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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 37  |  Issue : 1  |  Page : 58-61

Factor V Leiden mutation and acquired activated protein C resistance in Indian women with recurrent fetal loss


1 Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi, India
2 Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, Delhi, India

Date of Submission02-Dec-2019
Date of Decision04-Mar-2020
Date of Acceptance01-Apr-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Dr. Meera Sikka
Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_106_19

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  Abstract 


Objectives: To study the prevalence and association of factor V Leiden (FVL) mutation and acquired APC resistance (APCR) in women with recurrent fetal loss (RFL).
Patients and Methods: Fifty women with two or more RFLs and 50 age-matched controls with no history of fetal loss and at least one live birth were included in the study. Complete blood counts and screening tests for coagulation (PT, APTT), APCR, and FVL (PCR) were done in all women.
Results: Age of the patients ranged from 20–42 years with a mean ± SD of 27.4 ± 4.8 years. Prolonged PT and APTT were observed in 2% and 8% cases, respectively. None of the controls had prolonged PT/APTT. APCR was observed in 8% cases and 2% controls. The prevalence of APCR was higher in women with first-trimester fetal loss (24.2%) as compared to women with the second trimester (13.3%) fetal loss. FVL was not observed in any of the cases or controls.
Conclusion: This study indicates that FVL mutation is not associated with RFL in the Indian population while APCR is observed in Indian women with RFL.

Keywords: Activated protein C resistance; factor V Leiden; recurrent fetal loss; thrombophilia.


How to cite this article:
Sinha P, Sikka M, Sharma S, Guleria K, Gogoi P. Factor V Leiden mutation and acquired activated protein C resistance in Indian women with recurrent fetal loss. Trop J Obstet Gynaecol 2020;37:58-61

How to cite this URL:
Sinha P, Sikka M, Sharma S, Guleria K, Gogoi P. Factor V Leiden mutation and acquired activated protein C resistance in Indian women with recurrent fetal loss. Trop J Obstet Gynaecol [serial online] 2020 [cited 2020 Sep 24];37:58-61. Available from: http://www.tjogonline.com/text.asp?2020/37/1/58/291989




  Introduction Top


Recurrent fetal loss (RFL) is defined as two or more consecutive pregnancy losses. It is a serious problem, affecting 1–5% of women in the reproductive age group with both psychological and social impact.[1],[2] Several etiological factors can cause RFL like chromosomal abnormalities, uterine anatomic malformations, endocrine dysfunction, infections, immunological, and environmental factors. However, in almost 50% of cases, the etiology remains unknown.[3]

Thrombophilia or an increased tendency to develop venous or arterial thrombosis may be inherited or acquired. Activated protein C resistance (APCR) is the most frequent cause of venous thrombosis.[4] In 90% of cases, APCR results from a point mutation at nucleotide position 1691 in the factor V (FV) gene resulting in a replacement of arginine by glutamine and is referred to as FV Leiden (FVL). In the absence of FVL mutation, acquired factors can also cause APCR.[4]

It is now established that thrombophilia increases the risk of first and second-trimester pregnancy loss by causing thrombosis of the placental bed.[5],[6],[7] A meta-analysis revealed that FVL was associated with both early and late recurrent fetal loss.[8] The reported prevalence of thrombophilia in women with RFL is highly variable.[9],[10]

With a high prevalence of APCR in Caucasians, most studies on APCR and RFL have been done in this population. There have been few studies on APCR in Asian women with RFL. The association is virtually unknown in Indians. The identification of these women and their treatment will increase the chance of a subsequent successful pregnancy.[9] The present study assessed the frequency of FVL and acquired APCR in Indian women with RFL.


  Materials and Methods Top


This case-control study was conducted on 50 women with ≥2 RFL. Fifty age-matched controls with no history of fetal loss and at least one live birth were also included. Patients with genital tract malformation, cervical incompetence, leiomyoma, chronic systemic disease, ABO and Rh incompatibility, diabetes mellitus, thyroid dysfunction, and the polycystic ovarian syndrome were excluded from the study. The study received clearance from the institutional ethics committee for human research. All patients gave informed consent before their inclusion in the study. After a detailed history and examination, the following investigations were done in all patients and controls: complete blood counts (automated hematology analyzer LH 500), prothrombin time (PT), activated partial thromboplastin time (APTT), and acquired APCR. Commercially available kits were used for estimation of PT (Thromborel S, Dade Behring USA), APTT (Dade Actin FS, Dade Behring USA), and APCR (clot based kit, Hemosil, Instrumentation Laboratory). FVL mutation was identified by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique after the extraction of DNA using the phenol-chloroform extraction method.

APCR was performed on semi-automated coagulometer START 4. APC sensitivity ratio (APC-SR) was calculated as the ratio of APTT with the addition of APC and APTT without added APC (APTT + APC/APTT-APC). APC-SR less than 1.92 was considered as positive, 1.92–1.99 borderline and more than 2 as negative.

Statistical analysis

Data were analyzed using SPSS software 23. The prevalence of APCR and FVL mutation was expressed as a percentage. A P value < 0.05 was considered significant.


  Results Top


There was no significant difference in the age of patients (27.4 ± 4.8 y) and controls (28.3 ± 4.3 y). Two, three, and >3 pregnancy losses occurred in 32%, 36%, and 32% women, respectively [Figure 1]. The majority (98%) of pregnancy losses occurred in the first/second trimester.
Figure 1: Number of abortion in patients

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Hematological parameters

The hematological parameters of patients and controls are shown in [Table 1]. Hemoglobin was significantly (P < 0.01) lower in patients as compared to controls. Anemia was detected in 11 (22%) patients and 4 (8%) controls, being mild in severity.[11]
Table 1: Complete blood counts of patients and controls

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Screening tests of hemostasis

PT was significantly (P = 0.02) higher in patients (12.5 ± 1.1 s) as compared to controls (12.0 ± 0.9 s). There was no significant difference in the APTT of patients (28.8 ± 3.1 s) and controls (28.1 ± 1.4 s). PT and APTT were prolonged in 1 (2%) and 4 (8%) patients respectively, being normal in all controls.

Acquired APCR and FVL mutation

This was measured using a clot-based assay and a sensitivity ratio was calculated. APC-SR <1.92 was indicative of APCR. Ten (20%) women with RFL and 4 (8%) controls showed acquired APCR. FVL mutation was not identified in any patient/control.

APCR and time of fetal losses

Of the 10 women with APCR; 6 (60%) had 2 abortions, 3 (30%) had 3 abortions, and 1 (10%) had 5 abortions. The majority of the abortions occurred in the first trimester. [Figure 2]
Figure 2: Time of abortion in APCR positive cases

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  Discussion Top


The role of maternal thrombophilias as an etiological factor of RFL has been evaluated in various studies. APCR has been proposed as a cause of placental thrombosis leading to fetal death.[12] This study evaluated FVL mutation and APCR in women with RFL.

Prolonged PT and APTT were observed in 2% and 8% patients, respectively, being normal in all controls. The results in the present study are similar to those observed by Creagh et al. who reported mild prolongation of PT in 2 of 66 women with sustained fetal loss.[13] There was no significant difference in the APTT of patients and controls. In contrast, a previous study done in our institution, observed significantly higher APTT in patients with RFL as compared to controls.[14] However, Abraitis et al. did not find any significant difference in the APTT of patients with RFL and controls.[15]

APCR was observed in 8% of women with RFL and 2% controls. Similar results have been reported by other authors.[16],[17],[18] In a study on 1111 Caucasian women with RFL and 150 controls, APCR was observed in 8.8% cases and 3.3% controls.[17] Al Allawi observed APCR in 9.7% of women with RFL and 1% controls.[18] In contrast, Oner et al. observed a higher prevalence (14%) of APCR in women with RFL.[19] In a previous study on 30 Indian women with RFL and 30 controls, acquired APCR was more frequent in the former (16.6%) as compared to the latter (3.3%). However, the difference was not statistically significant.[16]

In this study, APCR was seen more often in women with first trimester (24.2%) as compared to those with the second trimester (13.3%) fetal losses. There are controversial data on the association of APCR and time of fetal loss. Abraitis et al. observed that APCR was associated with first-trimester RFL.[15] In contrast, other authors have reported a greater association of APCR with second-trimester abortions.[18],[20]

Even though FVL is the most common cause of APCR, the present study did not observe FVL in any patient or control. The low frequency of FVL observed in this study agrees with other studies.[17],[21],[22] Townson et al. did not identify FVL in any of the women with RFL.[22] In contrast, Brenner et al. observed FVL in 19 (48%) patients with at least 3 successive first trimester or 2 successive second-trimester abortions.[23]

The results of this study indicate that FVL is not associated with RFL in Indian women. This may be due to the low prevalence of FVL in India. In an occasional study from India, heterozygosity for FVL was observed in 1/32 (3.1%) subjects from Gujarat and 1/29 (3.4%) Sikhs. Homozygosity was not identified in any of the subjects.[24]

In this study, FVL was not identified in any of the women with acquired APCR. Acquired APCR is reported to be associated with a high concentration of FVIII, antiphospholipid antibodies, pregnancy, and the use of oral contraceptives.[25] None of the women were on oral contraceptives. However, lupus anticoagulant, FVIII concentration, and other antiphospholipid antibodies were not measured in these women.


  Conclusion Top


This study indicates that the frequency of FVL mutation in Indian women with RFL is low. The absence of FVL in the study group may be due to the low prevalence of FVL in India as also the lack of association of FVL with RFL. However, APCR was observed in women with RFL and was more common in women with first-trimester pregnancy loss. Screening for APCR is recommended in women with RFL. This study is limited by the small sample size. Further studies on a larger number of subjects with a long period of follow-up are required in our population to confirm these findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meka A, Reddy BM. Recurrent spontaneous abortions: An overview of genetic and non-genetic backgrounds. Int J Hum Genet 2006;6:109-117.  Back to cited text no. 1
    
2.
Pandey MK, Rani R, Agrawal S. An update in recurrent spontaneous abortion. Arch Gynecol Obstet 2005;272:95-108.  Back to cited text no. 2
    
3.
Alhalaki W, Altanoukhi IA, Alhalabi M. The association of activated protein C resistance Resistance (aPCR) with recurrent pregnancy loss in Syrian population. Int J Pharm Sci Rev Res 2016;38:290-5.  Back to cited text no. 3
    
4.
Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H, et al. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature 1994;369:64-7.  Back to cited text no. 4
    
5.
Kovalevsky G, Gracia CR, Berlin JA, Sammel MD, Barnhart KT. Evaluation of the association between hereditary thrombophilias and recurrent pregnancy loss: A meta analysis. Arch Intern Med 2004;164:558-63.  Back to cited text no. 5
    
6.
Robertson L, Wu O, Langhorne P, Twaddle S, Clark P, Lowe GD, et al. Thrombosis: Risk and economic assessment of thrombophilia screening (TREATS) study: Thrombophilia in pregnancy: A systematic review. Br J Haematol 2006;132:171-96.  Back to cited text no. 6
    
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Micco PD, Uva MD. Recurrent pregnancy loss and thrombophilia. Open Atheroscler Thromb J 2009;2:33-5.  Back to cited text no. 7
    
8.
Rey E, Kahn S, David M, Shrier I. Thrombophilic disorders and fetal loss: A meta-analysis. Lancet 2003;361:901-8.  Back to cited text no. 8
    
9.
D'Uva M, Di Micco P, Strina I, Ranieri A, Alviggi C, Mollo A, et al. Etiology of hypercoagulable state in women with recurrent fetal loss without other causes of miscarriage from Southern Italy: New clinical target for antithrombotic therapy. Biologics 2008;2:897-902.  Back to cited text no. 9
    
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Nahas R, Saliba W, Elias A, Elias M. The prevalence of thrombophilia in women with recurrent fetal loss and outcome of anticoagulation therapy for the prevention of miscarriages. Clin Appl Thromb Hemost 2018;24:122-8.  Back to cited text no. 10
    
11.
De Maeyer EM, Adiels-Tegman M. The prevalence of anemia in the world. World Health Stat Q 1985;38:302-6.  Back to cited text no. 11
    
12.
Dahlback B. Physiological anticoagulation, resistance to activated protein C and venous thromboembolism. J Clin Invest 1994;94:923-7.  Back to cited text no. 12
    
13.
Creagh MD, Malia RG, Cooper SM, Smith AR, Duncan SL, Greaves M. Screening for lupus anticoagulant and anticardiolipin antibodies in women with fetal loss. J Clin Pathol 1991;44:45-57.  Back to cited text no. 13
    
14.
Rawat A, Sikka M, Rusia U, Guleria K. Lupus anticoagulants and anticardolipin antibodies in Indian women with spontaneous, recurrent fetal loss. Indian J Hematol Blood Transfus 2015;31:281-5.  Back to cited text no. 14
    
15.
Abraitis V, Simoliuniene R, Mongirdienė A, Makari S. Prevalence of activated protein C resistance among women with recurrent miscarriage. Medicina 2004;40:225-31.  Back to cited text no. 15
    
16.
Jyotsna LP, Sharma S, Trivedi SS. Coagulation inhibitors and activated protein C resistance in recurrent pregnancy losses in Indian women. Indian J Pathol Microbiol 2011;54:752-5.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Rai R, Shlebak A, Cohen H, Backos M, Holmes Z, Marriott K, et al. Factor V leiden and acquired activated protein C resistance among 1000 women with recurrent miscarriage. Hum Reprod 2001;16:961-5.  Back to cited text no. 17
    
18.
Al Allawi NAS, Shamdeen MY, Mohammed QO, Ahmed AS. Activated protein c resistance and antiphospholipid antibodies in recurrent fetal loss: Experience of a single referral center in Northern Iraq. Indian J Hematol Blood Transfus 2014;30:364-9.  Back to cited text no. 18
    
19.
Oner G, Muderris II, Saatci C. Activated protein C resistance, endogenous anticoagulants and coagulation parameters in recurrent pregnancy loss. J Turk Soc Obstet Gynecol 2011;8:244-8.  Back to cited text no. 19
    
20.
Rai R, Regan L, Hadley E, Dave M, Cohen H. Second trimester pregnancy loss is associated with activated protein C resistance. Br J Hematol 1996;92:489-90.  Back to cited text no. 20
    
21.
Cardona H, Castañeda SA, Cardona Maya W, Alvarez L, Gómez J, Gómez J, et al. Lack of association between recurrent pregnancy loss and inherited thrombophilia in a group of Colombian patients. Thrombosis 2012;2012:367823.  Back to cited text no. 21
    
22.
Townson DS, Kinney S, Branch DW, Ward K. The factor V Leiden mutation is not a common cause of recurrent miscarriage. J Reprod Immunol 1997;34:217-3.  Back to cited text no. 22
    
23.
Brenner B, Mandel H, Lanir N, Younis J, Rothbart H, Ohel G, et al. Activated protein C resistance can be associated with recurrent fetal loss. Br J Hematol 1997;97:551-4.  Back to cited text no. 23
    
24.
Rees DC, Cox M, Clegg JB. World distribution of factor V leiden. Lancet 1995;346:1133-4.  Back to cited text no. 24
    
25.
Kujovich JL. Factor V leiden thrombophilia. Genet Med 2011;13:1-16.  Back to cited text no. 25
    


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