Predicting pregnancy outcome by the observation of a gestational sac or of early fetal cardiac motion with transvaginal ultrasonography

Ultrasound Assessment of First-Trimester Bleeding

OBJECTIVE

To assess the outcome (to the end of the first trimester) of pregnancies with vaginal bleeding and the influence of ultrasound-acquired information on care and cost of care.

METHODS

A chart review was performed of 1,240 patients receiving care at an integrated medical center for threatened abortion from 1998-2000. Records from 715 patients with adequate follow-up data were reviewed and outcomes studied. Charges for outpatient and inpatient care were obtained from the data warehouse.

RESULTS

Main findings include that on endovaginal ultrasonography, 44% of the pregnancies were viable, of which 86% continued to the end of the first trimester and that of the 33% of pregnancies that were nonviable, 74% successfully miscarried without intervention. Charges for the care varied significantly, based on outcome and choice of site of care.

CONCLUSION

Endovaginal ultrasonography for the evaluation of early pregnancy bleeding has a significant effect on care decisions and costs.

LEVEL OF EVIDENCE

II-3.

Fetal loss in threatened abortion after embryonic/fetal heart activity

OBJECTIVES

To study the incidence of fetal loss in threatened abortion after detection of embryonic/fetal heart activity.

METHODS

A prospective study was performed on pregnant women with clinically diagnosed threatened abortion between 6 and 14 weeks of gestation. All had a good menstrual history and the calculated gestational age using crown-rump length in the first trimester ultrasound was in agreement. Embryonic/fetal heart rate measurements were obtained by a 5 MHz vaginal probe using M-mode and real-time B mode imaging. All cases were followed up with respect to pregnancy outcomes. The data were analyzed using the SPSS computer program.

RESULTS

Eighty-seven pregnant women were included in the study. There were three pregnancies (3.4%) which resulted in fetal loss before 20 weeks of gestation. In viable pregnancies, the mean embryonic/fetal heart rate increased with advancing gestational age. The individual values of embryonic/fetal heart rate for fetal losses were within the reference range.

CONCLUSIONS

The incidence of fetal loss in threatened abortion after detection of embryonic/fetal heart activity was 3.4%. There was no evident pattern of bradycardia or tachycardia that signaled the incipient of viability.

Emergency management of the nonviable intrauterine pregnancy

Fetal death early in gestation is common. Patients in the first trimester of pregnancy with abdominal pain or vaginal bleeding often present to the emergency department for care. Over the past 20 years, the technology available to confirm or exclude the diagnosis of a nonviable pregnancy has improved dramatically. These improvements have altered the diagnostic approach to these patients and have lead to a change in the terminology used to categorize the pregnancy status. In addition, the therapeutic options available to manage patients with a confirmed nonviable pregnancy have expanded greatly. In this article, we re-evaluate the classification scheme used to categorize patients with first trimester pain or bleeding given the improved technology that is available to the emergency physician today. We discuss the role of ultrasound and biochemical markers in confirming or excluding the diagnosis of a nonviable pregnancy. Finally, we review the therapeutic options, including expectant, surgical as well as medical management that are available once the diagnosis of a nonviable intrauterine pregnancy has been confirmed.

Transvaginal volumetry of first trimester gestational sac: a comparison of conventional with three-dimensional ultrasound

The aim of this study was to determine whether three-dimensional (3D) ultrasound is superior to two-dimensional (2D) ultrasound in evaluating first trimester gestational sac volume (GSV). 130 mainly low risk pregnancies between 5 and 12 weeks gestation were prospectively investigated. The 2D volumetry of GSV was performed using the ellipsoid formula; the 3D volumetry was carried out in all three planes using the contour mode and the volume from the measured circumferences and the distances between them were computed by a software. The data were analysed by variance and regression. The mean GSV increased from 1.5 +/- 2 ml with 5 weeks to 127 +/- 27 ml with 12 weeks (3D, longitudinal plane). The standard deviation of measured GSV increased with gestational age (GA) and GSV, and was more evident using 2D than 3D volumetry. GSV of pregnancies with similar GA differed considerably and viable pregnancies followed by miscarriage did not show different GSV. We conclude, that 3D volumetry of first trimester GSV is superior to 2D volumetry in its estimation, but seems to be without a prognostic significance for gestational outcome.

Vaginal bleeding and early pregnancy outcome in an infertile population

OBJECTIVE

Our purpose was to determine the prognostic value of vaginal bleeding in early pregnancy outcome as well as to analyze the role of cardiac activity in predicting pregnancy viability in the presence of vaginal bleeding.

STUDY DESIGN

This was a cohort study of pregnancies obtained using either assisted reproductive technology (ART) or routine infertility treatment (RIT). Two hundred twenty-eight pregnant women were divided into two groups based on the presence or absence of vaginal bleeding. Successive measurements of beta-hCG levels were obtained every 2 days, starting on day 14 after ovulation or embryo transfer. All pregnancies underwent weekly transvaginal ultrasound (UTZ) examinations beginning on day 21. The occurrence of vaginal bleeding was monitored weekly.

RESULTS

Seventy of the 228 patients (31%) had bleeding in early pregnancy, resulting in 31 (44%) pregnancy losses. Only 22 pregnancy losses (14%) were observed in 158 patients who did not have bleeding (P < 0.001). The abortion rate for the bleeding versus nonbleeding groups was 35 and 9%, respectively (P < 0.001). Vaginal bleeding was associated with a higher abortion rate in pregnancies following RIT than ART (51 vs 8%; P < 0.001). Fetal cardiac activity was noted by vaginal ultrasound in 189 patients. In this subpopulation, bleeding was also associated with a higher abortion rate than that in the nonbleeding group (17 vs 4%; P < 0.001). However this higher incidence was observed only in pregnancies following RIT, not ART (28 vs 5%; P < 0.001).

CONCLUSIONS

Although bleeding significantly decreased the chance of a normal pregnancy outcome, more than 50% of the pregnancies did progress to term. The presence of cardiac activity in this population as a sign of fetal viability offered a better pregnancy prognosis. However, the predictive value of fetal cardiac activity was reduced in the presence of vaginal bleeding in an infertile population treated with RIT.

The profound impact of patient age on pregnancy outcome after early detection of fetal cardiac activity

OBJECTIVE

To evaluate the influence of maternal age on pregnancy loss rates after early documentation of fetal cardiac activity by transvaginal ultrasound (US) in previously infertile women.

DESIGN

Retrospective, observational study.

SETTING

Tertiary fertility center.

PATIENTS

One hundred eighty-six previously infertile women 20 to 43 years of age undergoing ovulation induction.

MAIN OUTCOME MEASURE

We analyzed 201 clinical pregnancies in which cardiac activity had been documented by transvaginal US 35 to 42 days after ovulation in a previously infertile population treated at a tertiary fertility center. Patient age, infertility diagnosis, ovulation induction protocol, and mode of insemination were analyzed by chi 2, Fisher's exact test and logistic regression analyses.

RESULTS

A profound increase in spontaneous abortion rates occurred as a function of maternal age in this population (chi 2 for trend = 15.1). A spontaneous abortion rate of 2.1% was observed for maternal ages < or = 35 years but this rate increased to 16.1% for patients > or = 36 years (odds ratio, 8.72; 95 percent confidence interval 2.3 to 32.9). A fivefold increase in spontaneous abortion rate was observed in women > or = 40 years compared with women 31 to 35 years (3.8% versus 20.0%. Infertility diagnosis, mode of insemination, and ovulation induction protocol were not associated with an increased risk of spontaneous abortion.

CONCLUSIONS

The incidence of pregnancy loss after confirmation of early fetal cardiac activity by transvaginal US is substantially greater in infertile patients than previously reported, when considered as a function of maternal age. In particular, patients > or = 36 years should be counseled that their risk of spontaneous abortion is significant even after fetal heart motion is present on transvaginal US. Cautious optimism and greater surveillance may be required during the first trimester of pregnancy in these women.

Outcome of triplet pregnancies after assisted reproductive techniques: how frequent are the vanishing embryos?

OBJECTIVE

To assess the incidence of spontaneous embryo reduction as well as the obstetric and neonatal outcome of triplet gestations after assisted reproductive techniques (ART).

METHODS

We analyzed the spontaneous outcome of 38 pregnancies in which three gestational sacs were identified with vaginal ultrasound between 21 and 28 days after ART. Weekly follow-up visits were scheduled during the first trimester until referral to a high-risk obstetrician. After delivery, each patient was interviewed individually and, if necessary, the obstetrician was contacted.

RESULTS

The triplets delivery rate was 47.4%, whereas 31.6% delivered twins, 18.4% delivered singletons, and only one patient miscarried all three cases (2.6%). Finding three fetal heart beats was associated with a triplet delivery rate of 69.2%, a twin incidence of 19.2%, and a singleton birth rate of 11.6%. Embryo resorptions were observed mainly during the first 7 weeks of gestation and did not occur beyond the 14th week. The mean gestational age at delivery and neonatal birth weight were significantly lower among triplets (32.8 weeks and 1,740 g versus 35.3 weeks and 2,352 g in twins and 39.1 weeks and 3,122 g for singletons). Triplets had a 100% prematurity and cesarean section rate compared with 67% and 75% in twins and 0% and 43% in singletons, respectively. Hospitalization at the Neonatal Intensive Care Unit was required in 83% of newborn triplets, 29% of twins, and 0% of singletons, with a mean stay of 34 and 21 days for triplets and twins, respectively. One stillbirth and no neonatal deaths were reported, with an overall perinatal mortality rate of 11.9 per 1,000.

CONCLUSIONS

Spontaneously, approximately 50% of triplet pregnancies will experience at least one embryo resorption. The ongoing triplets demand a complex and more expensive perinatal management, a strong argument to consider limiting the number of oocytes-embryos transferred in ART.

First trimester three-dimensional ultrasound volumetry of the gestational sac

First trimester amniotic fluid is an ultrafiltrate of maternal plasma and constitutes the major component of gestational sac volume (GSV). We hypothesized that GSV, assessed by 3-dimensional (3-D) ultrasound volumetry, would reflect function of the early uteroplacental unit and therefore provide a basis for predicting pregnancy outcome. We tested this hypothesis in 38 pregnancies which had first trimester GSV measurements by two investigators thus allowing determination of interobserver variation. Gestational age (GA) was based on a careful history and conventional 2-dimensional ultrasound measurements. Serum for beta-hCG, estradiol (E2) and progesterone (P) was obtained at the time of ultrasound examinations. "Normal" outcome was defined as confirmation of a viable fetus. "Abnormal outcome" was defined as either a "blighted ovum" or embryonic demise. Statistical analysis was performed by Independent t-test and regression analysis. There were 31 "normal" and 7 "abnormal" pregnancies studied between 5 and 11 weeks gestation (mean +/- SD 8.3 +/- 1.3 weeks). GSV was significantly correlated to GA (r = 0.74, P < 0.001), higher than to beta-hCG (r = 0.40, P = 0.034), E2 (r = 0.70, P < 0.001) and P (r = 0.21, P = 0.334), respectively. In the abnormal group 2/2 pregnancies with a twin sac had a GSV within 1 SD of the mean. 3/5 cases of missed abortions or blighted ovum had a GSV < 2 SD of the mean. The interobserver correlation was high (r = 0.99, P < 0.00f2p4This is the first clinical study investigating the diagnostic use of 3-D ultrasound volumetry in first trimester pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

The predictive value of a single beta human chorionic gonadotropin in pregnancies achieved by assisted reproductive technology

OBJECTIVE

To investigate whether a single serum beta-hCG in pregnancies achieved by assisted reproductive technologies (ART) can accurately predict pregnancy viability and, in viable pregnancies, multiple gestation.

DESIGN

Four hundred sixty-one consecutive successful ART pregnancies were studied retrospectively. Seventy-one of the 461 patients were excluded because their beta-hCG was either drawn on the incorrect day or outside our facility. Three hundred ninety subjects had a serum beta-hCG drawn 14 days after ET or 16 days after gamete transfer. The beta-hCG samples were analyzed by immunoradiometric assay based on the Third International Reference Standard (IRS) (First International Reference Preparation (IRP)). Pregnancy status was followed, at minimum, through the first trimester.

RESULTS

One hundred fifty (38%) of the 390 were found to be nonviable, resulting in spontaneous abortion (n = 38, 10%), ectopic pregnancy (n = 27, 6%), or biochemical pregnancies (n = 85, 22%). A statistically significant difference by the Scheffe F-test was found between the mean beta-hCG value of the nonviable (115 mIU/mL) (conversion factor to SI unit, 1.00) and viable (428 mIU/mL) pregnancies. The positive predictive value of a single beta-hCG > 100 mIU/mL in distinguishing viable from nonviable pregnancies was 0.83 (sensitivity 91%, specificity 71%). Of the 240 viable pregnancies, 74 (32%) were multiple gestations (57 twins, 14 triplets, and 3 quadruplets). The mean beta-hCG of the singleton pregnancies (266 mIU/mL) was significantly different from that of the multiple gestations (792 mIU/mL). The positive predictive value of a single serum beta-hCG < or = 400 mIU/mL in distinguishing singleton from multiple gestations was 0.92 (sensitivity 86%, specificity 82%).

CONCLUSION

A single early serum beta-hCG may be used in ART pregnancies to predict which pregnancies will continue beyond the first trimester and to identify multiple gestations. Early reassuring tests may reduce anxiety.

The screening of embryonic viability in early asymptomatic pregnancy by a single endosonographic scan associated with plasma human chorionic gonadotropin determination

PURPOSE

Our purpose was to assess, with a prospective study with random assignment of the day of the first evaluation, whether a single transvaginal ultrasonographic evaluation together with the determination of plasma hCG levels could be used to screen embryonic viability in early asymptomatic pregnancy.

METHODS

In 260 pregnant women observed from January 1991 to November 1993 with spontaneous pregnancies where the exact date of ovulation was known, a single transvaginal ultrasonographic measurement of gestational sac with determination of plasma hCG levels, transformed to their natural logarithm (lnhCG), was performed. An abnormal result was defined as a value of lnhCG per mean gestational sac below the 95% lower confidence limit of the viable pregnancy group.

RESULTS

The sensitivity was 31%, with a specificity of 97%.

CONCLUSION

The study demonstrates that this method has a poor predictive capacity to distinguish viable pregnancy from nonviable pregnancy with a kappa value less than 0.4.

Pregnancy outcome following ultrasound-detected fetal cardiac activity in women with a history of multiple spontaneous abortions

OBJECTIVE

To determine whether women with two or more previous spontaneous abortions of unknown etiology, by conventional testing criteria, have a different rate of subsequent fetal loss than controls after ultrasonic documentation of fetal cardiac activity.

METHODS

Medical records were reviewed from 185 women with spontaneous abortion of unknown etiology. Of these women, 91.9% were found to have evidence of cellular immunity to trophoblast and were treated with progesterone for immunosuppression. Ultrasound evaluation was obtained at 5-6 weeks' gestation to document fetal cardiac activity. A control group of 63 women was also studied. All women were followed for pregnancy outcome.

RESULTS

A total of 248 pregnancies were identified from the 185 study patients with multiple spontaneous abortions. Fetal cardiac activity was visualized by ultrasound in 209 pregnancies from 171 study subjects; of these, the outcomes of 208 pregnancies were known. The rate of spontaneous abortion after ultrasound documentation of fetal cardiac activity was 22.7%. Neither maternal age nor number of previous losses was associated with an increased incidence of spontaneous abortion following documentation of fetal cardiac activity. The rate of spontaneous abortion in the control group after documentation of fetal cardiac activity was 3.3%.

CONCLUSION

These data may help clinicians give couples who have experienced recurrent pregnancy loss a more realistic prognosis for pregnancy success once fetal cardiac activity has been confirmed.

First-trimester ultrasonography findings in women with a history of recurrent pregnancy loss

OBJECTIVE

We tabulated first-trimester ultrasonography findings in women with recurrent pregnancy loss and determined the rate of subsequent pregnancy loss and live births after demonstration of a live embryo.

STUDY DESIGN

Sixty-seven women with three or more recurrent miscarriages underwent first-trimester ultrasonography and were prospectively followed through 101 pregnancies.

RESULTS

First-trimester ultrasonography showed a dead embryo in seven pregnancies. Two of gestational sac in 12, and an empty uterus in four. A live embryo was seen in 78 pregnancies. Two of these pregnancies were terminated because of fetal chromosomal abnormalities. Of the remaining 76 pregnancies, 13 (17%) ended in a fetal loss (spontaneous abortion or fetal death) and 63 (83%) resulted in viable live births.

CONCLUSIONS

Among women with recurrent pregnancy loss the presence of a live embryo detected by first-trimester ultrasonography is not as encouraging as in normal pregnant women. These findings are useful in counseling patients with recurrent pregnancy loss.

Can a single, early quantitative human chorionic gonadotropin measurement in an in vitro fertilization-gamete intrafallopian transfer program predict pregnancy outcome?

STUDY OBJECTIVE

To assess the predictive value of a single serum human chorionic gonadotropin (hCG) measurement obtained on day 14, 15, or 16 after transfer in in vitro fertilization or gamete intrafallopian transfer pregnancies.

DESIGN

Retrospective.

SETTING

Assisted reproductive technology (ART) programs.

PATIENTS

One hundred thirty-four consecutive pregnancies from two ART programs were reviewed.

RESULTS

The incidence of livebirth was only 6% when day 14 to 16 hCG values were less than 100 mIU/mL, but increased to 82% with levels greater than 100 mIU/mL (P less than 0.001). The incidence of livebirth and multiple birth correlated with rising hCG levels. Only 1% (1/71) of pregnancies with serum hCG values greater than 100 mIU/mL was ectopic, and this case was a bilateral (double) ectopic.

CONCLUSIONS

A single serum hCG measurement obtained 14 to 16 days after embryo or gamete transfer not only is diagnostic but also has good predictive value for pregnancy outcome.