Predictive factors for massive hemorrhage in women with retained products of conception: a prospective study

Retained products of conception (RPOC) is a common cause of postpartum bleeding, which may be life-threatening; however, no evidence-based guidelines exist to assist in evaluating the risk of massive hemorrhage in women with RPOC. In this prospective study, we aimed to evaluate the predictive factors for massive hemorrhage in women with RPOC. The primary and secondary endpoints were to validate the usefulness of power Doppler color scoring (PDCS) in evaluating hypervascularity and to identify other predictive factors (such as maximum RPOC diameter and serum βhCG and Hb level at first visit), respectively. Among the 51 women with RPOC included in this study, 16 (31.5%) experienced massive hemorrhage during follow-up. None of the women with PDCS 1 or 2 (18) experienced massive hemorrhage, whereas 16 (48.5%) women with PDCS 3 or 4 (33) did. Multiple logistic regression analysis showed that the odds ratio [95% confidence interval] (P value) for PDCS, assisted reproductive technology (ART), and low serum hemoglobin (Hb) levels were 22.39 [2.25 - 3087.92] (P = 0.004), 5.72 [1.28 - 33.29] (P = 0.022), and 4.24 [0.97 - 22.99] (P = 0.056), respectively. Further, the decision tree method identified PDCS, ART, and low serum Hb levels as potential predictive factors for massive hemorrhage. This study identified PDCS as useful predictor of massive hemorrhage in women with RPOC. With additional inclusion of factors such as ART and low serum Hb levels, the risk of massive hemorrhage may be effectively evaluated, leading to better management of women of reproductive age.

Color Doppler Imaging of Vascular Abnormalities of the Uterus

ABSTRACT

Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.

Risk factors of retained products of conception after miscarriage or termination with gemeprost in the second trimester of pregnancy: a retrospective case-controlled study in Japanese population

Retained products of conception (RPOC) is a complication that occurs in the second trimester of pregnancy. We enrolled 98 women who had a miscarriage or termination with gemeprost in the second trimester of pregnancy. Eighteen cases (18.4%) were RPOC-positive. The gestational week at miscarriage or termination was earlier in the RPOC-positive group than those in the RPOC-negative group (p = .003). The period of the third stage of labour was longer in the RPOC-positive group than in RPOC-negative group (p = .040). The proportion of placental forceps use was higher in the RPOC-positive group than in RPOC-negative group (p = .003). Multivariate logistic regression analysis showed that gestational week (OR: 3.53; p = .04) and use of placental forceps at delivery (OR: 2.21; p = .012) were independent risk factors for RPOC. Earlier gestational weeks at miscarriage or termination and use of placental forceps at delivery were predictive factors for RPOC after second trimester miscarriage or termination with gemeprost.Impact StatementWhat is already known on this subject? There have been some reports on risk factors of RPOC. A previous report showed that the termination of pregnancy with misoprostol at earlier periods was associated with an increased risk of RPOC.What the results of this study add? There have been few studies on the risk factors of RPOC after miscarriage or termination with gemeprost. In this study, we evaluated the risk factors of RPOC after miscarriage or termination of pregnancy with gemeprost in the second trimester. We found that an earlier gestational age (between 12 and 17 weeks) at delivery and using placental forceps to remove placenta were significant risk factors of RPOC after miscarriage or termination of pregnancy with gemeprost in the second trimester.What the implications are of these findings for clinical practice and/or further research? An earlier gestational age and using forceps to remove placenta may be significant risk factors for RPOC. The accurate evaluation and treatment for RPOC is important for maternal life-saving efforts and subsequent pregnancies. Further research is needed to draft a standardised protocol for RPOC.

Predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding

Purpose

To identify predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding.

Methods

This was a planned secondary analysis of data from a published randomized controlled trial comparing expectant management with vaginal single dose of 800 µg misoprostol treatment of women with embryonic or anembryonic miscarriage. Predefined variables—serum-progesterone, serum-β-human chorionic gonadotropin, parity, previous vaginal deliveries, gestational age, clinical symptoms (bleeding and pain), mean diameter and shape of the gestational sac, crown-rump-length, type of miscarriage, and presence of blood flow in the intervillous space—were tested as predictors of treatment success (no gestational sac in the uterine cavity and maximum anterior–posterior intracavitary diameter was ≤ 15 mm as measured with transvaginal ultrasound on a sagittal view) in univariable and multivariable logistic regression.

Results

Variables from 174 women (83 expectant management versus 91 misoprostol) were analyzed for prediction of complete miscarriage at ≤ 17 days. In patients managed expectantly, the rate of complete miscarriage was 62.7% (32/51) in embryonic miscarriages versus 37.5% (12/32) in anembryonic miscarriages (P = 0.02). In multivariable logistic regression, the likelihood of success increased with increasing gestational age, increasing crown-rump-length and decreasing gestational sac diameter. Misoprostol treatment was successful in 80.0% (73/91). No variable predicted success of misoprostol treatment.

Conclusions

Complete miscarriage after expectant management is significantly more likely in embryonic miscarriage than in anembryonic miscarriage. Gestational age, crown-rump-length, and gestational sac diameter are independent predictors of success of expectant management. Predictors of treatment success may help counselling women with early miscarriage.

Doppler Color Scoring System in Women With an Incomplete Miscarriage: Interobserver and Intraobserver Reproducibility Study

OBJECTIVES

Doppler Color Scoring (DCS) has been used to predict successful expectant management of incomplete miscarriage. The aim of this study was to assess inter- and intraobserver reproducibility of the DCS system in women with incomplete miscarriage noted on transvaginal sonography.

METHODS

This was a prospective reproducibility study involving offline analysis of 32 prerecorded video sets on transvaginal sonography in real time of women with incomplete miscarriage. Vascularization of retained products of conception was recorded using the DCS system adopted from the International Ovarian Tumor Analysis group. Five gynecologic sonologists of varying experience assigned a DCS classification to each video in the analysis. The same videos were reanalyzed, in a different order, at least 7 days later, to assess intraobserver agreement. Inter- and intraobserver correlations were performed to determine agreement. Interobserver agreement was also measured between each observer and the reference standard (G.C.). A Cohen's κ coefficient value less than 0 suggests poor agreement, 0.01 to 0.20 slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 and 0.99 almost perfect.

RESULTS

Interobserver agreement for all observers for DCS allocation ranged from 0.480 to 0.751. Overall interobserver agreement for 5 observers was substantial (κ, 0.626). Overall interobserver agreements for the 2 inexperienced and 3 experienced observers compared to G.C. were 0.521 and 0.618, respectively. Experienced observers achieved overall almost perfect intraobserver agreement, compared to substantial agreement for inexperienced sonologists.

CONCLUSIONS

DCS interobserver reproducibility between all observers and GC ranged from moderate to substantial. DCS intraobserver reproducibility was substantial to almost perfect. The DCS system appears to be a reproducible tool in evaluating women with incomplete miscarriage.

Ultrasonographic vascularity assessment for predicting future severe hemorrhage in retained products of conception after second-trimester abortion

Objectives: To investigate the spontaneous outcomes of vascularized retained products of conception (RPOC) detected by ultrasonography after second-trimester abortion, and to identify the predictive factors for the development of severe postpartum hemorrhage (SPPH).Study design: This is a retrospective cohort study on all cases after second-trimester abortion managed at our institute between January 2014 and December 2016. We assessed the associations between the occurrence of SPPH requiring invasive treatment and clinical factors including ultrasonographic findings (size and the vascularity status of RPOC classified as follows: type 1: vascularity confined to endometrium, type 2: vascularity reaching <1/2 myometrium, and type 3: vascularity reaching ≥1/2 myometrium) in vascularized RPOC cases.Results: Among 103 cases after second-trimester abortion, 19 patients (18.4%) were diagnosed as RPOC, and five patients eventually failed expectant management due to SPPH. Of them, 66.7% (4/6) of patients with type 3 developed SPPH as compared with 7.7% (1/13) of patients with type 1/type 2 (p < .05). The maximum vascularized mass diameter was significantly greater among the five patients who experienced SPPH than among the 14 patients who demonstrated spontaneous remission (43.0 ± 12.0 mm versus 20.7 ± 8.3 mm, p < .01). Patients with type 3 RPOC and a maximum vascularized mass diameter ≥30 mm, compared with other patients, demonstrated sensitivity, specificity, and risk ratio related to SPPH of 80, 92.9%, and 11.2, respectively.Conclusions: Our findings suggest that the ultrasonographic assessment of RPOC focused on the depth of vascularity in combination with the measurement of its size appears to be essential in determining women with RPOC who are at high risk for SPPH.

Choosing the optimal therapeutic strategy for placental polyps using power Doppler color scoring: Transarterial embolization followed by hysteroscopic resection or expectant management?

OBJECTIVE

To evaluate a protocol for selection of placental polyp management, including expectant management and hysteroscopic resection with or without transarterial embolization (TAE), using power Doppler color score (PDCS) as the vascularity parameter.

MATERIALS AND METHODS

This retrospective case-control study included 25 patients who were diagnosed with placental polyps. We evaluated the vascularity of placental polyps with PDCS measured by transvaginal ultrasonography as follows: PDCS 1, no blood flow; PDCS 2, minimal flow; PDCS 3, moderate flow; and PDCS 4, marked blood flow. We then selected expectant management or hysteroscopic resection with or without TAE.

RESULTS

Three of 17 patients with PDCS 1 or 2 underwent surgical intervention, and expectant management was successful in 14. Seven of eight patients with PDCS 3 or 4 underwent surgical intervention, while expectant management was successful in only one patient.

CONCLUSION

PDCS is a simple examination for evaluating the vascularity of placental polyps. PDCS might be useful for selecting the optimal treatment for placental polyps, such as expectant management or surgical intervention, according to their vascularity.

Clinical and imaging predictors of management in retained products of conception

OBJECTIVES

To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC).

METHODS

334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis.

RESULTS

Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery.

CONCLUSIONS

Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

Rationalising the change in defining non-viability in the first trimester

Introduction: With the publication of four papers in late 2011, international cut‐offs for definitions of non‐viability in the first trimester of pregnancy were challenged. These definitions were inconsistent across different international guidelines. For example, a gestational sac with absent yolk sac or embryo and a mean diameter of ≥ 16 mm would be classified as a miscarriage in the USA, whereas the same sac would have to measure ≥ 20 mm in the UK or Australia to meet this definition. Likewise, an embryo with no detectable heartbeat and a CRL of ≥ 5 mm would also meet criteria for missed miscarriage in the USA, compared to a CRL ≥ 6 mm in the UK or Australia.

Methods: Later in 2011 and then in 2012, guidelines across the three countries were updated and are now consistent, defining an empty gestational sac with a mean diameter of > 25 mm as a non‐viable pregnancy and/or an embryo with CRL > 7 mm and no detectable heartbeat. In this paper we explore the rationale that led to these changes in order to potentially avoid wrongly diagnosing miscarriage at the decision boundary measurements and in turn avoiding inadvertent termination of potentially viable pregnancies.

Conclusion: Although reducing women's anxiety and making a definitive diagnosis as early as possible is desirable, the need for absolute certainty is paramount before diagnosis of the death of an early pregnancy is made.

Maximum Peak Systolic Velocity and Management of Highly Vascularized Retained Products of Conception

OBJECTIVES

The purpose of this study was to evaluate blood loss and procedure-related complications during and after surgical removal of retained products of conception with high-velocity enhanced myometrial vascularity.

METHODS

We conducted a prospective study of 18 consecutive women with a diagnosis of retained products of conception and enhanced myometrial vascularity, with a peak systolic velocity (PSV) higher than 60 cm/s. All underwent ultrasound-guided surgical removal of the retained products under general anesthesia. Blood loss during the procedure was collected and recorded. The removed tissue was sent for histologic examination. An ultrasound examination was repeated within 24 hours.

RESULTS

Five patients had retained products of conception after a term delivery, 1 after a second-trimester termination of pregnancy, 7 after a spontaneous first-trimester miscarriage, and 5 after a first-trimester termination elsewhere. The PSV in the area of enhanced myometrial vascularity at diagnosis ranged from 61.0 to 152.6 cm/s (mean, 104.9 cm/s). The estimated blood loss at surgery ranged from 20 to 1000 mL (mean, 200 mL). After surgery, the PSV in the myometrium dropped dramatically (≤30 cm/s in all but 1 case). In all cases, trophoblastic tissue was confirmed at histologic examination.

CONCLUSIONS

Although surgical removal of retained products of conception was uneventful in most cases, heavy bleeding has to be anticipated in cases of high-velocity flow in the myometrium underlying residual trophoblastic tissue. Accordingly, in cases of high-velocity enhanced myometrial vascularity, we advocate surgical removal of the residual tissue under ultrasound guidance by an experienced surgeon and in the presence of a fully informed anesthetist.

Variable color Doppler sonographic appearances of retained products of conception: radiologic-pathologic correlation

OBJECT OF STUDY

Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. We hypothesize that variability in sonographic vascularity may be due to histopathologic variation in the placental tissue.

MATERIALS, METHODS, AND PROCEDURES

After institutional review board approval, sonographic images and pathologic specimens were retrospectively reviewed in 26 patients with pathologically proven RPOC. Ultrasound (US) images were scored 0-3 for the degree of vascularity by two radiologists blinded to the diagnosis. Corresponding pathologic specimens were evaluated for vascularization of chorionic villi, degree of inflammation, morphology of maternal arteries, chorionic villous preservation, and percentage of clot, membranes, chorionic villi, and decidua/myometrium. Statistical analysis, including multiple linear regression, was performed.

RESULTS

RPOC with histologically avascular chorionic villi or those with markedly reduced vascularization had significantly lower US vascularity scores (p = 0.030) than those with chorionic villi showing normal or decreased vascularization. Sonographically avascular RPOC had a significantly lower percentage villi (p = 0.028) and higher percentage of decidua (p = 0.004) than specimens where US showed any Doppler vascularity. Histologic vascularity of villi (p = 0.049) and non-observation of maternal arteries (p = 0.001) were significant predictors of US vascularity scores in multivariate linear regression analysis, while inflammation of villi (p = 0.053) was a marginally significant predictor.

SIGNIFICANCE OF THE CONCLUSIONS

Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity. This finding may underlie known differences in clinical outcomes between sonographic vascularity groups.

Uterine artery Doppler in the management of early pregnancy loss: a prospective, longitudinal study

Background

The pharmacological management of early pregnancy loss reduced substantially the need for dilation and curettage. However, prognostic markers of successful outcome were not established. Thus the major purpose of this study was to determine the sensitivity and specificity of the uterine artery pulsatility (PI) and resistance (RI) indices to detect early pregnancy loss patients requiring dilation and curettage after unsuccessful management.

Methods

A cohort prospective observational study was undertaken to include women with early pregnancy loss, ≤ 12 weeks of gestation, managed with mifepristone (200 mg) and misoprostol (1600 μg) followed by PI and RI evaluation of both uterine arteries 2 weeks after. At this time, in 173/315 patients, incomplete miscarriage was diagnosed. Among them, 32 underwent uterine dilatation and curettage at 8 weeks of follow-up.

Results

The cut-off points for the uterine artery PI and RI, leading to the maximum values of sensitivity (69.5%, CI_95%: 61.5%-76.5% and 75.0%, CI_95%: 57.9%-86.8%, respectively) and specificity (75.0%, CI_95%: 57.9%-86.8% and 65.6%, CI_95%: 48.3%-79.6%, respectively), for the discrimination between the women who needed curettage from those who resolved spontaneously were 2.8 and 1, respectively.

Conclusions

The potential usefulness of uterine artery Doppler evaluation to predict the need for uterine curettage in patients submitted to medical treatment for early pregnancy loss was demonstrated.

Ultrasound evaluation of the first trimester

Ultrasound is a valuable diagnostic test throughout the first trimester of pregnancy. Early in this trimester, it is used to distinguish between normal intrauterine, failed intrauterine, and ectopic pregnancies. Later it can be used with maternal blood tests to screen for trisomy 21 and other forms of aneuploidy, and in some centers to assess fetal anatomy and diagnose structural anomalies. First trimester sonography is also useful for accurate assessment of gestational age. This article reviews these applications, the approach to establishing diagnoses, and ways to avoid diagnostic mistakes that can lead to serious errors in patient management and adverse pregnancy outcome.