intervention(s): Retrospective collection of de-identified images and video from manual vacuum aspiration (MVA) performed after firsttrimester pregnancy losses. This project was exempt from institutional review board approval as no patient-identifying data were used. Main Outcome Measure(s): Reduction of maternal cell contamination and improvement of the accuracy of chromosome analysis. Result(s): Video demonstration of separation of miscarriage tissue from maternal decidua after MVA. Conclusion(s): Chromosome analysis of a miscarriage is performed to assess the etiology of miscarriage and recurrent pregnancy loss. However, maternal cell contamination can limit the accuracy. This video demonstrates a technique for separating miscarriage tissue from maternal decidua after MVA to reduce maternal cell contamination prior to sending tissue for analysis. The same technique has been used in our clinic with first-trimester dilation and curettage using mechanical suction. (Fertil SterilÒ Use your smartphone 2014;102:e9–10. Ó2014 by American Society for Reproductive Medicine.) to scan this QR code Key Words: Recurrent pregnancy loss, miscarriage, chromosome analysis, karyotype analysis, and connect to the maternal cell contamination Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/murugappang-miscarriage-tissue-maternal-decidua/
SUGGESTED READING 1.
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Bell KA, Van Deerlin PG, Haddad BR, Feinberg RF. Cytogenetic diagnosis of ‘‘normal 46,XX’’ karyotypes in spontaneous abortions may be misleading. Fertil Steril 1999;71:334–41. Bernardi LA, Plunkett BA, Stephenson MD. Is chromosome testing of the second miscarriage cost saving? A decision analysis of selective versus universal recurrent pregnancy loss evaluation. Fertil Steril 2012;98:156–61. Borrell A, Stergiotou I. Miscarriage in contemporary maternal-fetal medicine: targeting clinical dilemmas. Ultrasound Obstet Gynecol 2013;42:491–7. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Chapter 3: Implantation, embryogenesis, and placental
5.
6.
development. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors. Williams obstetrics. 23rd ed. New York: McGraw-Hill. Available at: http://www.accessmedicine.com.ezp-prod1. hul.harvard.edu/content.aspx?aID¼6030341; 2010. Accessed August 12, 2013. Foyouzi N, Cedars MI, Huddleston HG. Costeffectiveness of cytogenetic evaluation of products of conception in the patient with a second pregnancy loss. Fertil Steril 2012;98:151–5. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, et al. Chapter 6: Surgeries for benign gynecologic conditions. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, et al., editors. Williams gynecology. 2nd ed. New York: McGraw-Hill.
Received March 7, 2014; revised June 29, 2014; accepted July 2, 2014; published online August 20, 2014. G.M. has nothing to disclose. S.G. has nothing to disclose. R.L. has nothing to disclose. Reprint requests: Gayathree Murugappan, M.D., Department of Obstetrics & Gynecology, Stanford Hospital & Clinics, 300 Pasteur Drive, Stanford, California 94305-5317 (E-mail: gm807@ stanford.edu). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.07.006 VOL. 102 NO. 4 / OCTOBER 2014
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discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Available at: http://www.accessmedicine.com. ezp-prod1.hul.harvard.edu/content.aspx?aID¼ 56717599; 2012. Accessed August 12, 2013. Lathi RB, Gray Hazard FK, HeeremaMcKenney A, Taylor J, Chueh JT. First trimester miscarriage evaluation. Semin Reprod Med 2011;29:463–9. Lathi RB, Gustin SL, Keller J, Maisenbacher MK, Sigurjonsson S, Tao R, et al. Reliability of 46,XX results on miscarriage specimens: a review of 1,222 firsttrimester miscarriage specimens. Fertil Steril 2014;101:178–82. Lathi RB, Milki AA. Tissue sampling technique affects accuracy of karyotype from missed abortions. J Assist Reprod Genet 2002;19: 536–8. Marquard K, Westphal LM, Milki AA, Lathi RB. Etiology of recurrent pregnancy loss in women over the age of 35 years. Fertil Steril 2010;94: 1473–7. Mescher AL. Chapter 22: The female reproductive system. In: Mescher AL, editor. Junqueira's basic histology. 13th ed. New York: McGraw-Hill. Available at: http://www. accessmedicine.com.ezp-prod1.hul.harvard. edu/content.aspx?aID¼57333733; 2013. Accessed August 12, 2013.
e9
VIDEO 12.
13.
e10
Qin JZ, Pang LH, Li MQ, Xu J, Zhou X. Risk of chromosomal abnormalities in early spontaneous abortion after assisted reproductive technology: a metaanalysis. PLoS One 2013;8:e75953. Stephenson M, Kutteh W. Evaluation and management of recurrent pregnancy loss. Clin Obstet Gynecol 2007;50:132–45.
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Viaggi CD, Cavani S, Malacarne M, Floriddia F, Zerega G, Baldo C, et al. Firsttrimester euploid miscarriages analysed by array-CGH. J Appl Genet 2013; 54:353–9. Wolf GC, Horger EO 3rd. Indications for examination of spontaneous abortion specimens: a reassessment. Am J Obstet Gynecol 1995;173:1364–8.
VOL. 102 NO. 4 / OCTOBER 2014
Separation of miscarriage tissue from maternal decidua for chromosome analysis Gayathree Murugappan, M.D., Stephanie Gustin, M.D., and Ruth B. Lathi, M.D. Department of Reproductive Endocrinology and Infertility, Stanford Hospital & Clinics, Stanford, California
Objective: To demonstrate a technique for separation of miscarriage tissue from maternal decidua to reduce maternal cell contamination for chromosome analysis. Design: Retrospective. Setting: University-based infertility center. Patient(s): Not applicable. Intervention(s): Retrospective collection of de-identified images and video from manual vacuum aspiration (MVA) performed after firsttrimester pregnancy losses. This project was exempt from institutional review board approval as no patient-identifying data were used. Main Outcome Measure(s): Reduction of maternal cell contamination and improvement of the accuracy of chromosome analysis. Result(s): Video demonstration of separation of miscarriage tissue from maternal decidua after MVA. Conclusion(s): Chromosome analysis of a miscarriage is performed to assess the etiology of miscarriage and recurrent pregnancy loss. However, maternal cell contamination can limit the accuracy. This video demonstrates a technique for separating miscarriage tissue from maternal decidua after MVA to reduce maternal cell contamination prior to sending tissue for analysis. The same technique has been used in our clinic with first-trimester dilation and curettage using mechanical suction. (Fertil SterilÒ Use your smartphone 2014;102:e9–10. Ó2014 by American Society for Reproductive Medicine.) to scan this QR code Key Words: Recurrent pregnancy loss, miscarriage, chromosome analysis, karyotype analysis, and connect to the maternal cell contamination Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/murugappang-miscarriage-tissue-maternal-decidua/
SUGGESTED READING 1.
2.
3.
4.
Bell KA, Van Deerlin PG, Haddad BR, Feinberg RF. Cytogenetic diagnosis of ‘‘normal 46,XX’’ karyotypes in spontaneous abortions may be misleading. Fertil Steril 1999;71:334–41. Bernardi LA, Plunkett BA, Stephenson MD. Is chromosome testing of the second miscarriage cost saving? A decision analysis of selective versus universal recurrent pregnancy loss evaluation. Fertil Steril 2012;98:156–61. Borrell A, Stergiotou I. Miscarriage in contemporary maternal-fetal medicine: targeting clinical dilemmas. Ultrasound Obstet Gynecol 2013;42:491–7. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Chapter 3: Implantation, embryogenesis, and placental
5.
6.
development. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors. Williams obstetrics. 23rd ed. New York: McGraw-Hill. Available at: http://www.accessmedicine.com.ezp-prod1. hul.harvard.edu/content.aspx?aID¼6030341; 2010. Accessed August 12, 2013. Foyouzi N, Cedars MI, Huddleston HG. Costeffectiveness of cytogenetic evaluation of products of conception in the patient with a second pregnancy loss. Fertil Steril 2012;98:151–5. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, et al. Chapter 6: Surgeries for benign gynecologic conditions. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, et al., editors. Williams gynecology. 2nd ed. New York: McGraw-Hill.
Received March 7, 2014; revised June 29, 2014; accepted July 2, 2014; published online August 20, 2014. G.M. has nothing to disclose. S.G. has nothing to disclose. R.L. has nothing to disclose. Reprint requests: Gayathree Murugappan, M.D., Department of Obstetrics & Gynecology, Stanford Hospital & Clinics, 300 Pasteur Drive, Stanford, California 94305-5317 (E-mail: gm807@ stanford.edu). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.07.006 VOL. 102 NO. 4 / OCTOBER 2014
7.
8.
9.
10.
11.
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Available at: http://www.accessmedicine.com. ezp-prod1.hul.harvard.edu/content.aspx?aID¼ 56717599; 2012. Accessed August 12, 2013. Lathi RB, Gray Hazard FK, HeeremaMcKenney A, Taylor J, Chueh JT. First trimester miscarriage evaluation. Semin Reprod Med 2011;29:463–9. Lathi RB, Gustin SL, Keller J, Maisenbacher MK, Sigurjonsson S, Tao R, et al. Reliability of 46,XX results on miscarriage specimens: a review of 1,222 firsttrimester miscarriage specimens. Fertil Steril 2014;101:178–82. Lathi RB, Milki AA. Tissue sampling technique affects accuracy of karyotype from missed abortions. J Assist Reprod Genet 2002;19: 536–8. Marquard K, Westphal LM, Milki AA, Lathi RB. Etiology of recurrent pregnancy loss in women over the age of 35 years. Fertil Steril 2010;94: 1473–7. Mescher AL. Chapter 22: The female reproductive system. In: Mescher AL, editor. Junqueira's basic histology. 13th ed. New York: McGraw-Hill. Available at: http://www. accessmedicine.com.ezp-prod1.hul.harvard. edu/content.aspx?aID¼57333733; 2013. Accessed August 12, 2013.
e9
VIDEO 12.
13.
e10
Qin JZ, Pang LH, Li MQ, Xu J, Zhou X. Risk of chromosomal abnormalities in early spontaneous abortion after assisted reproductive technology: a metaanalysis. PLoS One 2013;8:e75953. Stephenson M, Kutteh W. Evaluation and management of recurrent pregnancy loss. Clin Obstet Gynecol 2007;50:132–45.
14.
15.
Viaggi CD, Cavani S, Malacarne M, Floriddia F, Zerega G, Baldo C, et al. Firsttrimester euploid miscarriages analysed by array-CGH. J Appl Genet 2013; 54:353–9. Wolf GC, Horger EO 3rd. Indications for examination of spontaneous abortion specimens: a reassessment. Am J Obstet Gynecol 1995;173:1364–8.
VOL. 102 NO. 4 / OCTOBER 2014
