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Sigma Pi Sigma induction
The Department of Physics at the University of Notre Dame inducted 10 undergraduate physics majors and 4 physics professors into Sigma Pi Sigma on Friday, April 13. Professor Peter Garnavich, faculty advisor of the Society of Physics Students, and Professor Mitchell Wayne, Department Chair, presented the inductees with their honor cords.
Sigma Pi Sigma is the official honor society of the physics profession. Through election to Sigma Pi Sigma, distinctive achievement and high scholarship in physics is recognized and celebrated.
Students inducted were: Adam Alongi, Matthew Anthony, Christopher Bell, Jeffery Berryman, Julie Cass, Thomas Catanach, Santina Consiglio, Alex Kocurek, Guiseppe Passucci, and Nancy Paul. Professors inducted were Ani Aprahamian, Morten Eskildsen, Christopher Howk, and Christopher Kolda.
More on Sigma Pi Sigma
Sigma Pi Sigma exists to honor outstanding scholarship in physics; to encourage interest in physics among students at all levels; to promote an attitude of service of its members towards their fellow students, colleagues, and the public; to provide a fellowship of persons who have excelled in physics. Sigma Pi Sigma's mission is not completed in the induction ceremony with the recognition of academic accomplishment. In the four dimensions of Honor, Encouragement, Service, and Fellowship, the mission of Sigma Pi Sigma takes a longer view.
Founded in 1921, Sigma Pi Sigma is a member honor society of the Association of College Honor Societies. Our society has some 75,000 historical members. Election to Sigma Pi Sigma is a lifetime membership.
The Society of Physics Students (SPS) was formed in 1968 with the union of Sigma Pi Sigma and the AIP Student Sections. Today Sigma Pi Sigma is housed within the SPS.

redpajama_set_name: RedPajamaCommonCrawl


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New CDC Social Distancing Guideline Recommends Remaining One "Hunky Gaston Bicep" Apart at All Times
WASHINGTON D. C. - The Center for Disease Control issued a new guideline this morning recommending that, instead of remaining six feet apart from one another at all times, citizens should now remain at least one big, hunky Gaston bicep apart instead, the organization confirmed.
"Germs can spread via cough, sneeze or spit very easily," noted CDC researcher Frances Bellwill. "We've come to realize that 'six feet' may be confusing, so you all may now use a measurement that's a little easier to maneuver: Just one of Gaston's huge, bumpy, brawny arm muscles is enough distance to keep everyone safe. And it should be easy, because as you see, he's got biceps to spare," she added before pointing to a chart featuring multiple photos of the cartoon Frenchman flexing.
National Institute of Allergy and Infectious Disease director Anthony Fauci also shared the pressing new advice.
"Oh yeah, one of those thick, rippling masses is definitely enough," noted the revered physician. "It's the perfect measurement. In fact, once this is over, they might have to change the song lyrics. 'No one's slick as Gaston, no one's quick as Gaston, no one's neck's as incredibly thick as Gaston' - and nobody protects against highly contagious, droplet-transferred diseases like Gaston."
Some locals are already abiding by the guideline.
"I was in the store today, and some people were just getting too close for comfort," noted local man Chris Tanno. "So, naturally, I started chanting 'Give five hurrahs, give twelve hip-hips, Gaston is the best, and the rest is all drips' and they got the message. I think using Gaston's monstrous, quivering, pure concrete arm stones is gonna really make everyone feel a lot more comfortable.
At press time, the CDC was looking to issue other Disney-inspired guidelines, such as washing your apples to make sure they're not "poison", and avoiding sea witches who may want to steal your voice - not specifically due to fear of coronavirus, but just in general, cause that's fucked up.


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BREAKING SILENCE
BREAKING SILENCE is a verité family portrait that follows father and daughter Walker and Leslie Estes as they build new bonds through their experiences in the criminal justice system. Walker, a deaf activist, shares how his daughter's incarceration and his past regrets inspired him to begin advocacy work within the prison system, and Leslie, a formerly incarcerated CODA, shares how imprisonment and re-entry have reshaped her relationship with her family and her own advocacy journey.
During Leslie's imprisonment, Walker found it so difficult to communicate with his daughter during his visits—he communicates through ASL and the guards required Walker to pick up the phone and speak through the glass—that he began volunteering at Angola State Prison, as well as teaching sign language at men's and women's prisons in Louisiana. In the film, we visit with some of the current and formerly incarcerated men Walker assists, and we see Leslie and her father's bond strengthen as she finds her way back home and they become more comfortable talking about the traumas and regrets that led to her incarceration.
Through personal interviews, we explore their memories of Leslie's childhood, the experience of being a hearing-abled child with deaf parents, and the traumas that Leslie experienced in adolescence triggering her cycle of incarceration. The film is narrated by Walker and Leslie in both spoken voice-over and sign language, and we center the film around Leslie's enduring relationship with her father—throughout the film we see the supportive and steadfast role that Leslie's father plays in her re-entry.
The film's style, approach, and tone take cues from the recent short films ALONE by Garrett Bradley, LOVE SONG FOR LATASHA by Sophia Naihla Allison, and NO CRYING AT THE DINNER TABLE by Carol Nguyen. BREAKING SILENCE is an intimate story of one family healing wounds and helping others through the lens of incarceration and deafness.
BREAKING SILENCE is a fiscally sponsored project of the Austin Film Society. You can make a donation to this project here. You will receive a letter acknowledging your gift to the Austin Film Society on behalf of the project. Since AFS is a non-profit organization, your donation may be deducted from your taxes as a charitable contribution under section 501(c)(3) of the Internal Revenue Service code.
ABOUT THE FILMMAKERS
Amy Bench (Co-Director, Producer) is a filmmaker and visual artist who is drawn to the immediacy of film and photography to tell stories of community and resilience. Trained as a cinematographer, her observational style highlights small details of the human experience that transcend formal explanation. Amy's animated documentary A LINE BIRDS CANNOT SEE (2019) won Special Jury Recognition at SXSW, Best Animated Short at Bend Film Festival, Best Doc Short at Oak Cliff Film Festival, and is now available on The New Yorker, where it was nominated for the 2020 Ellie Award (video) for excellence in digital magazine journalism. Her next film in the series, MORE THAN I WANT TO REMEMBER (2022) has won 4 Oscar-qualifying awards in 2022 (Tribeca, Hot Docs, Cleveland, and deadCENTER) and is being distributed by MTV Documentary Films for release on Paramount Plus in Fall 2022.
Annie Silverstein (Co-Director) is a filmmaker and educator based in Austin. Her short film, SKUNK, won the Cinéfondation jury award at the Cannes Film Festival in 2014. Silverstein's feature debut, BULL, was selected for the Sundance Screenwriter and Director's Labs in 2016, and premiered in Un Certain Regard at Cannes in 2019. BULL went on to receive awards internationally, including 3 Independent Spirit Award nominations in 2021. Silverstein's documentary work has screened on PBS Independent Lens and at festivals internationally, including SXSW and Silverdocs. Silverstein earned her MFA at University of Texas at Austin in 2010, and currently is a professor at Texas State University.
« A STRIKE AND AN UPRISING


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About Dr. Kedar Ganla
Our Team at Ankoor Fertility Clinic
Press Release & Publications About Ankoor Fertility Clinic
Get Diagnosed
Determining Ovulation
Detect Abnormalities
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Pregnancy & Aftercare
Antenatal Care – During Pregnancy
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IVF & IUI Success Stories – Patient's Video Testimonials
Recurrent Pregnancy Loss / Recurrent Miscarriages / Recurrent Abortions
Miscarriage is one of the most devastating experiences that can happen to a woman. Having one miscarriage is sadly, not that uncommon. Approximately two out of every ten pregnancies will result in miscarriage. After having one miscarriage most women go on to have a healthy pregnancy.
Still there are a few women that will continue to have two, three or more miscarriages. Women are considered to have recurrent miscarriages when they have two or more miscarriages in a row. According to the American Society for Reproductive Medicine, only about one percent of women will have three consecutive miscarriages or more.
It is a vexing clinical problem and the cause is often unexplained. The treatment options are variable, ranging from masterly inactivity to aggressive management. The psychological implications of Recurrent pregnancy loss or abortions are tremendous. A multidisciplinary approach, involving gynecology, genetics, endocrinology, immunology is mostly required.
What do you mean by recurrent pregnancy loss (RPL)?
Pregnancy loss is synonymous with miscarriage or abortion. A miscarriage/abortion is a pregnancy that ends before 20 weeks from last menstrual period. A recurrent miscarriage is 2 or more consecutive, spontaneous pregnancy losses, under 20 weeks of gestation from the last menstrual period (WHO1977).
Primary recurrent pregnancy loss refers to couples that have never had a live birth Secondary recurrent miscarriage is the loss of at least three pregnancies to miscarriage following one successful pregnancy.
Pregnancy losses at higher gestations are called as Stillbirths or preterm neonatal deaths. However, pregnancy losses after week 20 are rare.
What is the incidence of recurrent pregnancy loss?
Miscarriage in early pregnancy is common. Studies show that about 8 to 20 percent of women who know they are pregnant have a miscarriage some time before 20 weeks of pregnancy, 80 percent of these occur in the first 12 weeks. But the actual rate of miscarriage is even higher since many women have very early miscarriages without ever realizing that they are pregnant.
According to some studies the rate of sporadic miscarriages is 12 -15% clinically and subclinical around 60-70%. 1% of couples trying to conceive have recurrent miscarriage.
The chance of having a second spontaneous abortion with a history of only one isolated spontaneous abortion is 15-20% (for clinically recognized pregnancy). If there have been 2 spontaneous consecutive abortions, there is about a 35% chance (1 in 3) that the next pregnancy will be lost. Therefore, the loss rate is almost doubled. If there have been 3 spontaneous abortions in a row, there is a 45-50% chance that the next pregnancy will be lost. There are reports indicating improvement in future pregnancy success for couples with recurrent pregnancy loss after there has been at least one prior live born for the couple. Therefore, the couple's prior reproductive history is also important.
Classification of RPL / repeated abortions
Table showing risk of repeat loss after a miscarriage
What are the possible causes of recurrent miscarriage?
Causes of RPL /Repeated miscarriages / abortions
In almost 50% of the cases no cause is found (Idiopathic). Some of the other common causes are as discussed below.
Some of the common causes of repeated abortions are as follows:
Genetic abnormalities:
Fetal genetic abnormality (trisomy in particular) is the most common cause of miscarriage before 10 weeks of gestation.
Antiphospholipid syndrome (APS):
This is the most important treatable cause of recurrent miscarriage.
This is a group of autoimmune disorders wherein the women's body rejects the fetus leading to abortion.
Antiphospholipid antibodies are a family of about 20 antibodies, which include lupus anticoagulant and anticardiolipin antibodies.
The prevalence of APS in women with recurrent miscarriage is between 5-15%.
Structural:
Uterine anomalies (arcuate or septate) are seen in between 10-25% of cases of recurrent miscarriage. Only 50% of pregnancies where there is a uterine structural abnormality achieve term delivery.
Uterine fibroids are present in up to 30% of women, but the way they affect reproductive loss is unclear.
Cervical incompetence where there is inherent weakness of the cervix or the mouth of uterus may lead to miscarraige after 13 weeks of pregnancy. These are usually painless. This is frequently cited as a cause of midtrimester recurrent miscarriage.
Infective:
Toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus (ToRCH) and listeriosis screening has been abandoned when investigating recurrent miscarriage. Still may gynaecologist believe in doing these tests on a routine basis.
As per WHO (World Health Organisation) there is no role of ToRCH test in current pregnancy. There is importance of only recent infections which can be diagnosed by using IgM testing. If there is recent infection, pregnancy has to be avoided during that time. In case of old infections, IgG will be positive, which shows that the woman had the infection some time back and now has antibodies against that infection. Nothing has to be done in such cases. This has no implication in current or future pregnancy.
There is poor evidence for bacterial vaginosis as a cause of early miscarriage secondary to endometritis.
Endocrine:
The relationship between polycystic ovarian syndrome, insulin resistance and pregnancy loss is now thought to be key.
Luteal phase defect where there is inadequacy of hormones needed to support pregnancy after conception is also an important cause.
Insulin resistance is common in women with recurrent miscarriage and has been associated with an increased rate of miscarriage.
Thyroid disorders and diabetes are also related with increased incidence of miscarriage.
Thrombophilias:
These are clotting disorders wherein deficiency of one of the clotting factors leads to abortion because of irregular blood supply to the uterus.
Three thrombophilic mutations were first identified in the mid-1990s: factor V Leiden (FVL) G1691A; factor II (prothrombin) G20210A and methylenetetrahydrofolate reductase (MTHFR) C677T.
However, women with the FVL mutation can have an uncomplicated full-term pregnancy, but multiple risk factors increase the likelihood of adverse pregnancy outcomes.
Excessive smoking or alcohol consumption, also exposure to chemicals like pesticides can also be related to abortion.
Unknown or idiopathic:
About in 50 % of cases the cause may not be found at all. And this is most difficult to manage.
Can one predict the cause of RPL depending upon the week of gestation?
Yes, sometimes the period of gestation at which the previous miscarriage or abortion occurred points to the cause of abortion. This is summarized below.
How is an early pregnancy diagnosed?
Diagnosis of an early pregnancy is done using:
Clinical history and examination
Transvaginal sonography &
Serum β HCG levels
On transvaginal ultrasonography the presence of Gestational sac is an early marker of pregnancy. It is the 1st definitive finding. It is a small round fluid collection with hyperechogenic rim. The mean sac diameter (MSD) and its position in the mid to upper uterus is important.
Yolk sac is the first anatomic structure within G sac. It is seen when mean sac diameter, MSD is 5-6 mm and always when MSD is over 8 mm. It confirms intrauterine location of the pregnancy. The diameter increases steadily till it detaches itself from embryo and is no longer seen by end of first trimester.
USG of early pregnancy showing Yolk sac
Some of the common sonographic features of early pregnancy loss are:
Large yolk sac
Small gestational sac and Subchorionic haematoma
Early pregnancy with yolk sac and subchrionic bleed
What is the role of Serum Beta HCG levels?
Serum Beta HCG levels and USG are complementary. G sac growth and HCG production are relate to trophoblastic function. There is an excellent correlation between sac size and HCG level.
If HCG > 1000 IU/ml, then an intrauterine gestational sac should be seen on TVS. The HCG levels double every 2 days below 1200 IU/ml and every 3 days below 6000IU/ml.
As the embryo grows on USG there is thickening along the periphery of yolk sac.
The Mean Sac Diameter, MSD is around 5 to 12 mm at 5 to 6 weeks of gestation.
The fetal cardiac activity may be appreciated once the embryo attains a length of 4 to 5 mm and Gestational Age (GA) of 6 to 6.5 weeks. The MSD now reaches about 13 to 18 mm and FHR 100 to 115 beats/min before 6 weeks which further increases to 144 to 170 at 8 weeks and 137 to 144 after 9 weeks.
During the embryonic period (Weeks 6 to 10) , the Crown Rump Length (CRL) increases by approx 1 mm/day. The Ventral folding of cranial and caudal ends of embryo are formed and the limb buds begin to grow around 7-8 weeks.
Absent intrauterine sac on USG suggests either there is no pregnancy OR Very early (normal or abnormal) intrauterine pregnancy OR Ectopic pregnancy (extra uterine pregnancy). In such cases a serum β HCG correlation is required.
What is blighted ovum or anembryonic pregnancy?
Anembryonic pregnancy occurs when there is developmental arrest before formation of embryo or before detection of embryo. In such cases the trophoblastic tissue continues to function. In some cases there may be continued sac growth at lower growth rate.
When the G. Sac is more than 8 mm with no yolk sac, the diagnosis is Blighted ovum.
USG image of Blighted ovum with no yolk sac
If the G sac is more than 16mm with no embryo, then the diagnosis is Blighted ovum.
USG image of Blighted ovum with yolk sac but no embryo / fetal pole
What if the cardiac activity is absent on USG?
If there is no cardiac on USG and G sac diameter is 9mm on TAS or 4-5 mm on TVS, an embryonic demise is suspected. A second opinion may be required in such cases. Chromosome abnormality may be present in the fetus.
It is seen that, if cardiac activity is present, risk of subsequent fetal loss is < 5%.
If on TVS, the Mean sac diameter > 20 mm with no fetal pole then an ANEMBRYONIC GESTATION should be suspected.
If the Crown Rump Length (CRL) is more than 6mm with no cardiac activity then an EMBRYONIC DEMISE should be suspected.
If on USG the embryo is more than 5 mm with no cardiac activity, then EMBRYONIC DEMISE should be suspected.
Etiology of RPL / recurrent miscarriages / recurrent abortions:
Ankoor fertility clinic recommendations:
If there is history of repeated first trimester abortions (early pregnancy, generally less than 8-10 weeks), with no cardiac activity detected on USG, then the most likely cause of miscarriages or abortions is Chromosomal / Genetic.
In such cases a detailed history of the couple is taken followed by karyotyping of the couple if required. Further management depends on that.
Does a woman's age play a role in recurrent abortion?
The spontaneous abortion rate rises as the woman's age increases, with a gradual increase starting about age 30, more rapid increases after age 35, and much more rapid increases after age 40. As a woman ages, the number of her eggs decreases, and the remaining eggs are more likely to have chromosomal errors. The most common abnormalities are Autosomal trisomies (13,16,18,21) in 50-60%, Monosomy X-20%,Triploidy–15% and Tetraploidy-5%.
When women over 40 or 45 years age are recipients of donor eggs from younger women they do not have this increased spontaneous abortion rate. This suggests that the cause of this increase in loss rate is related to egg rather than uterine factors. However, age can also negatively affect the uterine lining, which needs to be healthy in order to maintain a pregnancy.
As the number of miscarriages increase, aneuploidy plays a decreasing role and maternal factors an increasing role.
25-32% of cases are due to Fetal chromosomal abnormality (Hence the need for karyotype analysis of the products of conception). This may be due to abnormalities in the egg, sperm or both. The most common chromosomal defects are Trisomy, Monosomy, Polyploidy.
Is advanced paternal age a risk factor?
Recently, advanced paternal age was identified as a risk factor for miscarriage. A large multicenter European study reported that the risk of miscarriage is highest for couples in which the woman is 35 years or older and the man is 40 years or older.
Sperm aneuploidy (13,18,21,X,Y ) directly influences the rate of aneuploidy in the conceptus (Carrellet al 2003).
Parental chromosomal abnormality (Balanced chromosomal rearrangements) are seen in 0.2 % of the general population & 4% in couples with recurrent miscarriages.3-5% of couples with RSA are carriers of balanced chromosomal rearrangements
What are the common Parental Chromosomal Abnormalities ?
Translocation is the commonest abnormality (1 in 500).
It is exchange of chromosomal segments between two, non-homologous chromosome. It is most common at 13,14,15,21,22. Women are more likely to be affected than Men.
a & b : . Picture showing translocation of chromosomes
There may be a Reciprocal (Two non-homologous chromosomes exchange information) [65%] Or Robertsonian (Two non-homologous acrocentric chromosomes break at the centromere and the long arms fuse. The short arms are often lost) [35%] translocation.
Other chromosomal errors are Mosaicism for a numeric aberration [12%] and Inversion.
What happens due to Reciprocal translocation?
Two non homologous chromosomes exchange information. If no genes are broken, no gain or loss of genetic information (normal phenotype) – individuals are translocation carriers t(11,22)
If one of the breaks occurs in a gene -gene can be disrupted (abnormal phenotype )
A & B. Reciprocal ranslocation
What is Robertsonian translocation?
The incidence of Robertsonian translocation is 1:1000. It occurs with acrocentric chromosomes. This produces one new large chromosome made from the two long arms of two different chromosomes. Two short arms of each chromosome are lost
For example –Down syndrome. Commonest is rob t(13,14)
Risk of Phenotypically abnormal offspring is 1%. The risk of recurrent miscarriages / abortions /RPL is up to 30%.
A& B Robertsonian translocation
Are any life style factors related to recurrent abortions/ miscarriages?
Yes. Studies have shown that certain lifestyle factors are associated with recurrent miscarriages like :
Obesity -PCOS
Caffeine consumption
Smoking –Aggravates thrombophilic factors
What is meant by genetic/chromosomal cause of miscarriage?
Up to 70% of miscarriages are caused by chromosomal errors. Chromosomal abnormalities are more common in women who are over 35. In most cases chromosomal defects are a random occurrence and are not likely to reoccur in subsequent pregnancies. Although chromosomal errors are the cause of the majority of miscarriages, they are not usually caused by an inherited trait from mother or father. Which means that both eggs and the sperms are normal but the embryo formed may be genetically abnormal.
Less than five percent of couples tested will have an inherited genetic cause of such chromosomal defects. Which means that either of the parents are having some genetic defect which is transmitted to the fetus making it genetically unstable liable to pregnancy loss. Sometimes, recurrent miscarriages do have a chromosomal cause. Women (and men) older than 35 have a greater tendency to produce eggs or sperm with chromosomal abnormalities.
In few cases, one or both partners may have a balanced translocation or other silent chromosomal abnormality that gives the couple a statistically increased odds of miscarriage in each pregnancy.
Ankoor clinic recommendations for genetic testing or evaluation :
If there is a history of RPL, clotting disorder , still birth/neonatal death, babies with dysmorphic features, mental retardation /developmental delay in previous baby, or other history of inherited disorder a genetic evaluation & testing is recommended.
How is genetic testing done?
Research suggests that after a couple has had 2 or more unexplained miscarriages, there is a 2-5% risk that one member of the couple is a carrier of a balanced chromosome rearrangement.
Chromosomal analysis of the products of conception (the miscarried fetal tissue) and of the woman and her husband (blood test) may provide additional important information that will affect future reproductive decisions and additional testing recommendations.
The "largest single class" of fetal chromosomal abnormality found in spontaneous abortions are the autosomal trisomies (roughly 50% of abnormal specimens), some of which reveal a maternal age effect. Monosomy X is the "single most common" chromosomal abnormality found in spontaneous abortions (roughly 25% of abnormal specimens), which usually occurs due to a loss of the paternal sex chromosome (Y chromosome) and is not more common with advancing maternal age.
Certain chromosomal abnormalities are universally accepted by infertility specialists as a cause for recurrent pregnancy loss. Fortunately, these major chromosomal abnormalities are uncommon. They may occur within either the maternal or paternal chromosomes. The overall incidence of chromosomal abnormality as the cause of recurrent pregnancy loss is low (less than 5% of couples with recurrent losses).
What are the common Single Gene Disorders in RPL?
These may lead to 2nd and 3rdtrimester losses. Common causes are Alpha Thalassemia, Myotonic dystrophy, X linked Dominant disorders, Incontinentia Pigmenti,Chondrodysplasia punctata, Focal dermal hypoplasia of Goltz, Rett Syndrome and Aicardi Syndrome.
The woman may give a history of previous child with blood abnormalities leading to repeated transfusions. This clue may be pointing towards thalasemia in the baby. In such cases genetic testing will help us to know whether one or both the parents are carriers of the gene. This will help us in planning the modality of treatment for the next baby.
What if a genetic abnormality is found?
If an abnormality is identified, prompt consultation with an experienced human geneticist is indicated since the theories and actual experiences in this field are complex and constantly changing. Preconception counselling and planning with respect to prenatal diagnosis is also important. Unfortunately, there is no available treatment to "fix abnormal chromosomes" at this time.
To increase the likelihood of subsequent successful pregnancy, preimplantation genetic screening of biopsied blastomeres during IVF has been recommended in order to prevent the transfer of karyotypically abnormal embryos in couples with normal karyotypes. Donor gamete can be used if any one of parent is chromosomally abnormal with the help of IUI or IVF.
Ankoor clinic recommendations :
If there is history of repeated late first trimester or second trimester abortions (12 to 24 weeks), with cardiac activity detected on USG, then painless abortion follows, the most common cause is an anatomical defect like cervical incompetence or uterine defects (septum etc). In such cases simple investigations, like discussed below, can diagnose the condition.
For eg.
USG for cervical length and internal os diameter or uterine malformations.
HSG (Hysterosalphinography) can also diagnose these uterine anomalies.
Hysteroscopy can help to diagnose as well as treat the condition.
If there is cervical incompetence ie. Weakness of cervix, then a simple stitch taken over the cervix (mouth of the uterus) will be needed.
Uterine abnormalities can mostly be corrected during operative hysteroscopy.
What are the anatomical factors associated with RPL?
Uterine abnormalities:
Uterine abnormalities account for ten to fifteen percent of repeated miscarriages. Some women are born with a double uterus or an abnormally shaped uterus. Uterus abnormalities may cause problems with proper implantation, create problems with blood supply to the uterus, or there may not be room for the baby to develop and grow.
Sometimes, something is physically different about a woman's uterus in a way that reduces her chances of a successful pregnancy. This might mean her uterine shape is abnormal or her cervix is weakened in a way that reduces her odds of a successful pregnancy. Multiple intramural and submucosal fibroids are associated with an increased risk of pregnancies ending in miscarriage.
Anatomical factors that may cause recurrent miscarriages include:
Uterine septum (or other congenital problems)
Cervical insufficiency
Fibroids (submucosal)
Uterine scarring (Post surgery or infection)
Incidence of Uterine anomalies leading to RPL:
General population 6.3%
Infertile women 7.6%
Women with recurrent miscarriages 16.1%
Most common anomaly is a septate or subseptate uterus. Other common conditions are T-shaped uterus, fibroids, intrauterine adhesions.
Incompetent Cervix:
Incompetent cervix may cause second trimester miscarriages (between 12-24 weeks of pregnancy) or premature labor.
Usually associated painless cervical dilation and usually requires emergency cervical cerclage operation.
There are certain uterine abnormalities like septate or bicornuate uterus associated with cervical weakness which is congenital.
There are certain uterine surgeries like recurrent curettages or removal of cervical fibroid which can traumatize the cervix and lead to weakness.
Incompetent (or weakened) cervix may require a surgical procedure called cerclage. Cerclage is a surgical stitch placed around the cervix at around 14-18 weeks of pregnancy to help keep it from dilating prematurely.
If there is a history of painless abortion in the late first or second trimester, it can be due to cervical incompetence. Sometimes these women give history of preterm vaginal deliveries or history of cervical stitch been taken in the previous pregnancy. This also points to cervical incompetence.
These abortions can be prevented by taking a simple stitch over the mouth of the uterus (cervix). This helps us to continue the pregnancy till term and avoid miscarriages.
How do anatomical causes lead to RPL?
Smaller uterine cavities have fewer suitable implantation sites. They also have aberrations of vascularisation. Sometimes they may be accompanied by cervical incompetence. This leads to both early & later pregnancy losses.
How do you evaluate the Uterine Cavity abnormalities?
Transvaginal ultrasound can only diagnose a few of the important uterine anomalies, and frequently further testing is required. It is sometimes possible to see abnormalities inside the uterus at the time of a scan, especially a vaginal scan. A scan will also enable the ovaries to be examined at the same time. Occasionally polycystic ovaries are diagnosed by ultrasound scan.
USG images of Uterine cavity malformations
Testing the uterine cavity can be done with a hysteroscope, a small camera place into the uterine cavity through the cervix.
Other testing such as hysterosalpingogram (HSG), saline infused sonogram or MRI can also be used.
The routine use of hysterosalpingography as a screening test for uterine anomalies in women with recurrent miscarriage is questionable.
It is associated with patient discomfort, carries a risk of pelvic infection and radiation exposure and is no more sensitive than the non-invasive two dimensional pelvic ultrasound assessment of the uterine cavity with (or without) Sonohysterography when performed by skilled and experienced personnel.
HSG images of uterine malformations and abnormalities
Saline installation sonography (SIS)
A small plastic tube is passed through the cervix and a water-like solution injected through it.
The scan can determine whether there is any abnormality inside the uterus.
Three-dimensional ultrasound
The diagnostic value of three-dimensional ultrasound has been explored and appears promising.
Since three-dimensional ultrasound offer both diagnosis and classification of uterine malformation its use may obviate the need for diagnostic hysteroscopy and laparoscopy.
This investigation, performed under general anesthesia, examines the inside of the uterus with a thin telescope (3-5 mm in diameter).
By inserting this telescope through the cervix and into the uterus, the doctor can see the shape of the uterus and examine its lining.
Hysteroscopic pictures of Uterine malformations and abnormalities
During hysteroscopy, if there is a uterine septum or polyp which may be the cause of repeated abortions, then these too can be removed hysteroscopically.
Classification of Mullerian Anomalies
What is the treatment of Uterine Anomalies?
Most experts recommend hysteroscopic resection of a uterine septum in women with recurrent miscarriage; since most women with bicornuate or unicornuate uteruses have good obstetrical outcomes, and surgical repair of these abnormalities is more invasive than septum resection and associated with a higher risk of complications, repair of these abnormalities is not generally advised.
The benefits of myomectomy are uncertain and supported only by reports of better outcomes after surgery than before surgery. More extensive surgery to remove uterine myomas involving laparoscopy or laparotomy poses hazards for subsequent pregnancies (e.g., a risk of uterine rupture), and its effect on the likelihood of subsequent miscarriage is uncertain.
Hormonal / Endocrinological causes:
Ankoor clinic recommendations:
When the age of the couple is more than 35 years, testing for blood sugars is generally recommended as they have a tendency for increased sugars. Diabetes can be associated with infertility as well as repeated miscarriages as the increased sugar levels affect the egg and sperm quality.
Woman with history of thyroid disorders need to take their medications regularly to avoid miscarriages.
What are the hormonal /endocrine causes of RPL?
A multitude of endocrinological events aid in the implantation & successful growth and development of the fetus. A small number do have certain endocrine alterations that could potentially lead to RPL.
8 to 12% of all RPL are due to endocrine factors.
Common endocrine factors are :
Diabetes – Poorly controlled Type 1 Diabetes has been associated with miscarriage. Improving blood sugars before conception will improve the outcome during pregnancy.
Hyper secretion of LH (PCOS)
Do I have a high risk of miscarriage if I have PCOS?
PCOS has been linked to miscarriage. Women with PCOS have higher levels of male hormones. This has been associated with infertility as well as miscarriage. Insulin resistance is common in women with RPL, and has been associated with an increased rate of miscarriage. Hyperinsulinemia is associated with impairment of the fibrinolytic response, which is important in the tissue remodeling that accompanies embryonic implantation. Over a third of all women who have recurrent miscarriage also have PCOS.
Treatment of PCOS often involves weight loss, insulin-sensitizing medications and ovulation induction. This treatment combination reduces the risk of miscarraige considerably.
How do you evaluate endocrine disorders?
The minimum workup includes a complete medical, surgical, genetic, and family history followed by physical examination.
On General physical examination look for signs of endocrinopathy (hirsutism, galactorrhea, thyroid), PCOS (hirsutism, hyperandrogenemia, obesity) and Syndrome X (obesity, hypertension, impaired GTT, hyperinsulinemia, hypertriglyceridemia.
Most cases can be evaluated with simple blood tests and treated if present.
The recommended hormonal testing will depend up on the symptoms experienced, but may include thyroid, prolactin, follicle stimulating hormone, fasting glucose and insulin levels.
Because measuring TSH is a sensitive and inexpensive tool to assess thyroid function, it should be considered in the evaluation of RPL for women with any signs or symptoms of thyroid dysfunction
Other testing that might be indicated based on the patient's presentation include insulin resistance testing, ovarian reserve testing and antithyroid antibody testing
Common investigations in cases of RPL
How does Type 1 Diabetes Mellitus (T1DM) lead to RPL?
Type 1 Diabetes Mellitus (T1DM), is a T-cell mediated autoimmune disease which results in destruction of insulin-producing βcells. There is increased risk of Autoimmune Polyglandular Syndromes (autoimmune thyroid disease, celiac disease, gastritis, Addison's Disease and vitiligo). 15 to 30% of patients with T1 DM have thyroid antibodies. 50% of patients progress to clinical autoimmune thyroid disease. Women with poorly controlled diabetes, as evidenced by high glycosylated HbA1c levels in the first trimester, are at a significantly increased risk of both miscarriage and fetal malformation. Spontaneous abortion rate increases 3-4 fold with poor glycemic control in early pregnancy.
Screening for occult diabetes in asymptomatic women is not necessary unless the patient presents with an elevated random glucose level or exhibits other clinical signs of diabetes mellitus or if there is an unexplained loss in the second trimester.
What is Autoimmune thyroid diseases ?
It is also known as Hashimoto`s disease. There is destruction of thyroid tissue. Presence of thyroid peroxides (TPO) or thymoglobulin antibodies, and elevated TSH concentrations.
Presence of antithyroid antibodies presents as recurrent pregnancy loss, which is brought about by increased T-cell or natural killer cell activation
When should the screening for thyroid dysfunction done?
Ideally, one should get the serum TSH checked pre conceptionally. If TSH is high, check FreeT3, FreeT4. If it is also high, then treat. If TSH high, and T3, T4 normal ie. subclinical hypothyroidism, then if planning pregnancy then treat otherwise the woman can be observed.
For TSH between 2.5-5.0 mU/L: recheck TSH during 1st trimester
If TSH is 0.4-2.5 mU/L: No need to recheck during pregnancy
If TSH not done pre conceptionally, do at earliest antenatal visit. If 0.1-0.4 mU/L: hCG effect (9% pregnancy), recheck in 5wk. If < 0.1 mU/L: recheck immediately with FT4, FT3, T4, T3.
Hypothyroidism can increased risk of abortion in overt cases. If antibodies are present, sub clinical cases also associated with abortion. IUGR and IUFD is seen in in uncontrolled cases.Rarely neurological deficit and low IQ can occur if thyroid is uncontrolled in 1sttrimester.
What is luteal phase defect?
Luteal phase defects are most often thought to result from inadequate progesterone effect on the uterine endometrial lining. Some researchers believe that Luteal Phase Defect is responsible for up to forty percent of recurrent miscarriage; however, there are some questions as to the accuracy of these studies.
Progesterone appears to have a critical role in implantation and the development of a normal pregnancy. Limited exposure to progesterone may result in infertility (severe) or recurrent pregnancy loss (milder). Characteristically, decreased progesterone results in a shortened (less than 11 day) luteal phase (period between ovulation and the onset of the next menses) or a persistently abnormal endometrial biopsy (greater than 2 days out of phase). When these changes are more severe, the impact on reproduction can be greater.
What is the cause of Luteal Phase Defect (LPD)?
Poor follicular phase leads to inadequate Luteal phase. Premature LH causes stimulation of immature granulose cells. Abnormal patterns of LH secretion in the Luteal phase can Attenuated "LH" & "FSH" ovulatory surge. There may be decreased endometrial nuclear progesterone receptors. In some cases LPD can also be found with normal levels of progesterone.
How are endocrine disorders treated?
DM should be controlled at least 6/12 prior to conception. HbA1c should be in normal range.
Treatment for Luteal Phase defect includes taking progesterone supplements or suppositories, Usual routes of administration of progesterone is Oral, Intramuscular, Vaginal Capsules, Gel.
Luteal Phase Support (LPS) like hCG injections , Progesterone, Estrogen + Progesterone tablets.
Thyroid – Hyper and Hypo thyroid should be controlled. Euthyroid with ↑ peroxidase antibody may benefit from treatment. Levothyroxine therapy should be administered for subclinical and overt hypothyroidism.
Poorly controlled hypo / hyperthyroidism, Subclinical hypothyroidism and Euthyroid women with high serum (TPO) are at increased risk of miscarriages.
Treated thyroid dysfunction is NOT a risk for RPL.
Therapy with insulin-sensitizing agents for the treatment of RPL in the presence of PCOS has recently gained popularity.
Treatment of documented hyperprolactinemia with Bromocriptine & Cabergoline shows benefit in terms of successful pregnancies, as well as prevention of ectopic pregnancy
What is the role of Progesterone in RPL?
Progesterone support in pregnancy has been in use for nearly 60years, dating back to the 1940s. Its initial use was inpatients who had habitual spontaneous abortion caused by Luteal phase deficiency (LPD). This is due to a failure of the function of the corpus luteum in the production of progesterone, which is indispensable during the first seven weeks of pregnancy. Surgical removal of the corpus luteum during this period of time results in pregnancy loss and progesterone replacement can help maintain the pregnancy. There is evidence of support in the concept that progesterone given in early pregnancy may be useful in some women with recurrent miscarriage and that the measurement of serum progesterone levels in early pregnancy can be an adjunctive marker for the further assessment of pathologic pregnancies.
Progesterone levels are based on her menstrual cycle and in the stage of pregnancy.
Before Pregnancy
Prior to ovulation: Progesterone levels tend to be < 2 ng/ml
After Ovulation: > 5 ng/ml
In Pregnancy
Progesterone levels rise with pregnancy. This can often indicate the health of a pregnancy.
First Trimester:9-47 ng/ml
Second Trimester: 17-147 ng/ml
Third Trimester: 55-200 ng/ml
Low progesterone levels are associated with increased risk of miscarriage in the first trimester. There are many forms of treatment or supplementation that help to increase and maintain the production of progesterone. The treatment options listed below are generally followed for the first trimester of pregnancy. Dosages vary based on specific need or deficiency.
Intra-muscular progesterone injections-self administered for the first trimester of pregnancy
Oral progesterone capsules (standard or sustained release)
Progesterone vaginal pressaries
HCG-Human chorionic gonadotropin
Immunological causes:
If there is history of repeated abortions after cardiac activity seen on USG with:
History of thrombosis of the vessels or premature birth with normal fetal morphology due to severe pre-eclampsia , or severe placental insufficiency.
In such cases the most common cause is immunological, Anti phospholipid antibody syndrome (APS).
In these cases abortions can be avoided by using blood thinning agents in the form of oral tablets (aspirin) or injections (Heparin). Good results are seen after using these agents before and during pregnancy.
How does the immunological disturbance lead to RPL?
Two major categories of immunologic causes of recurrent pregnancy loss are autoimmune, in which the woman's immune system attacks her own organs and tissues, and alloimmune, in which the immune system attacks tissues considered foreign.
Immunomodulation occurs during pregnancy
The Embryo / Fetal antigens produce two types of antibodies:
T Helper I Cell response
T Helper II Cell response
Thus, if T helper I cell response is activated it produces harmful cytokines and fetus is rejected.
Exact alignment between binding surfaces of the paternal antigens and maternal antibodies causes activation of the complement cascade leading to abortion of the fetus.
Interferon's (IFNs) Type I and /or Type II are important in establishing uterine receptitivity to implantation in mammals. Uterine receptivity to implantation is progesterone dependent. Hence IFNs and progesterone activate complimentary cell signaling pathways to modulate expression of genes for attachment of trophectoderm to uterine luminal and superficial glandular epithelia .
What is meant by autoimmune?
An important feature of the immune system is its ability to distinguish foreign (unwanted) material from its own (desired) self. If this ability to distinguish non-self from self fails, then the system produces an immune response against itself (or its own tissues). This is called "autoimmune" disease.
Autoimmune disease or dysfunction may play a role in up to 10% of recurrent pregnancy loss.
Anti-phospholipid syndrome (APS) is the autoimmune dysfunction that is classically associated with recurrent pregnancy loss. APS is associated with pregnancy loss in any trimester, placental thrombosis (blood clots), and small placentae.
There may be thrombosis of the venous (may be unusual sites)/ arterial/small vessel.
Adverse pregnancy outcome in the form of ≥3 consecutive miscarriage (<10weeks), ≥1 fetal death (>10 weeks normal morphology) and ≥1 premature birth (<34 weeks with normal fetal morphology) due to severe pre-eclampsia or severe placental insufficiency are see in Anti-phospholipid syndrome (APS)
In APS there is inhibition of trophoblast function & differentiation. It affects the activation of complement pathways at the maternal-fetal interface resulting in a local inflammatory response. In later pregnancy, thrombosis of the uteroplacental vasculature
The interruption of the circulation to the fetus via these blood clots is a possible reason for the fetal losses. Establishing the diagnosis of APS is important since most of the treatment options involve considerable expense and some added risk. All couples with recurrent pregnancy loss should be screened for APS.
The prevalence of APS in normal population is around 2%, and 30-40% of women with SLE have APS. Around 30% of APS have thrombosis, and up to 30% women with severe early onset pre-eclampsia have APS.
15% women with RPL have APS. Live birth rate without treatment is only around 10%.
The tests that we routinely order include one of the coagulation tests (aPTT) that relies on the activation of the "prothrombin activator complex" and which will be appropriately diluted with normal plasma when abnormal, the anti-cardiolipin antibody test (positive in 2-3% of the general population, 7-45% of women with recurrent pregnancy loss- depending on what level is considered abnormal), and the lupus anticoagulant test (positive in 1-2% of the general population, 10% of women with recurrent pregnancy loss) APS is classically defined as a triad of recurrent pregnancy loss, thrombosis and autoimmune thrombocytopenia (decreased platelet concentration).
For diagnosis of APS there should be persisting presence of either Lupus anticoagulant OR Anticardiolipin antibodies OR β-2 glycoprotein 1 antibodies on separate occasions at least 12 weeks apart.
For those couples with recurrent pregnancy loss, the positive finding (on 2 separate occasions) of either an appropriately performed coagulation based test or a direct antibody test is generally all that is required to propose treatment.
Without treatment, couples with APS have a poor chance of carrying a fetus to term. The worst prognosis appears to occur when there is a prior fetal loss and high anti-cardiolipin antibodies.
Treatment options for APS include:
Low dose aspirin (75 mg per day) starting prior to pregnancy.
Heparin – We usually use low molecular weight heparin at the dose of 1unit/kg/day. This form of heparin has lesser side effects and is equally effective. However there are some side effects associated with taking these injections which one needs to discuss with the doctor.
Prednisone (30-60 mg per day) to suppress the immune system. This corticosteroid can have several potentially serious complications. When given during pregnancy for this indication, prednisone has been associated with preterm premature rupture of the fetal membranes, preterm delivery and pregnancy induced hypertension. This medication should only be given by physicians experienced in its use for this indication and typically in a research setting. We do not routinely recommend this medication.
Immunoglobulin (Ig) therapy, with intravenous injections of Igs, has been used for several decades in the treatment of immunodeficiency conditions and more recently in the treatment of autoimmune disorders. The mechanism of action is not known, the dosing is not standardized for recurrent pregnancy loss, and this treatment is very expensive. On the other hand, early experience with this treatment has been very encouraging.
APS without previous thrombosis and recurrent early (Pre embryonic or embryonic) miscarriage Low dose aspirin alone or together with either unfractionated heparin (UH) or LMWH
APS without previous thrombosis and fetal death (>10 weeks gestation) or previously early delivery (<34 weeks gestation) due to severe pre eclampsia or placental insufficiency These women at high risk of thrombosis.Low dose aspirin plus:· Unfractionated heparin (UH) to maintain mid interval aPPT 1.5 times the control.· LMWH (usual prophylactic doses)Heparin / Low molecular weight heparin (LMWH) should be started when Fetal cardiac activity is visualized on USG.
APS with thrombosis Low dose aspirin plus:· Unfractionated heparin to maintain mid interval aPPT in the therapeutic range.· LMWH (usual prophylactic doses)· The anticoagulation should continue six weeks postpartum.
What is meant by alloimmune dysfunction?
Alloimmune dysfunction resulting in recurrent pregnancy loss has also been proposed. Allogenic antigens are molecular structures that occur in different members of the same species and have the ability to elicit an immune response. Normally, a person will reject dissimilar (non-self) tissues or structures from the body using the immune system. In pregnancy, the placenta and growing embryo are not entirely "self" but rather are a result of both the maternal and paternal genetic heritages (referred to as a semi-allograft). The placenta (and pregnancy) has a "privileged" relationship with the pregnant woman that allows for it to escape rejection.
The mechanism for this privilege is not known. There have been several interesting and complex theories attempting to describe how the normal pregnancy achieves its privileged status in the maternal uterus. None of these theories has been generally accepted and proven.
The diagnosis of alloimmune recurrent pregnancy loss is one of exclusion. That is, when all other tests have been performed and the findings have come back normal then some of those with "unexplained" losses are thought to fall into this category.
Several physicians refuse to treat alloimmune recurrent pregnancy loss since there are no direct diagnostic tests, treatment options are expensive and their benefits are largely unproven, and treatment options potentially involve risk. The treatment is largely limited to a research facility with expertise in these therapies.
The two main treatment options include unified leukocyte (white blood cell, WBC) immunization with paternal or donor blood cells, using 200-300 million mononuclear cells from the isolated buffy coat of blood, once the woman is pregnant and prior to 6 weeks gestation on one occasion only immunoglobulin (Ig) therapy, with intravenous injections of Igs. The mechanism of action is not known, the dosing is not standardized for recurrent pregnancy loss, and this treatment is very expensive.
Progesterone favours the development of human T helper cells producing Th2-type cytokines and promotes IL –4 production. Progesterone inhibits in vitro embryotoxicTh1 cytokine production in trophoblast in women with recurrent pregnancy loss.
There is modulation of cytokine production by dydrogesterone in lymphocytes from women with recurrent miscarriage. Dydrogesterone inhibits the production of the Th1 cytokines IFN-γ and TNF–α from lymphocytes and up-regulates the production of the Th2 cytokines IL-4 & IL-6 inducing Th1 to Th2 cytokine shift.
What are Cytokines ?
Cytokines are secreted molecules that regulate the intensity and duration of the immune response by exerting a variety of effects on lymphocytes and other immune cells. Cytokines are the messengers of the Immune System (Th1 : TNFα,Il-2, Th2 : IL-4, IL-10) just as Hormones are the messengers of the Endocrine System.
Th-1 cytokines trigger thrombotic / inflammatory processes at the maternal uteroplacental blood vessels by activation of vascular endothelial cell procoagulant.
While, Th-2 cytokine inhibit Th-1 induced tissue destruction by monocytes. TNF-β is supposed to suppress the growth of trophoblasts by inducing apoptotic changes in these cells.
Infective causes:
Testing for infections like Toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus (ToRCH) and listeriosis screening has been abandoned when investigating recurrent miscarriage. As per WHO (World Health Organisation) there is no role of ToRCH test in current pregnancy. There is importance of only recent infections which can be diagnosed by using IgM testing. If there is recent infection, pregnancy has to be avoided during that time. In case of old infections, IgG will be positive, which shows that the woman had the infection some time back and now has antibodies against that infection. Nothing has to be done.
Testing for Rubella infection, identifies candidates for immunization. This immunization has to be done when the patient is not pregnant. It is advised to avoid pregnancy for 3 months after vaccination.
Can infections lead to RPL?
Certain infections have been linked to miscarriage.
Genital infections such as bacterial vaginosis may increase a woman's risk of having a miscarriage.
Although any bacterial or viral infections that spread to the uterus may cause sporadic miscarriage, there is no proven infectious cause of recurrent miscarriage.
Testing for infections is not routinely done in women who have no symptom of infection.
Thus, screening tests for TORCH, ureaplasma, chlamydia, and other infectious agents are not recommended in the evaluation of recurrent miscarriage.
Unexplained causes:
In certain cases even after looking for all known causes of recurrent abortions, no etiology can be found. These are called as unexplained abortions / miscarriages.
In such cases there may be an underlying problem at the level of gametes or endometrium.
For eg. They may have male sperm abnormalities. This can be diagnosed by using special tests like DNA fragmentation of the semen or FISH (Fluorescent in situ hybridization) of the semen.
Sometimes there may be subtle abnormalities in the endometrial blood flow. These can be diagnosed using special Doppler ultrasound imaging before and after ovulation.
Advanced maternal age also causes changes in the egg / ovum which may not be picked up by the usual tests.
All these conditions require specialized testing and management.
Medications can be given to improve the gamete quality of both the husband and wife.
Endometrial blood flow and thickness can be improved by giving drugs like sildenafil citrate vaginally along with blood thinners like aspirin, and drugs like pentoxyphylline and estrogen.
What about the male causes for miscarriage?
There is some evidence that defects in the male's sperm may cause miscarriage. It is not known how often sperm defects are the cause of recurrent miscarriage. Some studies suggest an effect of male age on miscarriage and other suggest the increased DNA damage in the sperm may contribute as well. Further research is needed in this area.
Sperm quality is dependent on the amount of damage to the sperm DNA or DNA fragmentation. DNA is arranged in a double helix or ladder configuration with side rails and rungs. If the rungs are broken, then the ladder is unsteady and will not function properly. Sperm DNA fragmentation has little or nothing to do with the parameters that we measure on the routine semen analysis like the shape of the sperms or whether the sperms are moving. Men with otherwise normal semen analyses can have a high degree of DNA damage and men with what was called very poor sperm quality can have very little DNA damage.
The degree of DNA fragmentation correlates very highly with the inability of the sperm to initiate a birth regardless of the technology used to fertilize the egg such as insemination, IVF or ICSI. Sperm with high DNA fragmentation may fertilize an egg and embryo development stops before implantation or may even initiate a pregnancy but there is a significantly higher likelihood that it will result in miscarriage.
What is the role of endometrial blood flow in RPL?
Successful implantation depends on a close interaction between the blastocyst(developing embro) & receptive endometrium.
Each month the human endometrium undergoes a series of distinct cyclical changes in preparation to receive the developing blastocyst.
Such changes need well controlled dynamic remodeling of endometrial micro vasculature through the process of angiogenesis & arteriogenesis.
Adequately prepared endometrium required for successful implantation.
Endometrial development regulated by steriod hormones various growth factor & cytokines.
Some of these factors need to be transferred to the endometrium.
For this it is essential that adequate blood supply should reach the functional layer of the endometrium.
Endometrial and subendometrial vascularity is significantly higher in pregnant patients with live birth following stimulated IVF treatment than in those who suffered a miscarriage.
Various studies concluded that Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers.
Some drugs like aspirin, glyceryl trinitrate, angiogenic growth factors & sildenafil citrate have shown good effect on endometrial perfusion.
What if the cause remains a mystery?
Up to 50 % of couples with RPL fail to reveal a cause even after testing. For women with unexplained RPL, empirical treatment with low-dose aspirin, prophylactic doses of low-dose heparin or both have shown to give better results.
Specialists may suggest reasonably safe forms of therapy that may prove helpful, such as low-dose aspirin and/or progesterone. Sometimes patient are also given a try with promising investigational treatment like intravenous immunoglobulin (IVIG). It is a drug which is used to treat many immune disorders and has been found to be useful in RPL by some studies.
Apart from this, lifestyle changes such as good diet, weight loss, exercise are highly advocated.
What is needed many a times is repeated assurance, motivation and encouragement by the treating fertility specialist as well as the family members.
Stress reduction therapies such as meditation, yoga, acupuncture etc have also helped some women. (These have been discussed in details in other section.) Understanding and support from health care professionals and family members will keep the woman motivated and will restore her self esteem.
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Lezyne Hecto Drive 500XL Front & Rear Light Set
Lezyne Hecto Drive 500XL Front
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Hecto Drive 500 Chart
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Slave Revolt and the Practices of Containment (Cameron Seglias)
Cameron Seglias is currently a Ph.D. candidate in Cultural Studies at the Graduate School of North American Studies, Freie Universität Berlin. Recent and forthcoming publications have appeared/will appear in the Pennsylvania Magazine of History and Biography and H-Soz-Kult.
Research and archival work for his dissertation, tentatively entitled "Paradoxes of Liberty: Antislavery, Print, and Colonial Power in Crisis, 1729-1793," has been generously supported by fellowships from the German Research Foundation (DFG), the Library Company of Philadelphia, and the Historical Society of Pennsylvania. His teaching interests include slavery and antislavery in the eighteenth-century Atlantic world, the history of pacifism in America, as well as modern and contemporary poetry and poetics. Seglias was a Barra Foundation International Fellow at the Library Company in 2019.
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Q: Header alignment problem in jQuery DataTable I have a problem with the implementation of a DataTable in jQuery. My DataTable is dynamically generated and the table content changes in size.
For some reason the header is not always aligned with the other rows. This table can scroll in X and Y directions, the presence of the one or the other depends on the content size.
In order to fix the problem, I tried to add the following code:
var table = $('#example').DataTable();
$('#container').css('display', 'block');
table.columns.adjust().draw();

Maybe I'm wrong the position in the code or this is not the right solution.
What could be the problem? Can anyone help me?
$(document).ready(function() {
  $('#example').DataTable({
    "scrollY": 250,
    "pageLength": 25,
    "scrollX": true,
    "sScrollXInner": "100%",
    "bSort": true,
    "dom": '<lf<t>ip>',
    "rowCallback": function(row, data, index) {
      if (data[4] == "0") {
        $('td', row).css('background-color', '#fca4a4');
      } else if (data[4] == 1) {
        $('td', row).css('background-color', '#c7e6c3');
      } else {
        $('td', row).css('background-color', '#b3b8b2');
      }
    }
  });

  var table = $('#example').DataTable();
  // Hide two columns
  table.columns([4]).visible(false);
});

This is an example of the table content:

Path names	Path String	Distance	Path Length	Final Effect

NF2-->DIFFERENTIATION	NF2--> LATS2--| WWTR1--> MYOD1--> DIFFERENTIATION	1.24	4	0

NF2-->DIFFERENTIATION	NF2--> LATS1--| WWTR1--> MYOD1--> DIFFERENTIATION	1.3	4	0

I add all css and js files that are needed to Data Table visualization.

<link rel="stylesheet" type="text/css" href="./mydirectoryPath/css/styleResults_pathway.css">
<link rel="stylesheet" type="text/css" href="./mydirectoryPath/css/jquery.dataTables.min.css">
<link rel="stylesheet" type="text/css" href="./mydirectoryPath/css/dataTables.bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="./mydirectoryPath/css/bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="./mydirectoryPath/css/buttons.dataTables.min.css">
<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap-glyphicons.css" rel="stylesheet">

Actually, I have now figured out that the code, taken alone, is correct. In fact, in order to reproduce this example to explain the problem, I extracted the data table object in a simple html file and the header is correctly aligned, then the problem could be due to some styles that are not correctly uploaded in the original page.

$(document).ready(function() {
  $('#example').DataTable({
    "scrollY": 250,
    "pageLength": 25,
    "scrollX": true,
    "sScrollXInner": "100%",
    "bSort": true,
    "dom": '<lf<t>ip>',
    "rowCallback": function(row, data, index) {
      if (data[4] == "0") {
        $('td', row).css('background-color', '#fca4a4');
      } else if (data[4] == 1) {
        $('td', row).css('background-color', '#c7e6c3');
      } else {
        $('td', row).css('background-color', '#b3b8b2');
      }
    }
  });

  var table = $('#example').DataTable();
  // Hide two columns
  table.columns([4]).visible(false);
});
table.dataTable thead .sorting { background: url('./images/sort_both.png') no-repeat center right; }
table.dataTable thead .sorting_asc { background: url('./images/sort_asc.png') no-repeat center right; }
table.dataTable thead .sorting_desc { background: url('./images/sort_desc.png') no-repeat center right; }

table.dataTable thead .sorting_asc_disabled { background: url('./images/sort_asc_disabled.png') no-repeat center right; }
table.dataTable thead .sorting_desc_disabled { background: url('./images/sort_desc_disabled.png') no-repeat center right; }
table.dataTable thead .sorting,
table.dataTable thead .sorting_asc,
table.dataTable thead .sorting_desc,
table.dataTable thead .sorting_asc_disabled,
table.dataTable thead .sorting_desc_disabled {
  background-image: none!important;
}
th {

    text-align:center;
    font-size: 10pt;

}

td {

    text-align:center;
    font-size: 8pt;

}

tr {
        text-align:center;
    border-radius: 25px;
    font-size: 8pt;
    width:100%;

}

<link rel="stylesheet" type="text/css" href="https://cdnjs.cloudflare.com/ajax/libs/datatables/1.10.19/css/jquery.dataTables.min.css">
<link rel="stylesheet" type="text/css" href="https://cdnjs.cloudflare.com/ajax/libs/datatables/1.10.19/css/dataTables.bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/4.3.1/css/bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="https://cdn.datatables.net/buttons/1.5.6/css/buttons.dataTables.min.css">
<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap-glyphicons.css" rel="stylesheet">

        Path names
        Path String
        Distance
        Path Length
        Final Effect

        NF2-->DIFFERENTIATION
        NF2--> LATS2--| WWTR1--> MYOD1--> DIFFERENTIATION
        1.24
        4
        0

        NF2-->DIFFERENTIATION
        NF2--> LATS1--| WWTR1--> MYOD1--> DIFFERENTIATION
        1.3
        4
        0

About the css styleResults_pathway.css I added here more details:
table.dataTable thead .sorting { background: url('./images/sort_both.png') no-repeat center right; }
table.dataTable thead .sorting_asc { background: url('./images/sort_asc.png') no-repeat center right; }
table.dataTable thead .sorting_desc { background: url('./images/sort_desc.png') no-repeat center right; }

table.dataTable thead .sorting_asc_disabled { background: url('./images/sort_asc_disabled.png') no-repeat center right; }
table.dataTable thead .sorting_desc_disabled { background: url('./images/sort_desc_disabled.png') no-repeat center right; }
table.dataTable thead .sorting,
table.dataTable thead .sorting_asc,
table.dataTable thead .sorting_desc,
table.dataTable thead .sorting_asc_disabled,
table.dataTable thead .sorting_desc_disabled {
  background-image: none!important;
}
th {

    text-align:center;
    font-size: 10pt;

}

td {

    text-align:center;
    font-size: 8pt;

}

tr {
        text-align:center;
    border-radius: 25px;
    font-size: 8pt;
    width:100%;

}

A: Maybe it helps to you, You should add responsive:true properties in Datatable function like
$(document).ready(function() {
  $('#example').DataTable({
    "responsive": true,
    "scrollY": 250,
    "pageLength": 25,
    "scrollX": true,
    "sScrollXInner": "100%",
    "bSort": true,
    "dom": '<lf<t>ip>',
    "rowCallback": function(row, data, index) {
      if (data[4] == "0") {
        $('td', row).css('background-color', '#fca4a4');
      } else if (data[4] == 1) {
        $('td', row).css('background-color', '#c7e6c3');
      } else {
        $('td', row).css('background-color', '#b3b8b2');
      }
    }
  });

  var table = $('#example').DataTable();
  // Hide two columns
  table.columns([4]).visible(false);
});

redpajama_set_name: RedPajamaStackExchange


text:
Amy Goodman Arrested at RNC
On September 1, 2008 By Jeff FenskeIn Freedom
[youtube=http://www.youtube.com/watch?v=oYjyvkR0bGQ]
From: Democracy Now!
Democracy Now!'s Amy Goodman, Sharif Abdel Kouddous and Nicole Salazar Released After Illegal Arrest at RNC
Goodman Charged with Obstruction; Felony Riot Charges Pending Against Kouddous and Salazar
ST. PAUL–Democracy Now! host Amy Goodman and producers Sharif Abdel Kouddous and Nicole Salazar have all been released from police custody in St. Paul following their illegal arrest by Minneapolis Police on Monday afternoon.
All three were violently manhandled by law enforcement officers. Abdel Kouddous was slammed against a wall and the ground, leaving his arms scraped and bloodied. He sustained other injuries to his chest and back. Salazar's violent arrest by baton-wielding officers, during which she was slammed to the ground while yelling, "I'm Press! Press!," resulted in her nose bleeding, as well as causing facial pain. Goodman's arm was violently yanked by police as she was arrested.
On Tuesday, Democracy Now! will broadcast video of these arrests, as well as the broader police action. These will also be available on: www.democracynow.org
Goodman was arrested while questioning police about the unlawful detention of Kouddous and Salazar who were arrested while they carried out their journalistic duties in covering street demonstrations at the Republican National Convention. Goodman's crime appears to have been defending her colleagues and the freedom of the press.
Sarah Palin: The Misperception About ANWR
Paul Craig Roberts: War With Russia Is On The Agenda
One thought on "Amy Goodman Arrested at RNC"
I support a woman's right to choose to do something so idiotic that she gets arrested for it, and then she can blog about it to make her First Amendment appeals. Only in America!
September 5, 2008 at 4:06 am	 Log in to Reply


Published at Friday, April 19th, 2019 - 5:10 AM. 3 Wiring Diagram. By Billy L. Stokes.
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AGOURA HILLS, CA (September 28, 2018) — The Mountains Recreation and Conservation Authority (MRCA) announced today that it had acquired 170 acres of iconic open space in the central Santa Monica Mountains south of the 101 Freeway along Kanan Road. Known for decades as the Triangle Ranch property because of the shape of the land holding, the $16.5 million property was purchased in three phases beginning in March of this year with grants from numerous State and local funding sources including the State Wildlife Conservation Board, the Santa Monica Mountains Conservancy, the County of Los Angeles, the City of Agoura Hills, and the nonprofit Conrad N. Hilton Foundation. The Phase 3, 70-acre acquisition was completed this week.
Thousands of motorists pass by the now permanently protected parkland each day, which has long been identified as a crucial linkage for habitat preservation, watershed protection, and wildlife movement in the area. The parkland ties the approximately 1,000-acre Ladyface Mountain core habitat area with the Liberty Canyon inter-mountain range wildlife corridor and Malibu Creek State Park. Existing informal trails will be developed to increase public access from Kanan Road.
"This acquisition preserves this irreplaceable landscape and secures wildlife corridors and pathways which animals depend upon for survival," said Craig Sap, Chairperson of the Santa Monica Mountains Conservancy and California State Parks Angeles District Superintendent. "For now, and forever this land will greet residents and visitors alike with its natural beauty." The Conservancy contributed a total of more than $9.8 million to all three phases of the acquisition with a combination of grants from Propositions 40, 50, 84, 1 and 68. The new parkland adds to more than 500 contiguous acres of protected open space owned by the Conservancy and the MRCA in this area.
The new parkland contains a section of Medea Creek, a tributary of Malibu Creek, which supports a population of western pond turtles, a sensitive species. It also features the largest known population of the federally-listed annual wildflower Lyon's pentachaeta. The property includes broad swaths of coast live oak woodland, chaparral, purple sage scrub, native and annual grassland, and valley oak savannah. Many rock outcroppings contain unique microsites for plants and animals. The new parkland supports mountain lion, mule deer, American badger, bobcat, gray fox, ring-tailed cat, long-tailed weasel, California quail, and dozens of reptile species.
Los Angeles County Supervisor Sheila Kuehl was an early and key supporter of the project, granting $2.5 million in Los Angeles County Proposition A funds towards the acquisition of Phase I. "I am very happy to support this significant expansion of open space at Triangle Ranch because it ensures that this wild and beautiful habitat will be available for the people and animals of LA County to enjoy for generations to come," said LA County Supervisor Sheila Kuehl.
Negotiations are pending for the final, fourth phase of the project, which includes 150 additional acres. This is anticipated to be completed sometime in 2019.
The Mountains Recreation and Conservation Authority (MRCA) is a local government public entity dedicated to the preservation and management of open space and parkland, watershed lands, trails, and wildlife habitat. The MRCA works in cooperation with other government partners to acquire parkland, participate in vital planning processes, provide natural resources and scientific expertise, and complete major park improvement projects. The MRCA manages and provides ranger services and fire protection for almost 75,000 acres of parkland that it owns and that are owned by the Santa Monica Mountains Conservancy or other agencies and provides comprehensive education and interpretation and leadership programs for youth. It is one of the lead agencies providing for the revitalization of the Los Angeles River.


text:
2brothers-store.com
Where the Wild Things Are is fifty years old! Maurice Sendak's Caldecott Medal-winning picture book has become one of the most highly acclaimed and best-loved children's books of all time. A must for every child's bookshelf.Introduce a new generation to Max's imaginative journey with this special anniversary edition. Let the wild rumpus continue as this classic comes to life like never before with new reproductions of Maurice Sendak's artwork.Astonishing state-of-the-art technology faithfully captures the color and detail of the original illustrations. Sendak himself enthusiastically endorsed this impressive new interpretation of his art before his death in 2012. This iconic story has inspired a movie, an opera, and the imagination of generations.
Categories: Books, Children's Books, Science Fiction and Fantasy
"The clearer reproductions of the original art are vibrant and luminous." (H.)
"Each word has been carefully chosen and the simplicity of the language is quite deceptive." (SLJ.)
"A timeless classic that continues to win over the hearts of children. The simple, rhythmic text and expressive illustrations are just as appealing today as they were when I was a child." 10 Must-Have Books for 2-Year-Olds (Brightly)
Fiftieth Anniversary Edition
Winner of the 1964 Caldecott Medal for the Most Distinguished Picture Book of the Year
The original pictures have never before been as faithfully reproduced as they are in this new edition. Maurice Sendak enthusiastically approved this remastered rendition of his art.
In addition to Where the Wild Things Are, Maurice Sendak's books include Kenny's Window, Very Far Away, The Sign on Rosie's Door, Nutshell Library (consisting of Chicken Soup with Rice, Alligators All Around, One Was Johnny, and Pierre), Higglety Pigglety Pop! or There Must Be More to Life, In the Night Kitchen, Outside Over There, We Are All in the Dumps with Jack and Guy, and Bumble-Ardy.
He received the 1964 Caldecott Medal for Where the Wild Things Are; the 1970 Hans Christian Andersen Award for Illustration; the 1983 Laura Ingalls Wilder Award, given by the American Library Association in recognition of his entire body of work; and a 1996 National Medal of Arts in recognition of his contribution to the arts in America. In 2003, he received the fi rst Astrid Lindgren Memorial Award, an international prize for children's literature established by the Swedish government.
P.when('A').execute(function(A) { A.on('a:expander:toggle_description:toggle:collapse', function(data) { window.scroll(0, data.expander.$expander[0].offsetTop-100); }); });
Maurice Sendak's children's books have sold over 30 million copies and have been translated into more than 40 languages. He received the 1964 Caldecott Medal for Where the Wild Things Are and is the creator of such classics as In the Night Kitchen, Outside Over There, Higglety Pigglety Pop!, and Nutshell Library. In 1970 he received the international Hans Christian Andersen Medal for Illustration, in 1983 he received the Laura Ingalls Wilder Award from the American Library Association, and in 1996 he received a National Medal of Arts in recognition of his contribution to the arts in America. In 2003, Sendak received the first Astrid Lindgren Memorial Award, an annual international prize for children's literature established by the Swedish government.
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text:
Politics·Analysis
What happens when #MeToo comes to Parliament Hill
A reckoning for Canadian politics would seem to be at hand — one that will challenge Parliament Hill to account for itself.
'Many of the stories I heard were heartbreaking,' says Labour Minister Patty Hajdu
Aaron Wherry · CBC News · Posted: Jan 25, 2018 7:50 PM ET | Last Updated: January 26, 2018
Minister of Employment, Workforce Development and Labour Patty Hajdu tabled new rules in November to deal with misconduct in federal workplaces, including Parliament. Bill C-65 is scheduled to be debated on Monday. (Justin Tang/Canadian Press)
Patrick Brown and Kent Hehr will not be the last. It is not a matter of when, but of how many more women will come forward to tell their stories.
"Staffers talked about having a whisper network, knowing which parliamentarians to avoid and which ones were more lecherous when they were drinking," Labour Minister Patty Hajdu said in an interview with CBC News on Thursday, recalling the conversations that preceded her tabling of new rules in November to deal with misconduct in federal workplaces, including Parliament.
"They didn't name names, but they said this was a regular occurrence, that they would share information about this."
Coincidentally, Hajdu's legislation, Bill C-65, is scheduled to be debated on Monday, when the House of Commons reconvenes (the government's decision to bring the bill forward was communicated to opposition parties on Wednesday afternoon, before Brown announced he was stepping down as Ontario PC leader).
Trudeau comments on Patrick Brown allegations
3 years agoVideo
'We take these allegations extremely seriously whenever they come up' 0:45
"We know there are countless stories about sexual harassment and assault on Parliament Hill," Lauren Dobson-Hughes, a former staff member for the NDP said on Thursday morning, hours after Brown resigned and hours before Hehr followed suit.
"I hope this is the start of the dam breaking," said Dobson-Hughes who recently discussed her experiences on Parliament Hill with The Canadian Press.
The problem with Parliament Hill
Such a reckoning has already made significant ground in American entertainment, media and politics. It has emerged in certain Canadian centres of power.
But while cases have emerged from Parliament Hill in recent years — Liberals MPs Scott Andrews and Massimo Pacetti in 2015, Hunter Tootoo in 2016 and Darshan Kang last year — the current moment did not seem to truly land in the world of Canadian politics until Thursday night.
"The #MeToo movement is a real thing, it turns out," Hajdu said.
The #MeToo movement is a real thing, it turns out. - Labour Minister Patty Hajdu
In other words, it is more than a hashtag.
"Many of the stories I heard were heartbreaking and woven into a power dynamic that is unique in some aspects," the minister said.
The Hill, of course, is a place of powerful people, still mostly men. It is also, Hadju noted, staffed by young people. There is "liberal access" to alcohol and long hours of work. And it is defined by partisanship and a team mentality. She has heard "how hard it is to come forward when it's actually a member of your own team because it politically could jeopardize your own team's success."
Hajdu has experienced flirtatious behaviour herself, but "my position is not threatened if I say no. It's the women or the vulnerable person who is in the least powerful position that is at the most risk."
Lisa Macleod: 'I believe women who come forward'
Progressive Conservative MPP Lisa Macleod is asked whether she believes former PC leader Patrick Brown, who had denied allegations of sexual misconduct. 1:07
'Every party has a problem'
"We have an obligation to believe women when they come forward with experiences of harassment and sexual violence," Hajdu said when asked whether she believes the woman who has accused Hehr of inappropriate comments.
In light of Hehr and previous examples, is it possible that Hajdu's own party has a problem? "I think there's a problem in occupations where we have people with high amounts of power and people in positions of low power," Hajdu said.
Breaking up the Old Boys club: #MeToo is encouraging women to run for office
Indeed, all partisans might resist the reflex to exploit individual cases. "Every party has a problem with harassment," Dobson-Hughes said. "This is a systemic, cultural issue."
So what happens when #MeToo comes to Parliament Hill?
Ontario premier reacts to allegations about Tory leader
'I believe victims when they come forward,' Kathleen Wynne says 1:38
All MPs, political parties and leaders might now be asked what they have known and what they have done about the problems in their midst.
In the United States, the president has escaped serious penalty despite more than a dozen accusations of misconduct. Will power or stature allow anyone on Parliament Hill to escape accountability?
Can parliamentarians set aside politics to deal with these issues across party lines? Can MPs settle on a complaints process that provides comfort and confidence for the mistreated?
"A House of Commons harassment policy is a drop in the ocean. It's almost beside the point when nobody trusts it or will use it," Dobson-Hughes said. "We need solutions that get at the underlying problem of culture and power imbalance."
'Politics needs to change'
Prominent figures will fall and the political ramifications could be seismic — Brown was on track, until Thursday night, to be the next premier of Ontario.
But, as many have noted, there have already been untold ramifications on the careers and lives of the woman who have been mistreated. This is ultimately about how women within and around the political process have been treated and what must change to move forward in a better way.
"I assure you that this isn't just my experience. It's the experience of many people who experience sexual harassment in political work," Kristin Raworth, whose tweets precipitated Hehr's resignation, said on Thursday night.
"Mr. Hehr resigned today, but this can't be the end of the conversation, because this isn't about him. Or me. We need to continue to support survivors and we need to continue to make politics a place for women."
The consequences might be new. But the problem was already here.
"I fell in love with politics and democracy when I was 18," Raworth said. "But loving something doesn't mean you're blind to its faults. Politics needs to change."
Aaron Wherry
Parliament Hill Bureau
Aaron Wherry has covered Parliament Hill since 2007 and has written for Maclean's, the National Post and the Globe and Mail. He is the author of Promise & Peril, a book about Justin Trudeau's years in power.
Follow Aaron on Twitter
Stamping out sexual harassment in politics can't be a partisan issue: Chris Hall
Workplace harassment bill will protect federal political staffers, Liberals say
Patrick Brown resigns — how it happened and what happens next: Fisher
Sport Minister Kent Hehr resigns from Trudeau cabinet amid sexual harassment allegations
Sexual advances by Patrick Brown left woman feeling 'anxious,' she tells CBC News


text:
package org.camunda.bpm.engine.impl.el;

import org.camunda.bpm.engine.ProcessEngineException;
import org.camunda.bpm.engine.delegate.VariableScope;
import org.camunda.bpm.engine.impl.bpmn.behavior.ExternalTaskActivityBehavior;
import org.camunda.bpm.engine.impl.cmmn.entity.runtime.CaseExecutionEntity;
import org.camunda.bpm.engine.impl.context.Context;
import org.camunda.bpm.engine.impl.javax.el.ELContext;
import org.camunda.bpm.engine.impl.javax.el.ELResolver;
import org.camunda.bpm.engine.impl.persistence.entity.ExecutionEntity;
import org.camunda.bpm.engine.impl.persistence.entity.ExternalTaskEntity;
import org.camunda.bpm.engine.impl.persistence.entity.TaskEntity;
import java.beans.FeatureDescriptor;
import java.util.Iterator;
import java.util.List;

/**
 * Implementation of an {@link ELResolver} that resolves expressions
 * with the process variables of a given {@link VariableScope} as context.
 * <br>
 * Also exposes the currently logged in username to be used in expressions (if any)
 *
 * @author Joram Barrez
 * @author Frederik Heremans
 */
public class VariableScopeElResolver extends ELResolver {

  public static final String EXECUTION_KEY = "execution";
  public static final String CASE_EXECUTION_KEY = "caseExecution";
  public static final String TASK_KEY = "task";
  public static final String EXTERNAL_TASK_KEY = "externalTask";
  public static final String LOGGED_IN_USER_KEY = "authenticatedUserId";

  public Object getValue(ELContext context, Object base, Object property)  {

    Object object = context.getContext(VariableScope.class);
    if(object != null) {
      VariableScope variableScope = (VariableScope) object;
      if (base == null) {
        String variable = (String) property; // according to javadoc, can only be a String

        if( EXECUTION_KEY.equals(property) && variableScope instanceof ExecutionEntity
                || TASK_KEY.equals(property) && variableScope instanceof TaskEntity
                || variableScope instanceof CaseExecutionEntity
                && (CASE_EXECUTION_KEY.equals(property) || EXECUTION_KEY.equals(property)) ) {
          context.setPropertyResolved(true);
          return variableScope;
        } else if(EXTERNAL_TASK_KEY.equals(property)
            && variableScope instanceof ExecutionEntity
            && ((ExecutionEntity) variableScope).getActivity() != null
            && ((ExecutionEntity) variableScope).getActivity().getActivityBehavior() instanceof ExternalTaskActivityBehavior) {
          List<ExternalTaskEntity> externalTasks = ((ExecutionEntity) variableScope).getExternalTasks();
          if(externalTasks.size() != 1) {
            throw new ProcessEngineException("Could not resolve expression to single external task entity.");
          }
          context.setPropertyResolved(true);
          return externalTasks.get(0);

        } else if (EXECUTION_KEY.equals(property) && variableScope instanceof TaskEntity) {
          context.setPropertyResolved(true);
          return ((TaskEntity) variableScope).getExecution();
        } else if(LOGGED_IN_USER_KEY.equals(property)){
          context.setPropertyResolved(true);
          return Context.getCommandContext().getAuthenticatedUserId();
        } else {
          if (variableScope.hasVariable(variable)) {
            context.setPropertyResolved(true); // if not set, the next elResolver in the CompositeElResolver will be called
            return variableScope.getVariable(variable);
          }
        }
      }
    }

    // property resolution (eg. bean.value) will be done by the BeanElResolver (part of the CompositeElResolver)
    // It will use the bean resolved in this resolver as base.

    return null;
  }

  public boolean isReadOnly(ELContext context, Object base, Object property) {
    if (base == null) {
      String variable = (String) property;
      Object object = context.getContext(VariableScope.class);
      return object != null && !((VariableScope)object).hasVariable(variable);
    }
    return true;
  }

  public void setValue(ELContext context, Object base, Object property, Object value) {
    if (base == null) {
      String variable = (String) property;
      Object object = context.getContext(VariableScope.class);
      if (object != null) {
        VariableScope variableScope = (VariableScope) object;
        if (variableScope.hasVariable(variable)) {
          variableScope.setVariable(variable, value);
          context.setPropertyResolved(true);
        }
      }
    }
  }

  public Class< ? > getCommonPropertyType(ELContext arg0, Object arg1) {
    return Object.class;
  }

  public Iterator<FeatureDescriptor> getFeatureDescriptors(ELContext arg0, Object arg1) {
    return null;
  }

  public Class< ? > getType(ELContext arg0, Object arg1, Object arg2) {
    return Object.class;
  }

}

redpajama_set_name: RedPajamaGithub